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PubMedDate not supplied

Organ-preserving resection of the gastroesophageal junction and substitution with a gastric corpus rotation tube: an experimental study.

Premalignant lesions of the gastroesophageal junction are treated conservatively or by antireflux surgical procedures. We describe a novel technique that replaces the distal esophagus after resection of the gastroesophageal junction. After resection of the gastroesophageal junction, 16 pigs were divided into two groups. In group 1 (n = 9) the gastroesophageal junction was replaced with a 3 cm wide horizontal gastric corpus tube, pedicled at the lesser curvature. In group 2 (n = 7) the tube was pedicled at the greater curvature. Tube length, volume, and compliance of the gastric remnant and blood flow in the tube (by laser Doppler flowmetry given in perfusion units [PU]) were measured before and after tube formation and 2 weeks postoperatively. Group 1 tubes were 9.5 +/- 1. 5 cm long and group 2 tubes were 8.2 +/- 0.7 cm long. Tube formation decreased volume and compliance of the gastric remnant. After tube formation, blood flow at the tip of the tube decreased from 254 PU to 64 +/- 22 PU (group 1) and 87 +/- 36 PU (group 2). Volume, compliance, and blood flow returned to baseline values 2 weeks postoperatively. No anastomotic leakage was found on postmortem examination. Horizontal gastric corpus tubes might offer an alternative to replace the distal esophagus and proximal stomach after resection of premalignant lesions of the gastroesophageal junction.

Animals↗
PubMed1999

Prosthesis implantation after radial free flap phalloplasty in patients with bladder exstrophy.

METHODS: Inflatable penile prosthesis were implanted into sensate radial free-flap phalloplasties in two adult patients with bladder exstrophy. RESULTS: Neither patient reported loss of sensation, and both were able to inflate the prosthesis and engage in sexual intercourse three months later. CONCLUSION: The construction of a functional neophallus is well described however has not previously been reported in exstrophy patients who are suited to this procedure due to the presence of crura, and the absence of a neourethra. Scarring from previous reconstructive procedures however may make implantation difficult, and long-term follow up is required to evaluate this procedure in patients with bladder exstrophy.

Adult↗
PubMed2000

Clinical, urodynamic and endoscopic characteristics of the stanford pouch ileal neobladder constructed with absorbable staples.

PURPOSE: The clinical, urodynamic and endoscopic aspects of the Stanford pouch ileal neobladder formed with absorbable staples were investigated. METHODS: A Stanford pouch ileal neobladder was formed using absorbable staples after radical cystoprostatectomy in 30 male patients with the diagnosis of muscle invasive carcinoma of the bladder between 1995 and 1998. The mean age of the patients was 62 (range 41-70) years. Patients were followed with arterial blood gas, serum biochemistry, pouch cystography, urodynamic tests and endoscopy. RESULTS: Five (16.7%) patients had early postoperative complications and three were related to the neobladder. One year postoperatively, low grade (I, II) vesicoureteral reflux was present in five (16.7%) cases. The mean preoperative and 6 months postoperative serum creatinine levels were 1.07+/-0.3 mg/dL and 1.2+/-0.4 mg/dL, respectively, but the difference was not statistically significant (P=0.1). Six months postoperatively the mean serum chloride level was 109+/-4.5 (range 100-113) mmol/L and the mean arterial blood pH was 7.37+/-0.2 (range 7.3-7.4). Two (6.7%) patients required oral alkaline supplementation because of high chloride levels. All the patients except one were continent throughout the day after 1 year. However, nocturnal enuresis was present in 25 (83.3%) cases. The pouch capacity was increased gradually up to 12 months postoperatively and the mean pouch capacity 12 months postoperatively was 460+/-95.8mL. Micturition occurred spontaneously in most patients while some needed abdominal straining. None of the patients had a residual urine of more than 60 mL. The mean maximum flow rate 6 months postoperatively was 9.8 (range 5.4-15.0) mL/s. After 6 months the stapled edge was noticed as a nodular line. One year postoperatively only a white scar could be observed at the suture line. CONCLUSION: The Stanford pouch ileal neobladder constructed using absorbable staples was able to provide a good capacity low pressure reservoir with a low rate of complications.

Absorbable Implants↗
PubMed1999

Three parameters optimizing closed-loop control in sequential segmental neuromuscular stimulation.

In conventional dynamic myoplasties, the force generation is poorly controlled. This causes unnecessary fatigue of the transposed/transplanted electrically stimulated muscles and causes damage to the involved tissues. We introduced sequential segmental neuromuscular stimulation (SSNS) to reduce muscle fatigue by allowing part of the muscle to rest periodically while the other parts work. Despite this improvement, we hypothesize that fatigue could be further reduced in some applications of dynamic myoplasty if the muscles were made to contract according to need. The first necessary step is to gain appropriate control over the contractile activity of the dynamic myoplasty. Therefore, closed-loop control was tested on a sequentially stimulated neosphincter to strive for the best possible control over the amount of generated pressure. A selection of parameters was validated for optimizing control. We concluded that the frequency of corrections, the threshold for corrections, and the transition time are meaningful parameters in the controlling algorithm of the closed-loop control in a sequentially stimulated myoplasty.

Algorithms↗
PubMed1999

Feminizing genital reconstruction, sigmoid vaginal replacement and anorectoplasty as a one-stage procedure for anorectal atresia associated with ambiguous genitalia.

Anorectal atresia associated with male pseudohermaphroditism presents both diagnostic and surgical challenges. In the past, multiple operations were necessary for feminizing genitoplasty in gender-reassigned children with ambiguous genitalia. We combined the repair of an imperforate anus with a feminizing genitoplasty, including sigmoid vaginal replacement using the posterior sagittal approach in a 3-months-old infant. We conclude that a primary complete reconstruction is advantageous and should be performed in this condition.

Anus, Imperforate↗
PubMed2001

Vaginal creation for müllerian agenesis.

OBJECTIVE: The purpose of this study was to determine the effectiveness of passive vaginal dilation and McIndoe vaginoplasty in the creation of a neovagina for patients with müllerian agenesis. STUDY DESIGN: Fifty-one patients with Mayer-Rokitansky-Kuster-Hauser syndrome were treated for vaginal agenesis at either Johns Hopkins Hospital or Emory University. These historic prospective data were obtained by a review of medical records and a current office or telephone consultation. Initial office visits dated from November 18, 1983, through June 6, 1998. Their progress towards both anatomic and functional success was followed through August 1, 2000, which was a range of 2 to 16.8 years. One-way analysis of variance, Student t test, and logistic regression analysis were performed when appropriate. RESULTS: Four patients were lost to follow-up in various stages of the treatment. Ten patients refused vaginal dilation and proceeded to a successful modified McIndoe vaginoplasty. Of the 37 remaining patients, 91.9% anatomic and functional success was achieved from the Ingram method for vaginal dilation. Passive dilation failed in 8.1% of patients, who underwent a modified McIndoe vaginoplasty; all neovaginal creations were successful. All patients who underwent McIndoe vaginoplasty were compliant with postoperative vaginal form use. None of our patients lost vaginal space through contractions or loss of skin graft. Of those patients for whom dilation failed, only 1 patient discontinued the study because of bleeding and discomfort. In addition, only 1 patient from the 3 cases of failure had undergone a previous hymenotomy. Interestingly, 6 patients for whom dilation was successful (6/34 patients; 17.6%) had also undergone a previous hymenotomy. The mean follow-up time for all patients in this study was 111.1 +/- 7.2 months, with a range of 25 to 188 months. The mean follow-up time for those patients for whom dilation failed or who refused dilation was significantly lower at 64.5 +/- 9.5 and 65.3 +/- 18.5 months, respectively (P <.005). The mean time to successful dilation was 11.8 +/- 1.6 months with a range of 3 to 33 months. Although longer, no statistically significant difference was observed for dilation time in those patients for whom there was a failure to achieve anatomic or functional success (20.5 +/- 12.5 months; range, 8-33 months). CONCLUSION: These data reveal that passive dilation with the Ingram method is capable of creating an adequate vaginal canal in patients with vaginal agenesis, with respect to both function and anatomy even in those patients with a previous hymenotomy and resultant scar formation. Our modified McIndoe procedure has proved to be an excellent option for patients for whom conservative dilation techniques failed and who refuse to attempt any dilation. Interestingly, our data indicate that patients may now be trending toward immediate surgical correction rather than diligently using dilation techniques to create a vaginal space.

Dilatation↗
PubMed2000

End-to-side pudendal nerve anastomosis for the creation of a new reinforcing anal sphincter in dogs.

BACKGROUND: An ideal reinforcing neo-sphincter should be innervated by the pudendal nerve to work in coordination with the external anal sphincter. The aim of this study was to create a skeletal muscle innervated by the pudendal nerve without inducing external anal sphincter morbidity. METHODS: Seven dogs were used. On the right side of each dog, the distal end of the transected nerve innervating the biceps femoris muscle was anastomosed to the perineural window of the pudendal nerve, where the epineurium was excised over a small area without injuring the funiculus. Reinnervation was studied 5 months after the operations. The left side of the dogs was used as a control. RESULTS: For all 7 dogs, there was no macroscopic difference detected in the external anal sphincter. For 6 dogs, the biceps femoris muscle was preserved after end-to-side pudendal nerve anastomosis. After the pudendal nerve central to the anastomosis site was electrically stimulated, the external anal sphincter contracted in all dogs. After end-to-side pudendal nerve anastomosis, the biceps femoris muscle contracted with the evoked potential in 5 dogs (71%) and demonstrated electric activity at rest in 3 dogs (43%), but there was no reflex activity after anal stimulation. The ratio of type 1 to type 2 muscle fiber in the biceps femoris muscle after end-to-side pudendal nerve anastomosis significantly changed and became the same as that in the external anal sphincter. The diameter of type 2 muscle fibers in the biceps femoris muscle significantly decreased after surgery. In addition, regenerated myelinated axons were observed in a cross section of the anastomosed nerve in 6 dogs. CONCLUSIONS: End-to-side pudendal nerve anastomosis is a promising technique for the creation of an anal sphincter in patients who have fecal incontinence. The technique preserved the original external anal sphincter and created a skeletal muscle that was innervated by the pudendal nerve in 71% of the dogs studied. This newly innervated skeletal muscle was capable of contracting in coordination with the original external anal sphincter on electric stimulation and also demonstrated characteristics closely similar to those of the external anal sphincter.

Anal Canal↗
PubMed2001

Surgically created double-orifice left atrioventricular valve: a valve-sparing repair in selected atrioventricular septal defects.

OBJECTIVES: Some features of the left atrioventricular valve (large mural leaflet, dystrophic tissue) represent a challenge for repair of atrioventricular septal defects without postoperative regurgitation. A retrospective study was conducted to evaluate the results of surgically creating a double-orifice left atrioventricular valve in such circumstances. Clinical results were analyzed according to valvular and subvalvular left atrioventricular valve measurements in pathologic specimens with atrioventricular septal defects. METHODS: Among 157 patients operated on for atrioventricular septal defect since October 1989, 10 patients underwent primary repair (n = 8) or reoperation (n = 2) by this procedure. Median age at repair was 3.3 years (0.1-33 years). Anatomic types were complete (n = 3), intermediate (n = 5), and partial (n = 2). Preoperative moderate to severe left atrioventricular valve regurgitation was present in 6 patients. After the repair (two-patch technique in complete atrioventricular septal defect, cleft closed in each case), these 10 patients were found to have moderate to severe residual regurgitation not amenable to repair by annuloplasty. The top edge of the mural leaflet was anchored to the facing free edge of the cleft. RESULTS: No hospital death or morbidity was observed. Left atrioventricular valve regurgitation was absent or trivial (8 patients) and mild (2 patients). Color-coded echocardiography did not show significant left atrioventricular valve stenosis. The mean diastolic pressure gradient across the left atrioventricular valve was 3.2 +/- 1.1 mm Hg (1.4-4.5 mm Hg). At a median follow-up of 72 months (6-91 months), there was 1 late death, unrelated to left atrioventricular valve malfunction, due to pulmonary vascular obstructive disease. Left atrioventricular valve regurgitation did not increase over time, except in 1 patient in whom regurgitation recently progressed from mild to moderate. At rest, the mean diastolic pressure gradient across the left atrioventricular valve was 3.8 +/- 2.9 mm Hg (1.5-11.2 mm Hg). One child had an early moderate stenosis without pulmonary hypertension. Studies on pathologic specimens (n = 34) indicated that long chordal lengths and large mural leaflet size are essential independent anatomic features to assess its feasibility. CONCLUSIONS: Surgical creation of a double-orifice left atrioventricular valve is an effective additional procedure for repair of atypical cases of atrioventricular septal defect. The operation may decrease the need for reoperation or left atrioventricular valve replacement.

Adult↗
PubMed2001

Laparoscopic orthotopic ileal neobladder.

BACKGROUND AND PURPOSE: Orthotopic ileal neobladder is currently the preferred continent urinary diversion in suitable patients undergoing radical cystectomy for muscle-invasive bladder cancer. To our knowledge, presented herein is the initial report of laparoscopic orthotopic ileal neobladder following cystectomy that was performed completely intracorporeally in a porcine model. MATERIALS AND METHODS: The laparoscopic technique was developed in seven pigs. Subsequently, a long-term survival study was performed in 12 consecutive animals. Laparoscopic cystectomy was performed, preserving the urethral sphincter. An ileal segment of 35 cm (first three animals), 45 cm (next four), or 55 cm (final five animals) with adequate mesentery was isolated; and ileal continuity was restored intracorporeally by a stapled anastomosis. Ileal detubularization for construction of an ileal neobladder, urethroileal anastomosis, and bilateral stented ileoureteral anastomoses to a tubular Studer limb extension were all created completely intracorporeally using only laparoscopic free-hand suturing and knot-tying. Biochemical data (preoperative and serial postoperative hemoglobin, renal panel, blood gases), radiologic studies (intravenous urogram, retrograde pouchgram), functional measures (neobladder urodynamics, Whitaker pressure-flow study of both ureters), and microscopic evaluation of the neobladder and ureteroileal and urethroileal anastomotic sites were obtained to evaluate the long-term functional and anatomic outcome. RESULTS: Completely intracorporeal laparoscopic construction of an ileal orthotopic neobladder was successful in all 12 animals without intraoperative or early postoperative complications or open conversion. The mean operating time was 5.4 hours (range 4.5-6.5 hours), and the blood loss was minimal. All study pigs survived their predetermined follow-up period, ranging from 1 to 3 months. Late complications occurred in three animals: one port-site abscess and two cases of E. coli pyelonephritis and azotemia, leading to one death at 2 months. The mean serum creatinine concentrations were 1.33 mg/dL, 1.61 mg/dL, and 1.55 mg/dL at 1, 2, and 3 months, respectively. The mean neobladder capacity was 420 mL (range 250-700 mL) with pressures < or = 20 cm H2O (range 17-20 cm H2O). Pre-euthanasia Whitaker testing confirmed excellent drainage in all 24 ureters. No ileoureteral or ileourethral anastomotic strictures or leaks were noted on intravenous urography, retrograde pouchgram, or postmortem physical calibration of the anastomotic sites. Histologic examination confirmed excellent healing without obvious fibrosis. CONCLUSION: Laparoscopic construction of an orthotopic neobladder is feasible. The anatomic and functional outcome is excellent and comparable to that of open surgery. Clinical application is imminent.

Animals↗
PubMed2001

Recurrent urethral hairball and stone in a hypospadiac: management and prevention.

A 32-year-old perineal hypospadiac man presented with recurrent urethral hair growth, stone, and stricture with a history of multiple urethroplasties. He was treated by urethrolithotomy, internal urethrotomy, laser epilation of the hair-bearing urethral graft, closure of the fistula, and chemical depilation of the neourethral hair. A dilute solution of thioglycolate was prophylactically instilled into the neourethra at intervals of 3 months to ensure complete tricholysis and to prevent recurrent hair growth in the future.

Adult↗
PubMed2001

Transperitoneal guide-wire or drainage catheter placement for guidance of laparoscopic marsupialization of lymphocoeles post renal transplantation.

BACKGROUND: Lymphocoeles post renal transplantation can be difficult to see laparoscopically. The objective of this study was to report a new technique of catheter or guide-wire placement for the guidance of laparoscopic marsupialization of symptomatic post renal transplant lymphocoeles, refractory to conservative therapy. METHODS: Conventional aseptic technique under local anaesthesia was used for guide-wire or catheter insertion, with the difference being the use of a transperitoneal approach. Computerized tomography (CT) or ultrasound (US) guidance was used. All lesions were confirmed to be sterile lymphocoeles beforehand by either needle aspiration or previous catheter drainage. RESULTS: Four catheters and one guide-wire were placed pre-operatively without complication. All cases underwent satisfactory laparoscopic marsupialization. No immediate complications were noted in any patient. The drainage catheters were inserted between 5 and 19 days before laparoscopic marsupialization, and guide-wire inserted immediately before. All patients proceeded to laparoscopic marsupialization. CONCLUSIONS: This technique offers precise guidance on laparoscopic surgery, is relatively simple to perform and no complications were experienced in this study. Its use is limited to sterile and benign lesions due to the risks of peritoneal seeding, making recurrent post-operative lymphocoeles ideally suited for this application.

Adult↗
PubMed1998

Microsurgical reconstruction of the digestive tract following pharyngolaryngectomy and total esophagectomy.

Total pharyngoesophageal reconstruction has remained a challenging field in digestive surgery. During the past 3 years, the authors performed six microsurgical reconstructions of the digestive tract following pharyngolaryngectomy and total esophagectomy due to a multiple cancer or skip metastasis. Digestive continuity was restored using a combination of a pulled-up gastric pedicle and free jejunal transfer in 2 patients, and an elongated gastric pedicle with microvascular augmentation in 4 patients. One elongated gastric pedicle developed partial necrosis, and a free jejunal graft was placed additionally. One patient suffered from respiratory dysfunction and died 1 month after surgery. Postoperative radiographic examination showed a good swallowing mechanism without reflux and stasis in all patients. Microvascular surgery contributes to the successful reconstruction of the digestive tract following extensive pharyngolaryngoesophagectomy.

Aged↗
PubMed2000

Colon interposition for esophageal replacement: an alternative technique based on the use of the right colon.

OBJECTIVE: To describe the technique and results of an alternative colon interposition procedure in which the ascending and transverse colon is used as graft, but that still relies on the left colonic artery for blood supply. SUMMARY BACKGROUND DATA: The standard procedure to obtain a left colon interposition graft requires ligation of the middle colic artery and mobilization of the left and right flexure. This approach carries a risk because preparation of the left flexure may damage arterial or venous collaterals located at this site that are crucial for graft perfusion. METHODS: The authors modified the standard technique so that mobilization of the left flexure is no longer necessary. To obtain a colon interposition graft that is long enough, the ascending colon was included into the graft by ligating the middle and the right colic artery. The left colic artery remained the blood-supplying vessel. From January 1997 to June 1998, 15 patients underwent modified colon interposition with a cervical anastomosis (12 esophagectomies, 3 esophagogastrectomies). RESULTS: In all cases, intraoperative blood supply from the left colic artery to the proximal ascending colon was sufficient. After surgery, four major complications occurred (27%). Endoscopy demonstrated a vital graft in all patients. In one patient a leakage of the cervical anastomosis was observed. One patient died of herpes pneumonia. Postoperative artificial ventilation was required for an average of 2.8 +/- 4.6 days, the average intensive care unit stay was 6.9+/-4.5 days, and the average total hospital stay was 24.1 +/- 15.1 days. CONCLUSION: An intact left colic artery, including its collaterals at the splenic flexure, supplies sufficient blood to the proximal ascending colon after central ligation of the middle and right colic artery. Even without mobilization of the left flexure, a sufficient graft length can be obtained. Preliminary complication rates with the use of this technique for colon interposition are in the range of those found for the standard colon interposition technique. These modifications may represent an alternative to established procedures for creating a colon interposition graft.

Anastomosis, Surgical↗
PubMed2001

Denervated stomach as an esophageal substitute recovers intraluminal acidity with time.

OBJECTIVE: To determine whether the denervated stomach as an esophageal substitute recovers normal intraluminal acidity with time. SUMMARY BACKGROUND DATA: Bilateral truncal vagotomy to the stomach as an esophageal substitute reduces both gastric acid production and antral motility, but a spontaneous motor recovery process takes place over years. METHODS: Intraluminal gastric pH and bile were monitored during a 24-hour period 1 to 195 months after transthoracic elevation of the stomach as esophageal replacement in 91 and 76 patients, respectively. Nine patients underwent a second gastric pH monitoring after a 3-year period. The percentages of time that the gastric pH was less than 2 and bile absorbance exceeded 0.25 were calculated in reference to values from 25 healthy volunteers. Eighty-nine upper gastrointestinal endoscopies were performed in 83 patients. Patients were divided into three groups depending on length of follow-up: group 1, less than 1 year; group 2, 1 to 3 years; group 3, more than 3 years. RESULTS: The prevalence of a normal gastric pH profile was 32.3% in group 1, 81.5% in group 2, and 97.6% in group 3. The percentage of time that the gastric pH was less than 2 increased from group 1 (27.3%) to group 2 (56.1%) and group 3 (70.5%), parallel to an increase in the prevalence of cervical heartburn and esophagitis. The percentage of time that the gastric pH was less than 2 increased from 28.7% to 81.2% in the nine patients investigated twice. Exposure of the gastric mucosa to bile was 12.8% in patients with a high gastric pH profile versus 19.3% in those with normal acidity. In the esophageal remnant in six patients, Barrett's metaplasia developed, intestinal (n = 2) or gastric (n = 4) in type. CONCLUSIONS: Early after vagotomy, intraluminal gastric acidity is reduced in two thirds of patients, but the stomach recovers a normal intraluminal pH profile with time, so that in more than one third of patients, disabling cervical heartburn and esophagitis develop. The potential for the development of Barrett's metaplasia in the esophageal remnant brings into question the use of the stomach as an esophageal substitute in benign and early neoplastic disease.

Adult↗
PubMed1999

Portal venoplasty for recipients in living-related liver transplantation.

BACKGROUND: In living-related liver transplantation (LRLT) in small children, standard end-to-end portal vein (PV) anastomosis is usually difficult because of a inadequate total PV length, or because of a size mismatch between the graft and the recipient PV. In this report, we present our new portal venoplasty technique for the recipient PV. METHODS: After dissection of the recipient PV, the wall between the right and left branches of the PV is severed longitudinally as in the branch patch technique. The anterior and posterior edges of both branches are joined using running sutures, to form a longer and wider PV for anastomosis. RESULTS: This new portal venoplasty technique was used in 7 of 28 child cases, and gave good results without thrombosis or other complications. CONCLUSIONS: Our new portal venoplasty technique is useful in LRLT in small children when the recipient or graft PV is not long enough.

Adult↗
PubMed1999

Disturbed enterogastric inhibitory reflex after esophageal resection and narrow gastric tube reconstruction.

BACKGROUND/AIMS: The gastric emptying pattern after esophageal resection and narrow gastric tube reconstruction is determined by multiple factors. One of the possible factors is a disruption in the neurohumoral enterogastric inhibitory reflex. The aim of the present study was to determine the possible alterations of this reflex after esophageal resection and narrow gastric tube reconstruction. METHODS: Nine patients each underwent two gastric tube emptying studies, one without and one with high caloric duodenal tube feeding. The dual isotope scintigraphic data were corrected for subject movement, radionuclide decay, downscatter and gamma-ray attenuation. RESULTS: The median gastric tube emptying rate of solid food was 57%/h (range 27-195). The median T(1/2) of liquid food was 67 (range 4->80) min. Both for solid and for liquid food, the gastric tube emptying patterns without and with duodenal tube feeding were not significantly different. CONCLUSION: The neurohumoral enterogastric inhibitory reflex is disrupted after esophageal resection and narrow gastric tube reconstruction, which may contribute to disturbed gastric emptying.

Adenocarcinoma↗