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OBJECTIVE - To assess the frequency, presentation, treatment, and outcomes of bladder neck contractures (BNCs) among patients who had an orthotopic urinary diversion after radical cystectomy.
PATIENTS AND METHODS - We retrospectively examined our single-institution database of 788 patients who had a radical cystectomy from 1 January 1996 to 4 January 2006 for BNC; variables evaluated included presentation, degree of stricture/contracture, clinical management, and outcomes after management.
RESULTS - Of the 374 patients who had an orthotopic urinary diversion, 11 (2.9%) men developed BNC; four BNCs were between 17 F and 22 F, six were <17 F, and one was pinhole-sized. Nine of the 11 patients presented with voiding difficulties, one in complete retention after complicated urinary tract infection, and one with new-onset nocturnal urinary incontinence. The treatment of BNC included cystoscopic dilatation in the clinic in six and under anaesthesia in three, and transurethral incision with a Collins knife or holmium laser in seven. After treatment, all patients were instructed to use continuous intermittent catheterization (CIC). Ten patients had follow-up data available after the intervention, with a mean (range) follow-up of 40.6 (10.6-98.0) months. Six patients were stricture-free for a mean period of 35.4 (10.6-98.0) months, while four patients had a recurrence within a mean of 7.4 (1.3-17.1) months. At the last follow-up, nine of the 10 patients were using CIC. No patient had significant daytime or night-time incontinence after treatment.
CONCLUSION - BNC develops in a small proportion of patients undergoing orthotopic urinary diversion, with most patients presenting with voiding difficulty. Most will require transurethral incision rather than an office-based dilatation. After endoscopic incision to correct BNC, we recommend CIC to ensure complete emptying and to maintain the patency of the anastomotic stricture.
Biliary complications following orthotopic liver transplantation have been reported in 10% to 30% of patients. Most surgeons perform an end-to-end choledochocholedochostomy with interrupted sutures for biliary reconstruction. The goal of this study was to compare biliary complications between interrupted suture (IS) and continuous suture (CS) techniques during liver transplantation in which an end-to-end choledochocholedochostomy over an internal biliary stent was performed. A retrospective cohort study of 100 consecutive liver transplants occurring between December 2003 and July 2005 was conducted. An end-to-end choledochocholedochostomy over an internal biliary stent was performed during liver transplantation. Data were analyzed using Kaplan-Meier methods, t tests, and chi-square tests of proportions. IS and CS techniques were used in 59 and 41 patients, respectively, for biliary reconstruction during liver transplantation. Mean follow-up time for the CS group was 17 +/- 8 months and 15 +/- 7 months for the IS group (P = .21). The overall biliary complication rate was 15%. There was no difference in the proportion of leaks (CS = 7.3%, IS = 8.5%; P = .83) or strictures (CS = 9.8%, IS = 5.1%; P = .37) between groups. Kaplan-Meier event rates show no difference in leaks (P = .79), strictures (P = .41), graft survival (P = .52), and patient survival (P = .32) by anastomosis type. In conclusion, there was no difference in biliary complications, graft survival, or patient survival between the 2 groups. CS and IS techniques for biliary reconstruction during liver transplantation yield comparable outcomes.
(c) 2007 AASLD.
The results of duct-to-duct biliary reconstruction in six pediatric patients who received a living donor liver transplant aged from 2 months to 11 yr old are reported. The graft was either entire or a part of the left lateral segments. The orifice of the bile duct of the graft was anastomosed to the recipients' hepatic duct in an end-to-end fashion by interrupted suture using 6-0 absorbable material. A transanastomotic external stent tube (4 Fr) was passed through the stump of the recipients' cystic duct. Mean time for reconstruction was 24 min. All the recipients survived the operation and reinitiated oral intake on postoperative day 3. There were no early biliary complications. One 5-yr-old boy suffered from an anastomotic stenosis 9 months after transplantation. He underwent re-anastomosis by Roux-en Y (R-Y) procedure and recovered uneventfully. Duct-to-duct anastomosis in pediatric living donor liver transplantation has benefits while the complication rate is comparable to R-Y reconstruction.
BACKGROUND/PURPOSE - Preoperative mechanical bowel preparation (MBP) for elective intestinal operations has been a long accepted practice. However, MBP is often unpleasant and time-consuming for patients, and clinical trials in adults have not shown improved outcomes. We conducted this pilot study to test whether omitting MBP before elective intestinal operations in infants and children would increase the risk of infectious or anastomotic complications.
METHODS - Retrospective review was performed of 143 patients who had an elective colon or distal small bowel procedure performed at our children's hospital between 1990 and 2003.
RESULTS - Thirty-three patients (No PREP) were managed by a single surgeon who routinely omitted MBP, whereas another 110 patients (PREP) were prepared with enemas, laxatives, or both. Both groups received 24 hours of preoperative dietary restriction to clear liquids and perioperative parenteral antibiotics. The No PREP group had one anastomotic leak and no wound infections, whereas the PREP group had 2 anastomotic leaks and 1 wound infection (P = .58). These results occurred despite greater duration of antibiotic therapy and incidence of delayed wound closures in the PREP group.
CONCLUSION - The results of this pilot study suggest that omitting MBP before elective intestinal operations in infants and children carries no increased risk of infectious or anastomotic complications. Eliminating MBP may reduce health care costs and inconvenience to patients. These findings warrant a large, prospective, randomized clinical trial to validate our findings and to investigate further the necessity of MBP in the pediatric population.
Mesenteric inflammatory veno-occlusive disease (MIVOD) is a rare cause of mesenteric ischemia that is diagnosed by histologic examination of the operative specimen. Recurrence of symptoms occurs, but further resection of ischemic intestine is seldom required. We describe the case of MIVOD in a young patient with clinical findings of ischemic colitis. The patient experienced complete resolution of the process, thus confirming the relatively benign course of this disease following resection. This report substantiates resolution of the inflammatory process after resection, colostomy, and reanastomosis. We review the literature and make conclusions regarding the clinical management of this disease.
BACKGROUND AND PURPOSE - Laparoscopic radical cystectomy with orthotopic ileal neobladder creation is a technically challenging and lengthy surgical procedure. We present our experience with a simplified technique for laparoscopic cystectomy and neobladder creation in the porcine model.
MATERIALS AND METHODS - Ten female minipigs underwent a purely laparoscopic radical cystectomy with orthotopic ileal neobladder creation. Nine ureterointestinal anastomoses were performed using a simplified "dunk" technique, where the ureter was prolapsed 5 mm into the afferent limb and the periureteral tissue was secured to the bowel serosa with three superficial sutures. Six ureters were not stented, and three had indwelling stents inserted. In 11 ureters, the anastomosis was performed using a running mucosa-to-mucosa technique (three with stents, eight without stents). The Lapra-Ty suture clip (Ethicon Endosurgery, Cincinnati, OH) was used to secure the running sutures on the urethra, ureters, and neobladder. Animals were harvested at 3 to 8 weeks (mean 6.5 weeks) after surgery. Serology, static cystogram, intravenous urography, and gross and histopathologic evaluations were performed.
RESULTS - Of six unstented dunked ureterointestinal anastomoses, two (33%) were widely patent, two were strictured but patent, and two were completely obstructed. In the three stented ureters implanted using the dunk technique, one (33%) was widely patent, one was strictured, and one was completely obstructed. All ureterointestinal anastomoses performed with a mucosa-to-mucosa running anastomosis, whether stented (three ureters) or not stented (eight ureters), were widely patent. Lapra-Ty clip migration into the neobladder pouch caused urethral obstruction resulting in delayed bladder perforation in two animals.
CONCLUSIONS - Laparoscopic cystectomy and ileal neobladder creation is technically feasible. Attempts to simplify the ureterointestinal anastomosis require further evaluation and modification. Stent placement appears to be unnecessary in the laparoscopic ureterointestinal anastomosis. Laparoscopic creation of the ileal neobladder remains a technically challenging procedure.
Bile leaks occur in up to 27 per cent of liver transplant patients after biliary reconstruction. Synthetic sealants have not been investigated for these biliary procedures. We performed a randomized controlled study to evaluate a novel absorbable polyethylene glycol/collagen biopolymer sealant (CT3 Surgical Sealant) after incomplete end-to-end choledochocholedochostomy (CDCD) in pigs. Pigs (n = 18) underwent transection of the common bile duct and incomplete CDCD over a T-tube, leaving a one-sixth circumferential defect anteriorly. Animals were randomly assigned to treatment (CDCD with sealant, n = 9) or control (no sealant, n = 9). Drains were used to monitor leak volume and bilirubin (bili) concentration. Cholangiography was performed on postoperative day 3. Leaks were defined as drain bili/serum bill > 3, total drain output > 10 mL/kg, and/or extravasation on cholangiography. Animals sacrificed at 3 and 8 weeks (n = 4 and n = 5 from each group, respectively) underwent pathologic examination of the CDCD site. Statistical methods included Student's t test, chi2, linear regression, and analysis of variance procedures. The control group had a higher drain output rate over the first 4 postoperative days than the treatment group (P < 0.05, analysis of variance). Five of nine (56%) control and one of nine (11%) treatment animals had a bile leak (P < 0.05, chi2). There was no major inflammatory response to the sealant versus controls. We conclude that CT3 is effective in decreasing biliary leaks in an incomplete CDCD porcine model with no major adverse pathologic changes. This sealant should be considered for trials for biliary reconstruction in humans.
OBJECTIVE - This study compares in vivo pulmonary blood flow patterns and shear stresses in patients with either the direct atrium-pulmonary artery connection or the bicaval tunnel connection of the Fontan procedure to those in normal volunteers. Comparisons were made with the use of three-dimensional phase contrast magnetic resonance imaging.
METHODS - Three-dimensional velocities, flows, and pulmonary artery cross-sectional areas were measured in both pulmonary arteries of each subject. Axial, circumferential, and radial shear stresses were calculated with the use of velocities and estimates of viscosity.
RESULTS - The axial velocities were not significantly different between subject groups. However, the flows and cross-sectional areas were higher in the normal group than in the two patient groups in both pulmonary arteries. The group with the bicaval connection had circular swirling in the cross section of both pulmonary arteries, causing higher shear stresses than in the controls. The disorder caused by the connection of the atrium to the pulmonary artery caused an increase in some shear stresses over the controls, but not higher than those found in the group having a bicaval tunnel.
CONCLUSIONS - We found that pulmonary flow was equally reduced compared with normal flow in both patient groups. This reduction in flow can be attributed in part to the reduced size of the pulmonary arteries in both patient groups without change in axial velocity. We also found higher shear stress acting on the wall of the vessels in the patients having a bicaval tunnel, which may alter endothelial function and affect the longevity of the repair.