Redo Reconstruction Research Articles

Re-Do Plastic Reconstruction for Locally Advanced and Recurrent Colorectal Cancer Following a beyond Total Mesorectal Excision (TME) Operation-Key Considerations.

Innovation in surgery and pelvic oncology have redefined the boundaries of pelvic exenteration for CRC. However, surgical approaches and outcomes following repeat exenteration and reconstruction are not well described. The resulting defect from a second beyond Total Mesorectal Excision (TME) presents a challenge to the reconstructive surgeon. The aim of this study was to explore reconstructive options for patients undergoing repeat beyond TME for recurrent CRC following previous beyond TME and regional reconstruction. MEDLINE and Embase were searched for relevant articles, yielding 2353 studies. However, following full text review and the application of the inclusion criteria, all the studies were excluded. This study demonstrated the lack of reporting on re-do reconstruction techniques following repeat exenteration for recurrent CRC. Based on this finding, we conducted a point-by-point discussion of certain key aspects that should be taken into consideration when approaching this patient cohort.

Redo hepatic artery reconstruction for thrombosis without retransplantation in 1355 adult living donor liver transplantations.

Hepatic artery thrombosis (HAT) after liver transplantation is associated with a marked increase in morbidity, leading to graft and patient loss. We evaluated the outcomes of adult living donor liver transplantation patients with HAT under an aggressive surgical intervention. A total of 1355 recipients underwent adult living donor liver transplantation at the Seoul National University Hospital. Surgical redo reconstruction for HAT was performed in all cases except in those with graft hepatic artery injury and late detection of HAT. Postoperative HAT developed in 33 cases (2.4%) at a median time of 3.5 days. Thirty patients (90.9%) underwent redo-arterial reconstruction. The survival rates in patients with HAT were similar to the rates in those without HAT (72.7% vs. 83.8%, p = 0.115). Although graft survival rates were lower in patients with HAT (84.8%) than in those without HAT (98.0%) ( p < 0.001), the graft survival rate was comparable (92.0% vs. 98.0%, p = 0.124) in the 25 patients with successful revascularization. Biliary complication rates were higher in patients with HAT (54.5%) than in those without HAT (32.0%) ( p = 0.008). In conclusion, the successful redo reconstruction under careful selection criteria saved the graft without retransplantation in 96.0% of the cases. Surgical revascularization should be preferentially considered for the management of HAT in adult living donor liver transplantation.

Ruptured True Aneurysm of a Below Knee Venous Bypass

A 58 year old male underwent simultaneous aortobifemoral and right below knee bypass with autologous great saphenous vein because of critical limb threatening ischaemia. Ten years later, he presented with a pulsatile mass in the right thigh (A, arrow). Computed tomography angiography confirmed an aneurysm of the proximal and mid portion of vein graft with rupture in the midthigh segment (B, arrow). The patient underwent redo reconstruction of the above the knee vein bypass using an 8 mm knitted polyester tube graft (Jotec GmbH, Germany). Bleeding control was established using balloon occlusion catheters.

Salvage mandibular reconstruction: multi-institutional analysis of 17 patients

Unsuccessful mandibular reconstruction occasionally occurs, leaving the patient with undesirable function and contours. In such cases, second- or third-time corrective operations are challenging. However, published studies on the complicated retreatment of such patients are scarce. A retrospective analysis covering the years 2015–2019 was conducted in three centers. All 17 patients included had undergone prior failed mandibular reconstructions in other institutions. Salvage secondary or tertiary reconstructive surgeries were attempted and the results are presented. Major factors for these failed reconstructions included exposed non-vascularized bone grafts (n = 7, 41.2%), flap loss (n = 4, 23.5%), exposed artificial joint (n = 3, 17.6%), skewed occlusion with deformity (n = 1, 5.9%), non-union (n = 1, 5.9%), and recurrence (n = 1, 5.9%). Fibula flaps were transferred in 15 patients, while iliac flaps were used in two patients for mandibular re-do reconstructions. Virtual surgical designs were conducted in nine (52.9%) patients, with navigation-guided approaches performed in three cases. Postoperative functions were relatively favorable in these complicated mandibular re-do reconstruction cases. Mandibular symmetry (mandibular length and height; P = 0.002) and condylar position (P < 0.001) were regained after these re-do attempts. Secondary or tertiary mandibular re-do reconstruction can still achieve good functional outcomes with appropriate preoperative selection and well-conceived designs, especially with the aid of virtual surgery and navigation.

Perineoscopic vesicourethral reconstruction: A novel surgical technique for anastomotic stricture following radical prostatectomy.

Vesicourethral anastomotic stenosis (VUAS) is frequently seen after prostate surgery because of various operative and postoperative factors. In this study, we aimed to present our results of perineoscopic bladder neck reconstruction, which is a new technique of the perineal approach in the treatment of patients with VUAS after prostate cancer surgery. Sixteen consecutive patients who underwent perineoscopic bladder neck reconstruction in our clinic between July 2017 and March 2019 were included in the study. Demographic characteristics, surgical history, postoperative continence status, and additional treatment requirements were recorded. Perineoscopic surgery is defined as the visualization of the surgical site with instruments used in laparoscopy and the surgeon performing the entire operative procedure through the screen. The mean number of preoperative endoscopic bladder neck resections of the patients was 7±5.1, with a history of suprapubic cystostomy in 7 (43.7%) and radiotherapy in 5 (31.2%) patients before surgery. The mean surgical time was 126.2±13.1 min. The mean follow-up period was 13.2±6.8 months, and the success rate was 81.25%. During follow-up, two (12.5%) patients received perineoscopic re-do reconstruction because of stricture recurrence, and one (6.2%) patient was included in a urethral dilatation program. Improving visualization and ergonomics with the perineoscopic approach can increase the success rate of bladder neck reconstruction in comparison with the standard approach. In addition, the lack of need for expanded dissection (corporal separation, inferior pubectomy) reduces postoperative complication rates.

MP71-04 ANY INTERVENTION AFTER PYELOPLASTY: THE INCIDENCE, ETIOLOGY AND OUTCOMES

You have accessJournal of UrologyPediatrics: Upper Urinary Tract Disorders and Fetal Urology (MP71)1 Apr 2020MP71-04 ANY INTERVENTION AFTER PYELOPLASTY: THE INCIDENCE, ETIOLOGY AND OUTCOMES Aznive H. Aghababian*, Sameer Mittal, Lauren Dinardo, Dana A. Weiss, Christopher J. Long, Aseem R. Shukla, and Arun K. Srinivasan Aznive H. Aghababian*Aznive H. Aghababian* More articles by this author , Sameer MittalSameer Mittal More articles by this author , Lauren DinardoLauren Dinardo More articles by this author , Dana A. WeissDana A. Weiss More articles by this author , Christopher J. LongChristopher J. Long More articles by this author , Aseem R. ShuklaAseem R. Shukla More articles by this author , and Arun K. SrinivasanArun K. Srinivasan More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000951.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Pyeloplasty for ureteropelvic junction obstruction (UPJO) ultimately has a >95% success rate, but the incidence of additional procedures en route to recovery is not well known. We hypothesized that the incidence of additional procedures is low and differences in management techniques of recurrent UPJO can be characterized. METHODS: A retrospective review was performed on all patients undergoing an open or minimally invasive pyeloplasty from 2012-2019. Patients requiring a subsequent unplanned procedure after the initial reconstruction were identified. Further data was abstracted on patients presenting signs and symptoms of recurrent UPJO, and on the techniques used in their subsequent treatment. Comparative statistics were performed using non-parametric and binary/categorical tests as appropriate. RESULTS: From 2012 to 2019, 386 patients were identified and 9.6% (n=36) underwent a subsequent unplanned procedure during the follow-up period. Of those 36, interventions were performed for stone disease in 5 (13.8%), stent migration in 11 (30.6%) and signs and symptoms of recurrent UPJO in 20 (55.6%) [Figure 1]. Of the 20 patients with concerns for recurrent UPJO, 6 (30%) patients were managed with only-endoscopic techniques and 14 (70%) patients ultimately required redo pyeloplasty or ureterocalicostomy. Between these two groups, more endoscopic procedures were performed in those ultimately requiring a redo reconstruction (2.0 vs 3.3, p<0.074) and no patient with a crossing vessel as the etiology of their UPJO was successfully managed endoscopically only (p<0.042) [Table 1]. Additionally, no difference in the time to 1st intervention or the type of initial pyeloplasty performed was identified between the two groups. CONCLUSIONS: Reconstruction for a UPJO is associated with a near 10% risk of requiring an additional intervention despite the high overall success rate. Recurrent UPJO with a history of a crossing vessel should have early redo reconstruction. These additional procedures may be a modifiable driver of morbidity and cost associated with the treatment of UPJO. Source of Funding: Children's Surgical Associates © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e1065-e1065 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Aznive H. Aghababian* More articles by this author Sameer Mittal More articles by this author Lauren Dinardo More articles by this author Dana A. Weiss More articles by this author Christopher J. Long More articles by this author Aseem R. Shukla More articles by this author Arun K. Srinivasan More articles by this author Expand All Advertisement PDF downloadLoading ...

Redo reconstruction of the digestive tract after gastric surgery

To formulate the concept of physiological reconstruction of the digestive tract during redo gastric surgery. There were 52 patients who underwent redo gastric surgery after previous resections, drainage and antireflux procedures in 2011-2017 at the Vishnevsky National Research Surgical Center. Redo resection of the stomach with Billroth-1 and Hofmeister reconstructions were performed in 5 (9.6%) and 1 patient (1.9%), respectively. Roux-en-Y reconstruction was performed in 4 (7.7%) patients after gastric remnant extirpation. Jejunogastroplasty was used in 30 (57.7%) patients. A segment of the transverse colon as the reconstructive material was used in 2 (3.8%) patients, left colon - in 8 (15.4%) after esophagectomy. One (1.9%) patient underwent extirpation of 'small' stomach and thoracic esophagus after previous gastric bypass. Gastric remnant was used as an isoperistaltic tube for subtotal esophagoplasty. Reconstruction was not possible in only 1 (1.9%) patient after advanced visceral resection for recurrent cancer within esophagojejunostomy due to deficit of visceral material. Postoperative complications were observed in 5 (9.6%) patients. Partial failure of esophagojejunostomy and duodenojejunostomy occurred in 2 (3.8%) and 1 patient (1.9%), respectively. Colon transplant necrosis was noted in 1 (1.9%) patient that required resection followed by colo- and esophagostomy nutrition. One patient died on the 1st postoperative day from progressive multiple organ failure. At the end of the study, 44 (86.2%) out of 51 patients were under follow-up. Good results were revealed in 26 (59.9%) patients, satisfactory outcomes - in 12 (27.4%) patients. Redo surgery was not effective in only 6 (13.7%) patients. Evaluation of our results demonstrates complete alleviation of pathological postoperative syndromes after gastric surgery in the majority of patients. Therefore, redo surgery with gastroplasty and restoration of duodenal passage are advisable.

Evaluating the Outcome of Direct Repair of Bile Duct Injury

AbstractBackground: Bile duct injury (BDI) during laparoscopic cholecystectomy is a surgical catastrophe with an incidence ranging. Between 0.3 to 1,4%. Many surgeons think that direct repair of BDI carries a high risk of stricture that is why the bilioenteric reconstruction is more popular.Aim of Study: Evaluating the results of direct repair in selected cases and compare it to the classic bilioenteric reconstruction.Methods: We had 2 groups, group A had direct bile duct repair and group B had bilioenteric reconstruction. The choice of doing the direct repair was based on the absence of risk factors for biliary complications. Both are compared as regards the presence of postoperative complications either leakage or stricture and hospital stay. All cases were done in Ain Shams university hospitals during the period between January 2013 until December 2017.Results: Bile leakage had happened in one case of group A (11%) and 2 cases of group B (16.7%) with no statistically significant difference, (p-value is 0.72). One case of group A (11.1%) had biliary stricture which was presented at 6 months follow up, managed first by ERCP and stent twice and required reconstruction by Roux en Y after 15 months. For group B, 2 cases had anastomotic strictures presented at 9 and 12 months. They were managed by PTC, dilatation, and stenting and followed by redo reconstruction of the anastomosis at 15 and 17 months after the surgery.Conclusions: Direct repair of the Bile duct can be safely done in properly selected patients with comparable results to bilioenteric reconstruction and no increase in the incidence of postoperative complications.

Compatibility of StratticeTM Matrix for Breast Reconstruction with Radiation Therapy

Introduction: StratticeTM is a porcine acellular dermal matrix used in breast reconstruction. It acts as a hammock for breast implants and to define the infra mammary fold. Method: All patients who underwent StratticeTM based reconstruction from 2010-15 under the care of one breast surgeon were included in this study. The StratticeTM matrix was used to create the sub pectoral pouch in which the implant was placed. Patients were divided into 2 Groups based on radiation therapy to the breast either before or after surgery (Group A) and those who received no radiation at any stage (Group B). Data regarding indication for surgery, size of implant, follow up time and significant complications were collected and analyzed using Windows Excel. Statistical analysis was performed using Chi-Squared test to compare the complications between the 2 Groups. A subgroup analysis was performed based on either breast surgery with skin sparing mastectomy and immediate reconstruction (SSM and IR), delayed reconstruction (DR) or re-do reconstruction (RR). Results: There were 76 cases with average age of 52 years (33-79). There were 30 cases in Group A and 46 in Group B. In Group A, 14 patients had IR, 15 DR and 1 RR. 3 patients had previous lumpectomy and radiation treatment for breast cancer followed by SSM and IR. In Group B, 25 had IR, 20 had DR and 1 had IR. The average size of implant used was 422 gms (195-765 gms). Follow up time was 27 months (1-62). In Group A there were 2 cases of infection, 1 case of capsule contracture and 2 wound breakdowns. 5 mastectomy flaps failed to stretch due to poor skin compliance secondary to radiation to the chest wall. There was 1 case of bottoming out of the implant in this Group requiring RR. In Group B, there was 1 case of extrusion requiring RR and 1 case of flap necrosis. Group A had more complications and implant loss than Group B and this was found to be statistically significant (p<0.0007). Conclusion: StratticeTM based breast reconstruction post radiotherapy carries higher risk of complications and abandoning due to non-compliant skin. This elevated risk should be emphasized to the patients and autologous flaps should be considered in these cases.

Early or Delayed Intervention for Bile Duct Injuries following Laparoscopic Cholecystectomy? A Dilemma Looking for an Answer.

Background. To evaluate the effect of timing of management and intervention on outcomes of bile duct injury. Materials and Methods. We retrospectively analyzed 92 patients between 1991 and 2011. Data concerned patient's demographic characteristics, type of injury (according to Strasberg classification), time to referral, diagnostic procedures, timing of surgical management, and final outcome. The endpoint was the comparison of postoperative morbidity (stricture, recurrent cholangitis, required interventions/dilations, and redo reconstruction) and mortality between early (less than 2 weeks) and late (over 12 weeks) surgical reconstruction. Results. Three patients were treated conservatively, two patients were treated with percutaneous drainage, and 13 patients underwent PTC or ERCP. In total 74 patients were operated on in our unit. 58 of them underwent surgical reconstruction by end-to-side Roux-en-Y hepaticojejunostomy, 11 underwent primary bile duct repair, and the remaining 5 underwent more complex procedures. Of the 56 patients, 34 patients were submitted to early reconstruction, while 22 patients were submitted to late reconstruction. After a median follow-up of 93 months, there were two deaths associated with BDI after LC. Outcomes after early repairs were equal to outcomes after late repairs when performed by specialists. Conclusions. Early repair after BDI results in equal outcomes compared with late repair. BDI patients should be referred to centers of expertise and experience.

Kuopio Treatment Strategy after Deep Sternal Wound Infection

Infection of sternotomy wound is a rare potentially fatal complication because of the risk for deep sternal infection. Current treatment comprises antibiotics, debridement, negative pressure wound therapy and sometimes transposition of muscle or omental flaps to fill the anterior mediastinal dead space. The management of 60 consecutive deep sternotomy wound infections is reviewed. The one stage treatment was mostly chosen. In 5 patients after debridement, negative pressure wound therapy was used before flap reconstruction. Fifty-seven patients were rewired and 3 patients had sternectomy. The choice of the flap was based mainly on anatomic location of a sternal wound defect and also on which grafts been used in cardiac operation. The unilateral turnover split pectoralis major flap was the choice for 50 patients. In 8 patients latissimus dorsi flap was used. Rectus abdominis was used as a standalone flap in 4 patients and in combination with pectoralis major in one. All patients survived after deep sternal wound infection. In only 33 patients the recovery was totally uneventful. In the remaining 27 patients there were one or more complications. Not a single flap was lost completely, but due to partial flap necrosis, a redo reconstruction was needed in 3 patients. Negative pressure wound therapy was used after flap reconstruction in eight patients with incomplete post-flap healing to prepare for wound revision and split thickness skin graft. A structured approach including both cardiac and plastic surgery in case of deep sternal wound infection is recommended. A single stage surgery with the help of muscle flap reconstruction is our standard treatment. With our protocol, we have been able to keep the mortality low.

A neosphincter for continent urinary catheterizable channels made from rectus abdominal muscle (Yachia principle): Preliminary clinical experience in children

PurposeWe investigated continence outcomes for patients undergoing primary or redo reconstruction of a urinary catheterizable reservoir involving the Yachia technique of intersecting two rectus abdominis strips over the outlet channel. Materials and methodsA retrospective evaluation of 22 consecutive patients operated from March 2009 to August 2010 was performed, consisting of 16 primary reconstructions (Macedo catheterizable ileal reservoirs) and 6 rescue cases for leaking stomas. Our data comprised 18 spina bifida patients, 1 sacral agenesis, 1 posterior urethral valves and 1 genitourinary tuberculosis. Mean age at surgery was 8.5 years (3–21 years). We evaluated continence at 3, 6, 12 months, and at the last follow-up based on data from urinary charts. ResultsMean follow-up was 21.1 months (12–29 months). Overall continence was 100% for the primary cases and 66% for the redos (2/6 failed). Three patients had initial difficulty in performing clean intermittent catheterization but this resolved with time and experience. ConclusionUsing Yachia's technique has improved the continence rate of our catheterizable reservoirs and was partially successful for suprafascial revision of incontinent conduits.

Injectable hydroxyapatite cement patch as an on-lay graft for the sellar reconstructions following endoscopic endonasal approach

Skull base reconstruction after endoscopic endonasal resection of a variety of skull base lesions remains challenging because of some lethal complications such as cerebrospinal fluid (CSF) leaks. We investigated the outcomes of hydroxyapatite (HA) cement patch as on-lay graft for skull base defects following endoscopic endonasal approach (EEA). We analyzed 53 consecutive patients who underwent sellar reconstruction using HA cement following EEA at our institution between July 2009 and March 2011. Patients were composed of 23 men and 30 women with a mean age of 47 years, ranging from 10 to 72 years. Among these patients, 29 patients (54.7%) experienced intraoperative CSF leaks with high-output, 10 patients (18.9%) underwent CSF leaks with low output, and 14 patients (26.4%) experienced no intraoperative CSF leak. Mean follow-up period for clinical outcomes was 8.6 months (range, 3-22 months). We performed injectable HA patch as on-lay graft over fascia lata for the skull base defects. Routine lumbar CSF drainage was not performed postoperatively in any patients since the introduction of HA. During the follow-up period, three of 53 patients (5.6%) demonstrated meningitis associated with postoperative CSF leaks and underwent re-do reconstruction surgery. There was no allergic symptoms associated with HA cement. At an outpatient clinic, the defects were found to be covered with surrounding nasal mucosa at an average of 14 weeks (range, 3-28 weeks). The use of HA cement as an on-lay patch for the reconstruction of sellar defect demonstrated a low incidence of CSF leaks with minimal complications. HA cement may be an alternative option for repair of CSF leaks following EEA.

65 SIX-YEAR EXPERIENCE WITH DORSAL BUCCAL GRAFTING TO RECONSTRUCT THE FOSSA AND/OR URETHRAL PLATE WITH SIMULTANEOUS ONLAY FLAP REPAIR

You have accessJournal of UrologyTrauma/Reconstruction: Trauma & Reconstructive Surgery II1 Apr 201065 SIX-YEAR EXPERIENCE WITH DORSAL BUCCAL GRAFTING TO RECONSTRUCT THE FOSSA AND/OR URETHRAL PLATE WITH SIMULTANEOUS ONLAY FLAP REPAIR Joel Gelman Joel GelmanJoel Gelman More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.112AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES When penile skin is available, onlay flap reconstruction represents an excellent choice for one-stage repair for complex hypospadias and strictures involving the glans and fossa navicularis. When urethra is deficient circumferentially, tube flaps and staged repairs are options. During the reconstruction of an adult patient with untreated proximal hypospadias and disabling chordee in 1993, division of the urethral plate and excision of fibrous tissue corrected the majority of the curvature but created a 5 cm circumferential deficiency of the distal urethra. Given the success of dorsal buccal grafting of the treatment of stricture disease, buccal mucosa was used to recreate the urethral plate and a ventral penile skin flap was used to complete the one-stage repair. We now report our 6-year experience with this circumferential tissue transfer technique. METHODS Nine patients (Ages 22-77, mean 45) underwent dorsal buccal grafting with ventral flap repair. Three patients with untreated hypospadias and medium caliber stricture disease requested correction of disabling chordee. Three hypospadias patients underwent prior surgeries complicated by stricture disease and ventral displacement of the urethral meatus, and had redundancy of the dorsal penile skin. Two patients had recurrent obliterative strictures involving the urethral meatus, and one patient who sustained foley trauma developed a scrotal abscess and an 11 cm stricture of the penile/bulbar urethra. Buccal mucosa was quilted to the ventral corpora of the penis to reconstruct the dorsal aspect of the urethra and the majority of these surgeries included buccal graft reconstruction of the glans and fossa. Onlay penile skin flap repair was then performed to complete the reconstruction. RESULTS All patients are currently free of disabling chordee or obstruction at this time with a mean followup of 2-81 months (mean 28). One patient who underwent treatment of disabling chordee developed urethrocutaneous fistulas and recurrence of distal chordee and required staged re-do reconstruction. Two other patients developed fistulas that required closure and this was performed successfully. CONCLUSIONS Dorsal buccal grafting with ventral flap reconstruction appears to be an excellent option for the repair of circumferential urethral deficiency when penile skin is available, especially when chordee correction with urethral plate reconstruction is required. Orange, CA© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e27 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Joel Gelman More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...