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Development of genotoxicity test procedures with Episkin, a reconstructed human skin model: towards new tools for in vitro risk assessment of dermally applied compounds?

Today reconstructed skin models that simulate human skin, such as Episkin, are widely used for safety or efficacy pre-screening. Moreover, they are of growing interest for regulatory purposes in the framework of alternatives to animal testing. In order to reduce and eventually replace results of in vivo genotoxicity testing with in vitro data, there is a need to develop new complementary biological models and methods with improved ability to predict genotoxic risk. This can be achieved if these new assays do take into account exposure conditions that are more relevant than in the current test systems. In an attempt to meet this challenge, two new applications using a human reconstructed skin model for in vitro genotoxicity assessment are proposed. The skin is the target organ for dermally exposed compounds or environmental stress. Although attempts have been made to develop genotoxicity test procedures in vivo on mouse skin, human reconstructed skin models have not been used for in vitro genotoxicity testing so far, although they present clear advantages over mouse skin for human risk prediction. This paper presents the results of the development of a specific protocol allowing to perform the comet assay, a genotoxicity test procedure, on reconstructed skin. The comet assay was conducted after treatment of Episkin with UV, Lomefloxacin and UV or 4-nitroquinoline-N-oxide (4NQO). Treatment with the sunscreen Mexoryl was able to reduce the extent of comet signal. A second approach to use reconstructed epidermis in genotoxicity assays is also proposed. Indeed, the skin is a biologically active barrier driving the response to exposure to chemical agents and their possible metabolites. A specific co-culture system (Figure 1) using Episkin to perform the regular micronucleus assay is presented. Micronucleus induction in L5178Y cells cultured underneath Episkin was assessed after treatment of the reconstructed epidermis with mitomycin C, cyclophosphamide or apigenin. This second way of using human reconstructed skin for genotoxicity testing aims at improving the relevance of exposure conditions in in vitro genotoxicity assays for dermally applied compounds.

4-Nitroquinoline-1-oxide↗

New methods for the computer-assisted 3-D reconstruction of neurons from confocal image stacks.

Exact geometrical reconstructions of neuronal architecture are indispensable for the investigation of neuronal function. Neuronal shape is important for the wiring of networks, and dendritic architecture strongly affects neuronal integration and firing properties as demonstrated by modeling approaches. Confocal microscopy allows to scan neurons with submicron resolution. However, it is still a tedious task to reconstruct complex dendritic trees with fine structures just above voxel resolution. We present a framework assisting the reconstruction. User time investment is strongly reduced by automatic methods, which fit a skeleton and a surface to the data, while the user can interact and thus keeps full control to ensure a high quality reconstruction. The reconstruction process composes a successive gain of metric parameters. First, a structural description of the neuron is built, including the topology and the exact dendritic lengths and diameters. We use generalized cylinders with circular cross sections. The user provides a rough initialization by marking the branching points. The axes and radii are fitted to the data by minimizing an energy functional, which is regularized by a smoothness constraint. The investigation of proximity to other structures throughout dendritic trees requires a precise surface reconstruction. In order to achieve accuracy of 0.1 microm and below, we additionally implemented a segmentation algorithm based on geodesic active contours that allow for arbitrary cross sections and uses locally adapted thresholds. In summary, this new reconstruction tool saves time and increases quality as compared to other methods, which have previously been applied to real neurons.

Algorithms↗

Tracheoesophageal speech following laryngopharyngectomy and pharyngeal reconstruction.

Voice restoration following total laryngectomy and pharyngeal reconstruction is an achievable yet challenging reconstructive task. Because numerous methods exist for pharyngeal reconstruction in conjunction with total laryngectomy, a thorough knowledge of the tissues used for reconstruction is necessary. This knowledge allows for realistic expectations for patient success. Also, specific modifications in voice restoration may be necessary with individual reconstruction methods. This article reviews the methods for reconstruction and the available literature on voice restoration in reconstructed patients.

Gastric Mucosa↗

On-line implant reconstruction in HDR brachytherapy.

BACKGROUND AND PURPOSE: To evaluate the accuracy of on-line planning in an Integrated Brachytherapy Unit (IBU) using dedicated image distortion correction algorithms, correcting the geometric distortion and magnetic distortion separately, and to determine the effect of the reconstruction accuracy on clinical treatment plans in terms of deviations in treatment time and dose. PATIENTS AND METHODS: The reconstruction accuracy has been measured using 20 markers, positioned at well known locations in a QA phantom. Treatment plans of two phantoms representing clinical implant geometries, have been compared with reference plans to determine the effect of the reconstruction accuracy on the treatment plan. Before clinical introduction, treatment plans of three representative patients, based on on-line reconstruction, have been compared with reference plans. RESULTS: The average reconstruction error for 10 in. images reduces from -0.6 mm (range -2.6 to +1.0 mm) to -0.2 mm (range -1.2 to +0.6 mm) after image distortion correction and for 15 in. images from 0.8 mm (range -0.5 to +3.0 mm) to 0.0 mm (range -0.8 to +0.8 mm). The error in case of eccentric positioning of the phantom, i.e. 0.8 mm (range -1.0 to +3.3 mm), reduces to 0.1 mm (range -0.5 to +0.9 mm). Correction of the image distortions reduces the deviation in the calculated treatment time of maximally 2.7% to less than 0.8% in case of eccentrically positioned clinical phantoms. The deviation in the treatment time or reference dose in the plans based on on-line reconstruction with image distortion correction of the three patient examples is smaller than 0.3%. CONCLUSIONS: Accurate on-line implant reconstruction using the IBU localiser and dedicated correction algorithms separating the geometric distortion and the magnetic distortion is possible. The results fulfill the minimum requirements as imposed by the Netherlands Commission on Radiation Dosimetry (NCS) without limitations regarding the usable range of the field of view of the image intensifier. However, the C-arm angle is limited to those angles for which magnetic distortion corrections have been obtained.

Algorithms↗

Plastic and reconstructive surgery approaches in the management of anal cancer.

Various reliable reconstructive options are available for treatment of perineal and perianal skin and soft tissue defects resulting from tumor ablation. Indications for TAR include the following: very low rectal cancers, in which low anterior resection or resection with coloanal anastomosis is not possible: persistent or recurrent anal cancer that has failed to respond to chemoradiation therapy; and previous rectal excision with either recurring colostomy complications or an unacceptable quality of life with a stoma. Of course, adequate surgical oncologic principles must not be compromised to enhance sphincter reconstruction. Either primary reconstruction at the time of cancer excision or secondary reconstruction at a later date is an acceptable alternative. Most investigators believe that primary reconstruction is technically easier and associated with fewer complications. Secondary reconstruction provides the advantage of oncologic certainty. Double dynamic graciloplasty after APR has proved to be anoncologically sound procedure with a good chance of continence and a life without a stoma in most patients. Finally, the preliminary experience with new techniques of electrode implants encourages further application. In most patients who have rectal cancer, a sphincter-saving resection can avoid the need for a permanent stoma. Very low rectal tumors, however, still require an APR as the treatment of choice when a safe coloanal anastomosisis not possible. In recent years, several authors have reported their experience on sphincteric reconstruction after APR. Most of these authors used gracilis muscles transposed from the thigh to the perineum (graciloplasty) to surround a coloperineal anastomosis after pull-through of the distal colon. The best way to achieve fecal continence is to obtain a mechanically sufficient contraction of the sphincter. Electrostimulation of the transposed gracilis muscles creates an essential framework for their postoperative muscular growth and contractility. In particular, adoption of continuous low-frequency stimulation has proved to be effective in increasing fatigue resistance of the transposed muscles, allowing their continuous "pseudotonic" contraction. Despite the general acceptance of the efficacy of this scheme, there are significant variations in various authors' experiences pertaining to graciloplasty configuration, surgical timing of resection and transposition, and electrostimulation device use and implantation.

Anus Neoplasms↗

Simple and safe method of cranial reconstruction after posterior fossa craniectomy.

BACKGROUND: Reconstructing the posterior fossa after surgical intervention in this region is important both for prevention of postoperative complication such as headache and for cosmetic purposes. Several methods have been reported that use either synthetic or natural graft, the latter being either autograft or allograft. The previously described methods require either surgical intervention on a second setting or an additional procedure that prolongs the time of the surgery and may contribute to morbidity. The present report describes a simple modified method of reconstructing the postcraniectomy defect by using the patients' own bone dust, tissue glue, and gel foam sheets. METHODS: The method of reconstruction requires collection of as much as possible of the produced bone dust at the time of craniectomy, adding tissue glue, placing in between 2 sheets of gel foam, and shaping it to match the surgical defect. RESULTS: Ten cases of various posterior fossa pathologies managed at King Faisal hospital of the university between January 2000 and September 2004 had reconstruction of the posterior fossa after craniectomy during the same operative setting using the described method of cranial reconstruction. No complication was noted. Patients did not have any delayed postcraniectomy pain at reconstruction site. Postoperative plane x-ray of the skull and computed tomography showed good healing and shaping of the suboccipital bone at the surgical defect. CONCLUSIONS: Reconstructive cranioplasty is an important part of any posterior fossa exposure. The present report describes a safe and simple method that gives acceptable results both clinically and radiologically.

Bone Cements↗

Back-table arterial reconstructions in liver transplantation: single-center experience.

Anatomic variations of the arterial supply to donor liver grafts often require complex hepatic artery reconstructions on the back table. Therefore, because of the additional anastomoses, there is a greater risk of arterial thrombosis and graft loss. Among the 620 orthotopic liver transplantations (OLT) in 549 adult and pediatric patients performed from June 1983 through August 2004, the rates and types of donor hepatic artery variations (HAV) and the type of reconstructions were reviewed as well as the 1- and 5-year grafts and patient survival rates after OLT. At least 1 HAV was present in 133 liver grafts (21.4%). The most frequent variations were as follows: right hepatic artery (RHA) from superior mesenteric artery (SMA) (44 cases); RHA from aorta (4 cases); and RHA from SMA, combined with a left hepatic artery (LHA) from left gastric artery (3 cases). No graft was discarded. Fifty-six of 133 (42%) HAV required arterial reconstructions, generally a termino-terminal (TT) anastomosis between RHA and splenic artery (26 cases, 46.4%). Less frequently performed anastomoses were the "fold-over" technique (15 cases, 26.8%) and the anastomosis between the RHA and the gastro-duodenal artery (6 cases, 10.6%); rare reconstructions were performed in 9 cases (16.0%). The rate of hepatic artery thrombosis was 5.4% (3 of 56 OLT) in complex hepatic artery reconstructions and 2.2% in other grafts. One- and 5-years graft and patient actuarial survival rates have been respectively 73.2%- 71.4% in hepatic artery reconstructions and 78.6%-76.8% in the absence of an artery reconstruction, respectively.

Adult↗

Efficacy of right anterior sector drainage reconstruction in right-lobe live-donor transplantation.

BACKGROUND: Without including the middle hepatic vein (MHV) into right-lobe grafts, venous drainage of the anterior segment (AS) has always been a concern. The efficacy and the necessity of additional venous reconstruction in the AS for graft viability and function are still controversial. METHODS: Since February 2002, 57 right-lobe grafts were implanted into adult recipients. The mean graft to ideal recipient weight ratio (GRWR) was 1.3% (minimum: 0.8%, maximum 2.1%). All minor venous tributaries to the MHV less than 5 mm in diameter were ligated. The management of MHV tributaries was categorized into three groups: (A) no major tributaries (n = 33); (B) major tributaries ligated (n = 11); and (C) major tributaries reconstructed (n = 13). Reconstructions were established using vascular grafts (PTF, n = 8; cadaveric, n = 2) or joining with right hepatic vein orifice (n = 6). The groups were homogenous in age, gender, MELD (17 +/- 6, 16 +/- 4, 18 +/- 7), graft weight (817 +/- 181, 838 +/- 152, and 855 +/- 159 g), and graft/ideal liver weight ratio (0.54 +/- 0.12, 0.57 +/- 0.13, and 0.57 +/- 0.1, respectively). We investigated the volume of ascites, serum bilirubin, albumin, and liver enzyme levels and INR on postoperative day 4 (POD4) and POD21. RESULTS: Two patients died of MRSA sepsis on POD18 and POD23 (MELD: 24 and 28) after initial graft function. Their graft weights were 800 g and 980 g, and their volumes were 47% (group B) and 62% (group A) of the ideal liver mass of the recipients, respectively. One PTF and another cadaveric vascular graft were found occluded 4 and 7 days after implantation without any negative consequence. At 6-month follow-up, the remaining 55 patients were alive with primary liver grafts. Vascular reconstructions were patent except for 2 early occlusions. Among the 3 groups, no significant difference was found on POD4. Three weeks after transplantation, the mean AST level in the major ligation group (46.7 +/- 8.14) was significantly higher than in the minor ligatation group (29.6 +/- 8.6) but not in the major reconstruction group (33.7 +/- 3.7; P = .03 and P = .29). The mean albumin level was highest after minor ligation (3.2 +/- 0.18), which was significantly better than the major reconstruction (2.7 +/- 0.1) but not the major ligation (3.1 +/- 0.14) cohorts (P = .02 and P = .13). CONCLUSIONS: In this study of a limited number of cases, right-lobe liver grafts with GRWR of > or =1.1% displayed optimal graft function without additional venous reconstruction to the AS.

Adult↗

Tissue expansion in management of failed phallic reconstruction: initial report of clinical series.

OBJECTIVES: To report the first significant experience with the use of tissue expanders in phallic reconstruction. Patients who have undergone multiple failed surgical procedures for repair of hypospadias or epispadias often have minimal residual skin available for additional reconstructive efforts. Although a variety of graft options exist, local skin expansion can provide pigment and texture-matched skin for reconstructive procedures. METHODS: We reviewed our experience with tissue expansion in patients after multiple failed phallic reconstructive efforts. A total of 18 males (mean age 13.2 years) with an underlying diagnosis of exstrophy/epispadias (n = 9), hypospadias (n = 7), partial androgen insensitivity syndrome (n = 1), and congenital adrenal hyperplasia (n = 1) had penile tissue expanders placed and inflated during a 6-week period. The expanders were removed at penile reconstruction. RESULTS: Tissue expanders were placed in 18 patients and successfully inflated in 17 patients. Good surgical results requiring no additional procedures were obtained in 8 (47%) of the 17 patients. Two patients subsequently underwent repeated tissue expansion; one of these patients had a good outcome after two expansions and supplemental pedicle graft, and the other had persistent fistulas and required a forearm graft. The implants were replaced because of extrusion in 3 patients and removed for malfunction, erosion, or infection in 1 patient each. CONCLUSIONS: The use of tissue expansion provides a useful option for reconstruction in patients with minimal or scarred skin after multiple failed prior phallic reconstructions and offers certain benefits over the transfer of free grafts. The availability of smaller tissue expanders makes this technique feasible even for young children.

Adolescent↗

Fibrin sealant as tissue glue: preliminary experience in complex genital reconstructive surgery.

OBJECTIVES: To report the outcomes of graft take and wound healing in the first reported series in which fibrin sealant was used as a tissue glue in the reconstruction of complex genital skin loss. METHODS: Between July 2001 and July 2005, 18 men requiring complex genital reconstruction underwent repair by two surgeons at our medical centers. Skin graft reconstruction was required in 6 men. Complete scrotal disassembly with extensive scrotal or thigh flaps was required for reconstruction of 12 others. In the skin graft cases, a thin layer of dilute fibrin sealant was sprayed on the recipient site immediately before graft apposition. In flap cases, fibrin sealant was injected beneath the flap to promote tissue adherence and prevent fluid accumulation. All wounds were followed up postoperatively and observed for evidence of graft take, seroma or hematoma formation, drainage, and infection. RESULTS: The 6 skin graft patients required a total of nine split-thickness skin grafts, all of which had 100% take. Of the 12 patients requiring flap reconstruction, 11 had excellent results. One flap case had a partial wound breakdown, but this reconstruction was performed immediately subsequent to a significant debridement and irrigation procedure in the same setting. Overall, 17 (94.4%) of 18 patients had no wound infection, seroma, hematoma, or other complications. CONCLUSIONS: Fibrin sealant performs very well as a tissue glue and appears to be a useful adjunct in cases of complex genital skin loss reconstruction.

Fibrin Tissue Adhesive↗

Medial canthotomy and cantholysis in eyelid reconstruction.

Combined medial canthotomy and cantholysis is a quick, technically simple, single-stage reconstructive technique for use in the reconstruction of the upper or lower eyelid. This technique, which transects one lacrimal canaliculus, provides up to 20% of the horizontal eyelid dimension for closure. Medial canthotomy and cantholysis is most frequently used in combination with other eyelid reconstructive techniques for difficult reconstructions, which would otherwise require more extensive surgical procedures. The surgical technique is readily performed with the patient under general anesthesia and entails the transection of one lacrimal canaliculus, lysis of one crus of the medial canthal tendon, and lateral advancement of the medial eyelid stump. We used medial canthotomy and cantholysis in the reconstruction of 29 eyelid defects (21 upper eyelids and eight lower eyelids) over a 12-year period with adequate reconstructive results in all cases. Eleven of the patients underwent simultaneous lateral canthotomy and cantholysis. Complications of the medial canthotomy and cantholysis technique include anterior displacement of the medial portion of the eyelid, epiphora, notching of the medial portion of the eyelid, medial ectropion, and blepharoptosis. If used with appropriate case selection, this technique allows an optimal reconstructive result to be achieved with a minimum of operative time and morbidity.

Eyelid Neoplasms↗

Cost analysis of breast conservation surgery compared with modified radical mastectomy with and without reconstruction.

BACKGROUND: Breast conservation surgery (BCS), consisting of lumpectomy, axillary lymph node dissection, and radiation therapy, is as effective as modified radical mastectomy (MRM) for the treatment of early stage breast cancer. The costs of these treatment options have not been adequately addressed in the current era of increasing utilization of BCS and breast reconstruction. The purpose of this study is to determine differences in treatment costs among BCS, MRM alone, and MRM with reconstruction. METHODS: Patients with stage I and II breast cancer receiving inpatient treatment at a private university-affiliated hospital between January 1996 and July 1997 were analyzed (n = 230). Charges were determined as follows: inpatient and radiotherapy charges from the hospital billing department, surgeon fees from group practice billing codes, and radiotherapy physician fees from the radiation oncology group practice. Inpatient length of stay was obtained from hospital medical records. RESULTS: Average hospital inpatient charge for BCS was $4,748 (n = 74), $6,280 for MRM alone (P <0.001, n = 132), and $11,946 for MRM with reconstruction (P <0.001, n = 24). Surgeons' fees for BCS were $2,840, $3,500 for MRM alone, and $10,774 for MRM with reconstruction. The average radiotherapy charge was $18,742. Average length of stay was 1.03 days for BCS, 2.44 days for MRM alone (P <0.001), and 3.71 days for MRM with reconstruction (P <0. 001). Average total cost of BCS ($26,330) was significantly greater than the average total cost of either MRM alone ($9,780, P <0.001) or MRM with reconstruction ($22,720, P <0.001). CONCLUSIONS: BCS is more expensive than MRM with or without reconstruction. It is the addition of radiotherapy that results in the higher total cost of CS.

Adult↗

Simple versus double jejunal pouch for reconstruction after total gastrectomy.

BACKGROUND: Even though many types of reconstruction after total gastrectomy have been proposed to reduce postgastrectomy syndromes, choosing a method that would further improve the quality of life and nutrition of the gastrectomized patient is controversial. Hunt-Lawrence single pouch reconstruction seems to obtain better results compared with the more common Roux-en-Y technique, but both of these reconstructive approaches are associated with some reduction in food intake and some problems in achievement of ideal body weight. METHODS: In this prospective, randomized trial, after total gastrectomy 18 patients had reconstruction according to the Hunt-Lawrence or single pouch technique (SP group), whereas for 23 patients, the technique was modified with construction of a second pouch in the distal portion of the jejunal loop (DP group). Patients in the two groups were compared at 12 months after surgery for problems in gastrointestinal function, quality of life, improvement in body weight and nutritional parameters, serum albumin, hemoglobin level, and serum protein. RESULTS: The DP group demonstrated fewer symptom problems, better weight maintenance, and better laboratory values when compared with patients undergoing standard single jejunal pouch reconstruction. CONCLUSIONS: Reconstruction with use of a double pouch as a gastric substitute leads to better outcome assessments than with a single pouch reconstruction. Our double pouch technique has demonstrated significant improvement in quality of life and nutritional recovery in terms of functional results as well as patient satisfaction.

Aged↗

Perspective on reconstruction after mastectomy.

BACKGROUND: We sought to evaluate the factors influencing our patients to receive or forego reconstruction after mastectomy and their subsequent satisfaction with their decision. METHODS: A questionnaire was sent to 819 patients who underwent mastectomy from 1994 to 1998 in a community-based health system. RESULTS: Response rate was 50% (408 of 819). Overall, 92% (n = 243) of women who did not have reconstruction and 89% (n = 152) of women who did proceed with reconstruction were happy with their decision. Fifty-five (17%) respondents were not offered reconstruction. For this group, age was a significant factor as 64% of them were 60 years or older (P < 0.0001). Dissatisfied patients were disappointed with their cosmetic, sensory, or functional outcome. Their result did not meet their expectations. There were no significant differences noted on the basis of marital status. CONCLUSION: Ninety percent of patients adjust well to mastectomy whether or not they receive reconstruction if they make informed decisions with realistic expectations. Surgeons should offer reconstruction to women of all ages although patients over 60 years old are less likely to proceed with, and complete, reconstruction.

Adult↗

Delayed reconstruction following Mohs' chemosurgery for skin cancers of the head and neck.

The case records of 52 patients with 55 cutaneous neoplasms treated by Mohs' chemosurgery and subsequently reconstructed by plastic surgeons were reviewed to determine if delay between resection and reconstruction adversely affected the outcome of reconstruction. Reconstruction was performed from 5 to 61 days after Mohs' chemosurgery for 45 basal cell carcinomas and 10 other cutaneous neoplasms. There were no complications during the interval between resection and reconstruction. Following reconstruction, minor wound complications occurred in 6% of patients; there were no major complications. Microscopic examination of the re-excised wound revealed residual disease in 2 of 45 cases of basal cell carcinoma and 0 of 10 other cutaneous malignancies. Both patients with residual basal cell carcinomas (i.e., false-negative margins after Mohs' surgery) had presented to the Mohs' surgeon with recurrent tumors. During a follow-up period of 3 months to 3 years after complete resection, recurrent tumor developed in 2 of 45 cases of basal cell carcinoma and 3 of 8 cases of squamous cell carcinoma. Delayed reconstruction, usually 5 to 20 days after Mohs' chemosurgery, can be performed without significant morbidity. Re-excision of the Mohs' chemosurgical wound for pathologic examination can detect residual disease and may be especially indicated for large recurrent wounds.

Adult↗

Comparison of postoperative wound complications and early cancer recurrence between patients undergoing mastectomy with or without immediate breast reconstruction.

The incidence of postoperative wound complications and early cancer recurrence was studied in 289 patients who had mastectomy alone and in 113 patients who underwent immediate reconstruction following mastectomy. Patients undergoing immediate reconstruction were younger and had less advanced disease than patients who had mastectomy alone. The postoperative hospital stay was 3.8 days and 4.4 days (p < 0.05) in patients with and without reconstruction, respectively. The overall incidence of postoperative complications was similar in the two groups of patients: 31% and 28% in patients with and without reconstruction, respectively. The incidence of postoperative seroma was higher among patients with mastectomy alone (19% versus 3%, p < 0.05), whereas the incidence of other wound complications was similar in the two groups of patients. Prosthesis-specific complications occurred in 17%. Eight prostheses were removed because of complications. During the relatively short follow-up period (approximately 20 months), local recurrence was noted in 16 patients (6%) who had mastectomy alone and in 1 patient (1%) who had immediate reconstruction after mastectomy (p < 0.05). There was no significant difference in the incidence of distant metastases between the two groups of patients. The results suggest that immediate breast reconstruction can be performed following mastectomy for cancer without increased risk for overall postoperative complications, prolonged hospital stay, or local recurrence. However, patients who choose to have immediate reconstruction need to be informed about risks for specific complications associated with the procedure, especially if an implant is used.

Adult↗

Five-year follow-up of neonates with reconstructed right common carotid arteries after extracorporeal membrane oxygenation.

OBJECTIVE: Serial Doppler ultrasonography and long-term neurodevelopmental follow-up outcomes were evaluated prospectively in neonates whose right common carotid artery (RCCA) was reconstructed after extracorporeal membrane oxygenation (ECMO). METHODS: Children with RCCA reconstruction (n = 34) were monitored for 3.5 to 4.5 years by Doppler ultrasonography for arterial patency, and 28 had IQ testing by 5 years. A comparison group consisted of 35 infants who had RCCA ligation after ECMO. Neonatal electroencephalograms and computed tomography/magnetic resonance imaging scans were also compared. RESULTS: Reconstructions were successful (<50% RCCA stenosis by Doppler ultrasonography) in 26 (76%) of 34 children, 3 (9%) had >/=50% stenosis, and 5 (15%) had occlusion. No significant differences were seen between reconstructed and ligated groups in neonatal complications or ECMO courses. Occurrence of marked neonatal electroencephalographic abnormalities did not differ between groups. Abnormalities on computed tomography/magnetic resonance imaging scans (4 of 31 vs 11 of 29, P =.025) and cerebral palsy (0 of 34 vs 5 of 35, P =.054) were more common in infants with RCCA ligation. No differences were seen in developmental or IQ scores between the 2 groups, and 4 in each group had cognitive handicaps (at least 1 IQ score <70). CONCLUSIONS: Most RCCA reconstructions remained patent, with 24% showing significant stenosis or occlusion. Compared with a historical control group, patients with RCCA reconstruction had fewer brain scan abnormalities and tended to be less likely to have cerebral palsy. RCCA reconstruction after venoarterial ECMO may improve outcome.

Birth Weight↗

Continent appendicocolostomy: a variation of the Mitrofanoff principle in pediatric urinary tract reconstruction.

There are numerous options for continent urinary reconstruction in children. If the appendix is available and the bladder capacity is satisfactory, a Mitrofanoff procedure may be performed using the appendix as a catheterizable tube implanted into the bladder. However, in many patients the bladder is absent or too small for this type of reconstruction. An alternative technique, termed appendicocolostomy, is to implant the appendix under the tenia of a detubularized patch of cecum or sigmoid colon, which becomes part of a continent neobladder or is attached to the bladder itself. This procedure has been used in 12 children and 1 adult undergoing continent reconstruction. Urological diseases included bladder exstrophy (10 patients) and a neuropathic bladder (3). Two patients underwent undiversion of a sigmoid conduit, while in 7 of the remaining patients the bladder was included in the reservoir. In 1 patient histological examination of the tip of the appendix revealed an incidental invasive carcinoid tumor necessitating appendectomy and revision of the reconstruction. Otherwise, no complications have occurred. Three adults were scheduled for this procedure but the appendix was diseased and an alternative form of diversion was necessary. Followup ranged from 2 months to 4 years. All patients are totally dry with a capacity of 300 to 750 cc (mean 475 cc). The appendicocolostomy is a superior form of conduit reconstruction that should be considered when the appendix is available during continent reconstruction. However, in adults the appendix may be fibrotic, precluding its use. Because most boys with exstrophy and a small bladder capacity requiring augmentation cystoplasty must perform intermittent catheterization, attachment of the appendix to the reservoir is an alternative that allows for easier and less painful intermittent catheterization than catheterization of the reconstructed epispadiac penis.

Adolescent↗