Stomal Revision Research Articles

2136 IS UROLOGIC SURGICAL TRAINING BENFICIAL IN THE POSTOPERATIVE CARE OF THE RENAL TRANSPLANT PATIENT?

You have accessJournal of UrologyTransplantation & Vascular Surgery: Renal Transplantation, Vascular Surgery I1 Apr 20122136 IS UROLOGIC SURGICAL TRAINING BENFICIAL IN THE POSTOPERATIVE CARE OF THE RENAL TRANSPLANT PATIENT? Hannah Kerr, Antonia Harford, and Michael Davis Hannah KerrHannah Kerr Albuquerque, NM More articles by this author , Antonia HarfordAntonia Harford Albuquerque, NM More articles by this author , and Michael DavisMichael Davis Albuquerque, NM More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.2306AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Historically, urologists have had a dominant role in renal transplantation. However, with the advent of other abdominal organ transplants, this procedure has become the purview of general surgeons. At UNM, renal transplantation is performed by the Division of Urology. We analyzed our experience to ascertain whether renal transplant recipients benefited postoperatively from the surgical expertise of a urologic renal transplant surgeon. METHODS We retrospectively reviewed 172 renal transplants from 2006–2010, looking at operative procedures up to 36 months after transplant that related to the transplant outcome. We compared the procedures that required a urologist to the procedures that any trained renal transplant surgeon could perform. RESULTS 132 of 172 patients (77%) required at least 1 subsequent surgical procedure. 178 procedures were performed. Of these, 144 (81%) were urologic procedures, and 34 (19%) were procedures that any trained renal transplant surgeon could perform. See table. Urologic Procedures Number General Transplant Surgery Procedures Number Cystoscopy/stent removal 119 Removal of PD catheter 15 Native nephrectomy 5 Revision of ureteroneocystotomy 2 TURP/TUIP 4 Seroma/lymphocele drainage 5 Radical orchiectomy 1 Removal of JP drain 2 Ileal conduit stoma revision 1 Transplant nephrectomy 5 Bladder biopsy 1 Wound dehiscence closure 1 Retrograde pyelograms 5 Adrenalectomy 1 Re-stenting 5 Open renal biopsy 3 Deflux injection 2 Dorsal slit 1 Total 144(81%) 34(19%) CONCLUSIONS Our data demonstrates that renal transplant patients benefit from the expertise of a urologist. A number of secondary operations/procedures are performed post-transplant which influence graft outcome. The advantage of having a urologist as the renal transplant surgeon is that care does not have to be coordinated with another specialist. The ultimate benefit is long term continuity of surgical care for these complex patients. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e862-e863 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Hannah Kerr Albuquerque, NM More articles by this author Antonia Harford Albuquerque, NM More articles by this author Michael Davis Albuquerque, NM More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

Ostomy Hemorrhage: Diagnosis and Current Therapeutic Options

Stomal hemorrhage immediately after ostomy creation is typically self-limited and is most often caused by mucosal trauma or a technical error in ostomy construction. In patients with underlying portal hypertension, the development of peristomal varices can result in massive blood loss and may be fatal. Acute stomal bleeding should initially be managed with resuscitation, correction of coagulopathy, and local control of bleeding using direct pressure or suture ligation. Current treatment options for peristomal variceal bleeding include local techniques (sclerotherapy, variceal ligation, selective percutaneous embolization, stomal revision), pharmacologic intervention (beta-blockade), portosystemic shunting procedures, and liver transplantation.

Cutaneous Ureterostomy Technique for Adults and Effects of Ureteral Stenting: An Alternative to the Ileal Conduit

We present surgical modifications that improved the outcome of cutaneous ureterostomies. A total of 310 patients with a median age of 71 years (range 38 to 88) underwent cutaneous ureterostomy as urinary diversion. Median followup was 25 months (range 1 to 172). The technique included 1) transposition of the left ureter above the inferior mesenteric artery, 2) mobilization of the ileocecal segment with repositioning above each terminal ureter, 3) abdominal wall hiatus fixation with 4 angle sutures and 4) YV plasty of the ureters with edge-to-edge anastomosis for stomal creation. In the 161 group 1 patients (59.1%) the Double-J® stents were removed in less than 3 months. Stents remained longer than 3 months in the 111 group 2 patients (40.8%). Of the 272 patients ureteral obstruction developed in 36 (13.2%). Ureteral obstruction was on the right side in 6 patients (2.2%), on the left side in 27 (9.9%) and bilateral in 3 (1.1%). Ureteral obstruction was treated with restenting in 20 cases (55.4%), stomal revision in 12 (33.3%) and conversion to a conduit in 4 (11%). Ureteral obstruction developed on the right side, on the left side and bilaterally in 3.7%, 13.7% and 1.82% of the patients in group 1, and in 0%, 4.5% and 0%, respectively, of those in group 2. Stenting time impacted only the left ureter with less obstruction in the group with longer stent placement (greater than 3 months) (p = 0.01). As with other types of urinary diversion, left ureteral obstruction is a common complication of bilateral cutaneous ureterostomies. Long-term stenting for greater than 3 months and the applied surgical modifications improved the clinical outcome of this type of urinary diversion.

Panniculectomy: an alternative approach to the revision of a difficult stoma

We describe a modified abdominoplasty technique as an alternative approach to the revision of a difficult stoma. A patient with a retracted colostomy secondary to change in abdominal wall contour following significant weight loss was treated with this technique. The patient had previous colostomy revision with marlex mesh insertion for combined parastomal and massive ventral hernia repair. A preoperatively marked crescent shaped left upper quadrant segment of skin and subcutaneous fat was excised and the defect was approximated in multiple layers. This shifted the stoma opening cephalad and eliminated the cutaneous crease that originally made it difficult to obtain a proper stoma seal. At one year follow up the patient was extremely satisfied with the results and was able to properly pouch the stoma. Modified abdominoplasty can be used as an alternative, low morbid approach in dealing with selected patients with difficult stoma problems.

Long-Term Followup and Time to Event Outcome Analysis of Continent Catheterizable Channels

Creation of a continent catheterizable channel has facilitated the treatment of patients undergoing lower urinary tract reconstruction. We present outcomes and complications of a single center series of continent catheterizable channels followed out to 15 years. We retrospectively reviewed medical records of all children who underwent continent catheterizable channel (Mitrofanoff and Monti) between 1992 and 2007. Collected data included age, underlying diagnosis, associated procedures, stoma site, conduit type (appendix or reconfigured bowel), time to complications and need for subsequent surgical revisions. We identified 71 girls and 98 boys who underwent surgery at a mean age of 7.5 years (range 6 months to 22 years) and were subsequently followed for a mean of 5.8 years (8 months to 15 years). Underlying diagnoses included neurogenic bladder (36% of patients), bladder exstrophy (25%), epispadias (6%) and posterior urethral valves (6%). Concurrent procedures were conducted in 71% of cases, including augmentation (35%) and bladder neck plasty (22%) or closure (8%). Surgical revision was performed in 39% of patients, including stomal revision (18%), redo operation (8%), bulking agent injection (8%) and prolapse correction (4%). Although an initial peak was followed by a relatively stable complication-free period, delayed problems were detected on long-term followup. No statistically significant differences in complication rates were noted when comparing use of appendix and reconfigured bowel or different stoma locations. Despite an initial decrease in complications soon after continent catheterizable channel creation, late problems appeared on long-term evaluation. In our experience no specific factor predicted the likelihood of complications. Nevertheless, despite the need for surgical revision, good functional outcomes were evidenced in this series.

1146 CUTANEOUS URETEROSTOMY TECHNIQUE FOR ADULTS AND EFFECTS OF URETERAL STENTING: AN ALTERNATIVE TO THE ILEAL CONDUIT

You have accessJournal of UrologyUrinary Diversion: Bladder Reconstruction, Augmentation, Substitution, Diversion1 Apr 20111146 CUTANEOUS URETEROSTOMY TECHNIQUE FOR ADULTS AND EFFECTS OF URETERAL STENTING: AN ALTERNATIVE TO THE ILEAL CONDUIT Alejandro R. Rodriguez, Alexandre Lockhart, Jeff King, Lucas Wiegand, Rafael Carrion, Raul Ordorica, and Jorge Lockhart Alejandro R. RodriguezAlejandro R. Rodriguez Tampa, FL More articles by this author , Alexandre LockhartAlexandre Lockhart Tampa, FL More articles by this author , Jeff KingJeff King Tampa, FL More articles by this author , Lucas WiegandLucas Wiegand Tampa, FL More articles by this author , Rafael CarrionRafael Carrion Tampa, FL More articles by this author , Raul OrdoricaRaul Ordorica Tampa, FL More articles by this author , and Jorge LockhartJorge Lockhart Tampa, FL More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.745AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Cutaneous ureterostomies (CU) have been an accepted modality for urinary diversion (UD) in children. The procedure has been done sparingly in adults due to surgeons' concern of obstruction. We present surgical technical modifications that have improved the outcomes of this type of urinary diversion. METHODS 310 patients with a median age of 71 years (38–88), received CU as a UD procedure. Median follow-up was 756 days (30–5229). The technique included: a) Mobilization of the left ureter and descending colon; b)Transposition of the left ureter above the IMA to the right hemi abdomen; c) Mobilization of the ileocecal segment with repositioning above both terminal ureters; d) Fixation of the abdominal wall hiatus with four angles sutures; e) Spatulation and Y V plasty of the ureters with edge to edge anastomosis for stoma creation. The first 161 patients (Group A, 59.1%) had the JJ stents removed in the immediate postoperative period. The second group of 111 patients (Group B, 40.8%), kept the stents longer (>3 months). Patients were followed with abdominal CT's and sometimes with lasix renography for evaluation of ureteral function and excretion, in addition to the necessary studies for their primary disease follow-up. The model used for analysis was binary logistic regression, which individually compared the binary response of left (L), right (R) and bilateral (B) renal obstruction, with the time patients had stent involvement. RESULTS 272 patients were available for follow-up. Ureteral obstructions occurred in 36 (13.2%). Fifty-five patients had received preoperative radiation. In the overall group, obstruction occurred on the right (R) in 6 patients (2.2%), on the left (L) in 29 patients (9.9%) and bilaterally (B) in 3 individuals (1.1%). Obstruction was treated with re-stenting in 20 pts (55.4%), stoma revision in 12 pts (33.3%) or conversion to conduit in 4 (11%). Ureteral obstruction occurred in Group A: R (3.7%), L (13.7%), and Bilateral (1.82%). In Group B: R (0%), L (4.5%), and Bilateral (0%). Length of stent placement did not affect obstruction on the right ureter. However, stenting time had an impact on the left ureter, with less obstruction in group B (> 3 months). (p=.01). CONCLUSIONS As in other types of urinary diversions, obstruction of the left ureter is a common complication of bilateral cutaneous ureterostomies. In our experience, long term stenting (>3 months) as well as the surgical modifications applied, improved the clinical outcome of this type of urinary diversion in adults, achieving similar results that are comparable to the ileal conduit. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e460 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alejandro R. Rodriguez Tampa, FL More articles by this author Alexandre Lockhart Tampa, FL More articles by this author Jeff King Tampa, FL More articles by this author Lucas Wiegand Tampa, FL More articles by this author Rafael Carrion Tampa, FL More articles by this author Raul Ordorica Tampa, FL More articles by this author Jorge Lockhart Tampa, FL More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

1191 RESULTS OF A SPLIT APPENDIX TECHNIQUE FOR CONCOMITANT CREATION OF MITROFANOFF AND MALONE CONTINENT CATHETERIZABLE CHANNELS

You have accessJournal of UrologyPediatrics: Reconstructive Surgery1 Apr 20111191 RESULTS OF A SPLIT APPENDIX TECHNIQUE FOR CONCOMITANT CREATION OF MITROFANOFF AND MALONE CONTINENT CATHETERIZABLE CHANNELS Alice Payton, Shumyle Alam, William Defoor, Eugene Minevich, Pramod Reddy, Paul Noh, and Curtis Sheldon Alice PaytonAlice Payton Cincinnati, OH More articles by this author , Shumyle AlamShumyle Alam Cincinnati, OH More articles by this author , William DefoorWilliam Defoor Cincinnati, OH More articles by this author , Eugene MinevichEugene Minevich Cincinnati, OH More articles by this author , Pramod ReddyPramod Reddy Cincinnati, OH More articles by this author , Paul NohPaul Noh Cincinnati, OH More articles by this author , and Curtis SheldonCurtis Sheldon Cincinnati, OH More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.824AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Urinary tract reconstruction in children with complex urologic abnormalities can be challenging. We have previously reported the technique of splitting the appendix to create both a Mitrofanoff neo-urethra as well as a Malone anterograde continence enema. The purpose of this study is to report our experience and longterm outcomes with this technique. METHODS A retrospective cohort study was performed of all children and young adults who underwent continent urinary reconstruction who had their Mitrofanoff and Malone created using a split appendix technique at a single pediatric institution from 1990 to 2010. Patient demographics, surgical technique, complications, and clinical outcomes were abstracted from the medical record. The distal end of the appendix was used for the Mitrofanoff and was implanted into the bladder using an extravesical technique and the stoma matured in the right lower quadrant in all cases. The proximal end of the appendix was used for the Malone and the stoma was brought to either the umbilicus or right lower quadrant. RESULTS A total of 40 patients (22 male and 18 female) were identified. Mean age at the time of reconstruction was 7.0 years and mean follow-up was 4.0 years (range 1–13 years). Diagnoses included myelomeningocele (21), anorectal malformation and cloacal anomalies (13), tethered cord and spinal cord abnormalities (6). There were no intra-operative complications or loss of the appendix due to vascular accident. Mitrofanoff outcomes included stomal stenosis in 5 patients, false passage in 2, and mild incontinence in 2. Mitrofanoff stomal revision for stenosis was required in 4 patients. Malone outcomes included stomal stenosis in 8 patients, fecal leakage in 3 patients, traumatic false passage in 2 patients, and prolapse in one patient. Revision of the Malone stoma was required in 3 patients. In addition, stenosis of the Malone was treated with topical steroids in 2 patients, dilation in 2 patients, and temporary Mic-key button placement in 1 patient. CONCLUSIONS Creation of continent catheterizable channels for both Mitrofanoff neo-urethra and Malone can be safely and effectively performed using a split appendix technique with an extravesical reimplantation into the bladder. This avoids harvesting additional enteric tissue for purposes of a Monti-mitrofanoff or a neo-appendicostomy. A bowel anastomosis is also avoided when an augmentation is not indicated. Stomal complications are not insignificant however, and comprise the majority of complications for this procedure. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e478 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alice Payton Cincinnati, OH More articles by this author Shumyle Alam Cincinnati, OH More articles by this author William Defoor Cincinnati, OH More articles by this author Eugene Minevich Cincinnati, OH More articles by this author Pramod Reddy Cincinnati, OH More articles by this author Paul Noh Cincinnati, OH More articles by this author Curtis Sheldon Cincinnati, OH More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

Novel Use of a Fully-Covered Esophageal Metal Stent in the Treatment of Resistant Anastomotic Stricture Following Gastric Bypass

Purpose: Self-expanding fully covered metal stents have often been used to treat esophageal strictures secondary to malignancy and post-operative anastomotic leaks. In this case, we report the use of such a stent in the successful treatment of a recurrent/resistant post-Roux-en-Y gastric bypass anastomotic stricture. A 41 year-old African American gentleman with morbid obesity underwent a laparoscopic Roux-en-Y gastric bypass and presented in the early post-operative period with complaints of nausea and vomiting. He was diagnosed with a high grade gastro-jejunal anastomotic stricture and underwent through the scope (TTS) balloon dilation but symptoms soon recurred. After a series of failed dilations and a failed surgical stomal revision, the placement of a fully covered esophageal metal stent (Alimaxx® 22x100 mm, Merit Medical Systems, South Jordan, UT) bridging the stricture alleviated all symptoms of obstruction. The stent was attached to the gastric mucosal lining with hemostatic clips to prevent stent migration. Four weeks after stent placement, the stent was successfully removed endoscopically with no complications. The patient has remained symptom free 6 months after successful stent removal and he has continued to lose weight appropriately. Though TTS balloon-dilation has long been accepted as the standard of care for such resistant strictures, this case specifically describes the novel use and possible consequences of the fully covered esophageal stent system when used for resistant stomal strictures. This case report is of specific interest to gastroenterologists and general surgeons who encounter patients in their practice with this serious and common complication of Roux-en-Y gastric bypass.Figure

Embolization of Bleeding Stomal Varices by Direct Percutaneous Approach

Stomal varices can occur in patients with stoma in the presence of portal hypertension. Suture ligation, sclerotherapy, angiographic embolization, stoma revision, beta blockade, portosystemic shunt, and liver transplantation have been described as therapeutic options for bleeding stomal varices. We report the case of a 21-year-old patient with primary sclerosing cholangitis and colectomy with ileostomy for ulcerative colitis, where stomal variceal bleeding was successfully treated by direct percutaneous embolization. We consider percutaneous embolization to be an effective way of treating acute stomal bleeding in decompensated patients while awaiting decisions regarding shunt procedures or liver transplantation.

Synchronous panniculectomy with stomal revision for obese patients with stomal stenosis and retraction

To report our experience of synchronous panniculectomy with stomal revision in morbidly obese patients after radical cystectomy (RC) and ileal conduit urinary diversion (UD). Abnormal skin folds with an uneven surface, stomal retraction and stomal stenosis result in a poorly fitting appliance which leads to urinary leakage, need for frequent change of appliances and skin excoriation. In all, 302 RCs with UD were done by one surgical team between 2002 and 2008, with ileal conduit diversion in 182 (60%); 18 had a body mass index (BMI) of >35 kg/m(2), and among them four had severe stomal stenosis with retraction. We report the technique we used for managing stomal stenosis in these patients. The mean (range) BMI of the patients was 42 (38-46) kg/m(2); all were women. The mean (sd) operative duration was 2 (0.5)h. The drain was removed once the drainage was <25 mL in 24 h. The mean (sd) hospital stay was 3 (1) days; there were no significant complications. After a mean follow-up of 3 years there was no recurrent stomal stenosis or retraction. The unique advantage of this procedure is that it avoids laparotomy in a morbidly obese patient, and it provides excellent cosmesis while correcting the stomal complication.

Incisionless revision of post-Roux-en- Y bypass stomal and pouch dilation: multicenter registry results

Background Surgical revision for weight regain after Roux-en- Y gastric bypass (RYGB) has been tempered by the high complication rates associated with standard approaches. Endoluminal revision of stoma and pouch dilation should intuitively confer a better risk profile. However, questions of clinical safety, durability, and weight loss need to be answered. We report our multicenter intraoperative experience and postoperative follow-up to date using the Incisionless Operating Platform for this patient subset. Methods The patients who had regained significant weight ≥2 years after RYGB after losing ≥50% of excess body weight after RYGB were endoscopically screened for stomal and/or pouch dilation. Qualified patients underwent incisionless revision using the Incisionless Operating Platform to reduce the stoma and pouch size by placing anchors to create tissue plications. Data on the safety, intraoperative performance, postoperative weight loss, and anchor durability were recorded to date as a part of 2 years of postoperative follow-up. Results A total of 116 consecutive patients were prospectively studied. Anchors were successfully placed in 112 (97%) of 116 patients, with an average intraoperative stoma diameter and pouch length reduction of 50% and 44%, respectively. The operating room time averaged 87 minutes. No significant complications occurred. At 6 months after the procedure (n = 96), an average of 32% of weight regain that had occurred after RYGB had been lost. The percentage of excess weight loss averaged 18%. The 12-month esophagogastroduodenoscopy results confirmed the presence of the anchors and durable tissue folds. Conclusions Incisionless revision of stoma and pouch dilation using the Incisionless Operating Platform can be performed safely. The data to date have demonstrated mild-to-moderate weight loss, and the early 12-month endoscopic images have confirmed anchor durability. Patients were actively followed up to document the long-term durability of this intervention in the entire patient subset.

A Case of Refractory Peristomal Variceal Bleeding Post-TIPSS and Review of the Therapeutic Options

Purpose: Results: A 69 year old man has a history of Ulcerative Colitis with total abdominal colectomy with ileostomy performed Febuary 2002 due to treatment refractory disease. He presented four years later with presumed lower GI bleed with bright red blood noted in his ostomy bag. Ileoscopy performed at that time showed normal ileal mucosa, while careful inspection of the ileostomy site showed continued oozing from an external source. Upper endoscopy was performed to assess other signs of portal hypertension showing mild gastropathy and small esophageal varices. Non-selective beta-blocker therapy was initiated at that time with a diagnosis of Laennec's Cirrhosis. A diagnosis of peristomal varices was made after confirmation on review of abdominal imaging. Recurrent bleeding continued to require hospitalization and transfusion on three separate presentations leading to initial TIPSS procedure as well as revision bringing porto-systemic pressure gradient from 15 mmHg to 4 mmHg. He was placed prophylactically on lactulose at that time, but progressive difficulties required the addition of rifaximin. Despite the TIPSS procedure, he continued to have episodes of bleeding from his peristomal varices requiring transfusion. Conservative measures were initially employed in attempts to control bleeding after repeat porto-systemic pressure gradient measurement confirmed a widely patent TIPSS. Application of silver nitrate, oversewing with suture, and injection sclerotherapy were all attempted in addition to direct pressure without durable result. After initial consultation with Colorectal Surgery, his ostomy was taken down and re-sited for definitive therapy of his recurrent peristomal variceal hemorrhage. In the 13 months since revision of his ileostomy, he has had far fewer difficulties with bleeding only requiring transfusion on two occasions. Conclusion: Peristomal variceal bleeding is difficult to control and can be a life-threatening complication of portal hypertension in patients with colonic resection requiring ileostomy. In patients with advanced liver disease as defined by Childs Classification, ectopic variceal bleeding frequently represents a terminal event. Stoma revision with devascularization has been found in previous reports to be temporarily effective in reducing recurrent peristomal variceal bleeding and has reduced the need for transfusion in our patient. Liver transplantation remains the only potential therapy for our patient at this time, but given his age and comorbid medical status it has been determined that he is not a candidate.

PL-313: Incisionless revision of post Roux-en-Y bypass stomal and pouch dilatation: Multi-center registry results

Surgical revision for weight regain after Roux-en-Y gastric bypass (RYGB) has partially failed to gain acceptance due to higher complication rates associated with standard approaches. Endoluminal revision of stoma and pouch dilatation should intuitively confer a better risk profile. However, questions of clinical safety, durability, and weight loss need to be answered. We report our multi-center intra-operative experience and post-operative follow-up to date utilizing the EndoSurgical Operating System™ (EOS) for this patient subset.

Mitchell's Detrusor Wrap-Around Bladder Neck (Dwbn), Ileocystoplasty, and the Extramural Serous-Lined Continent Outlet: An Optimal Triad

Purpose Providing continence for children with non compliant bladder and low detrusor leak point pressure secondary to neuropathic dysfunction or bladder exstrophy is a challenging task. A one stage reconstruction triad is presented. Material and Methods Between May 2005 to July 2008, 21 patients underwent DWBN, ileocystoplasty, and extramural serous lined tunnel as continent outlet in one stage. Patients included 15 boys and 6 girls with mean age of 7.6 years. Nine patients had previous complete repair of bladder exstrophy, 4 had staged repair and 8 had neuropathic bladder dysfunction. The ileum was fashioned in the shape of U in 4, S in 13, and W in 4. The appendix was used in 17 and Monti was used in 4. Neo umbilicus was constructed for the outlet in 13. In all patients the continent outlet was located in the umbilicus or a neo-umbilicus. Results Mean follow-up duration was 19 months (range 4-39). Early postoperative complications included prolonged ileus in 1 and urine leak in 1 and both were conservatively managed. Vesicoureteral reflux persisted in 13/21 (62%) patients. All patients were completely dry on CIC except 1. The leakge was through the urethra and was successfully managed by macroplastique injection at the bladder neck. No patient leaked through the continent outlet. Stomal stenosis was encountered in 2 patients with neo-umbilicus and both had stomal revision. No patient had bladder stones or perforation during follow-up. Conclusions Children with urinary incontinence secondary to the combination of a non-compliant bladder and sphincteric deficiency could be optimally managed with this triad. The DWBN provides optimal bladder neck reconstruction. The extramural serous-lined technique has the advantages of a leak-proof continent outlet, ease of catheterization through a straight channel, and the orthotopic position of the outlet in the umbilicus/neo-umbilicus in all patients.

Mitrofanoff continent catheterizable conduits: Top down or bottom up?

During augmentation and Mitrofanoff procedures, conduits are usually implanted into the posterior bladder wall. Anatomical considerations may necessitate an anterior conduit. To compare the relative drainage efficiency in patients with posterior and anterior conduits, we studied their rates of bladder stone formation and urinary tract infection (UTI). A retrospective chart review identified exstrophy patients who underwent augmentation and Mitrofanoff between 1991 and 2003. Patients with 3 years or greater follow-up were included. Fifty-four patients fit this criterion, with a conduit implanted anteriorly (33) or posteriorly (21). We compared rates of bladder stone formation and UTI. Stomal revisions and the status of the bladder neck were also noted. Stone formation and UTI rates were higher in the anterior conduits, although only UTI showed a statistically significant difference. Patient demographics were similar between the two groups, including age and sex. The rates of stomal complications and the bladder neck status were also similar. Patients with anterior conduits had an increased risk of UTI and bladder stone formation compared to those with posterior conduits, although this was not significant in the case of bladder stone rate. This may indicate sub-optimal bladder drainage and should be addressed with careful preoperative counseling and close follow-up.

Minimally invasive total Proctocolectomy with Brooke Ileostomy for Ulcerative Colitis

In the 21st century, minimally invasive surgery (MIS) for ileal pouchanal anastomosis (IPAA) has emerged as the procedure of choice for the surgical treatment of chronic ulcerative colitis (CUC). However, minimal literature exists regarding MIS total proctocolectomy with permanent Brooke ileostomy (TPC-BI). The aim of this study was to describe the safety and feasibility of MIS TPC-BI for CUC. Using a prospective institutional database, we identified a cohort of CUC patients who underwent MIS TPC-BI from 2000 - 2007. Peri-operative variables and short-term (30-day) outcomes were abstracted. Statistically significant differences between three MIS subgroups were assessed using Kruskal-Wallis and Fisher's exact test for continuous and categorical variables, respectively; p>0.05 were considered not significant. Numbers represent frequency (proportion), or median (range). Over 7 years, 44 patients underwent MIS proctocolectomy with permanent ileostomy for CUC. Median age was 65 years (54 - 73), 24 were male (55%), and the BMI was 26.5 (22.1 - 30.2) kg/m2. Duration of disease was 66 months (24 - 240); 18 (40%) patients had prior abdominal surgery, with a median Charlson score of 3 (0 - 4). The surgical indication was refractory colitis in 36 (82%), and neoplasia in 8 (18%). Factors influencing the non-restorative surgical approach were advanced age in 18 (41%), lifestyle in 13 (30%), medical comorbidities in 11 (25%), fecal incontinence in 10 (23%), oncologic reasons in 3 (6.8%), and obesity in 3 (6.8%); 18 (41%) of patients had >1 factor. MIS approaches included hand-assisted laparoscopic surgery (HALS) in 23 (52%), laparoscopic-assisted (LAP) in 13 (30%); and laparoscopic-incisionless (INC-LESS) with transanal specimen extraction in 8 (18%). Operative variables and outcomes are shown in Table 1. Two LAP cases (4.6%) were converted, and one HALS patient (2.2%) required transfusion after a pelvic bleed. Operative time was 329 (173 - 538) minutes, and length of stay 5 (3 - 10) days. Major post-operative complications (>= Clavien grade 3) occurred in 4 (9%) including stoma revision in 3 (7%), and relaparoscopy for pelvic bleeding in 1 (2.2%). There were no 30 day mortalities. Operative Variables and Outcomes Operative Variables and Outcomes MIS total proctocolectomy with Brooke ileostomy is a safe and feasible option for the surgical treatment of ulcerative colitis. These surgical approaches offer short lengths of stay and low morbidity rates, and should be considered in patients with refractory CUC or neoplasia who choose not to undergo, or who have contraindication to, IPAA.

Ileostomy revision using noncutting linear stapler

The study aimed to evaluate the outcome of ileostomy revision for retraction and prolapse using noncutting linear stapler. Forty five patients undergoing a total of 94 stapled revisions between 1.1.1995 and 31.12.2005 were identified by the unique code for stomal revision. Medical records for all patients were examined. Thirty-five (77.8%) of the 45 patients were women. In 43 (95.6%), the indication was stomal retraction. Median follow-up was 28 months (2-122). One or more stapling procedures resulted in a normal stoma at follow-up in 18 (41.9%) of 43 patients treated for stomal retraction. When other types of repair were included, a normal stoma was achieved in 30 (69.8%) of 43 patients. Patients with a low BMI had the lowest success rate (44%), but none of the possible factors analysed for influence on success had a statistically significant impact. Two patients were treated for prolapse, and both needed other types of revision. Stapled ileostomy revision is easy to perform and has a low morbidity. Less than half the patients achieve a satisfactory long-term result after one or more stapling procedures. Many patients still benefit from other types of revision when stapling has failed.

Gastrojejunal stomal reduction with the T-tag device in porcine models (with videos)

Roux-en-Y gastric bypass is the most commonly performed bariatric operation in the United States. Gastrojejunal (GJ) stomal dilatation associated with weight regain is a late complication. Surgical revision is usually required for stomal or pouch reduction. Our purpose was to evaluate the technical feasibility, efficacy, and safety of stomal reduction with endoscopic T-tag devices. Prospective nonsurvival studies were conducted in pigs (n = 2, 110 pounds each). Three GJ stomas were created in each pig through a midline laparotomy by using circular staplers. Endoscopic GJ stomal reduction/revision was performed on these newly created stomas with an Olympus T-tag device. Necropsy was performed to examine the deployed T-tag locations and procedure-related adjacent tissue/organ injury and to assess the effectiveness of stomal reduction. Endoscopic stomal revision was performed on 5 stomas with moderate stomal reduction. One GJ stoma could not be accessed easily by endoscopy because of the small size of the gastric pouch. An average of 4 T-tag devices was deployed around each stoma. The procedural time was about 61 +/- 12 minutes for each stomal reduction. Overall, 26 of 39 (66.7%) T-bars were deployed in accepted locations. The stomas were reduced from 1.60 +/- 0.21 mm x 1.44 +/- 0.14 mm to 1.28 +/- 0.29 mm x 0.98 +/- 0.17 mm and the percentage of stomal reduction was 27.3% +/- 13.3%. In the end, a therapeutic gastroscope could not be advanced through the reduced stomas. In 2 stomas, 5 of 39 (12.8%) T-bars injured or attached to the adjacent organs: isolated stomach and abdominal wall. Nonsurvival pig studies. Endoscopic stomal reduction with T-tag device is technically feasible and effective in two thirds of trials. However, it is associated with a small risk of adjacent organ/tissue injury with the current prototype device and deployment method.

Use of Customized MIC-KEY Gastrostomy Button for Management of MACE Stomal Complications

Severe bowel dysfunction often accompanies neurogenic bladder, and Malone antegrade continence enema procedures can lead to improvement in the quality of life for these patients. The most commonly reported complication has been stomal stenosis of the conduit. We report our experience with the use of the MIC-KEY gastrostomy button for the management of this complication. A retrospective cohort study of 53 consecutive children who had undergone the Malone antegrade continence enema (ACE) procedure from 2000 to 2006 was performed. The records of patients with stomal complications were assessed for presentation, management, and outcomes. We identified 20 patients (38%) with stomal stenosis. Stomal dilation and stenting alone was successful in 4 patients, and stomal revision was necessary in 16 (30%). Six children required placement of the MIC-KEY gastrostomy button into the ACE stoma for recurrent stomal stenosis (n = 5) or a buried stoma (n = 1). All patients were successfully treated with placement of a MIC-KEY button to continue their bowel irrigation. The size of the button was determined by the endoscopic assessment of the length and width of the ACE stoma and was custom made by the manufacturer. The average time that the button was in place was 26 months, and it was generally changed every 3 months. In the rare subset of patients with recurrent stomal stenosis or a buried stoma, the MIC-KEY gastrostomy button was found to be a practical and easy method for the management of these conditions and to preserve the ACE conduit.

Rectus sheath tunnels for continent stomas

Continent stoma rectus sheath tunnel (CSRST) has been used in antegrade colonic enema (ACE) and urinary continent cutaneous diversion (UCCD) stomas to reduce leakage and to support a straight track for the continent conduit. All patients that underwent CSRST between 1995 and 2005 were identified and their case notes retrospectively reviewed. Patients were divided into two groups: the ACE group and the UCCD group. Demographic data, age at surgery and complications including stenosis and leakage were recorded. Forty patients underwent CSRST between 1995 and 2005. The mean age and standard deviation (SD) at surgery was 6.8 (2.1) years. Eighteen patients underwent ACE with a mean (SD) follow-up of 7.6 (3.1) years. No patient has faecal leakage. No patient had stomal revision, but one patient (5.5%) required an indwelling gastrostomy button to maintain patency. Twenty-two patients underwent UCCD with a mean (SD) follow-up of 8.1 (2.8) years. No patient developed urinary leakage. Two patients (9%) required revision of the stoma and one (4.5%) required an indwelling catheter because of recurring stomal stenosis. CSRST prevents stoma leakage. Revision surgery rate after CSRST is low, particularly after ACE reconstruction.