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PubMed1993

The use of a long split rectal tube to aid in pull-through procedures for imperforate anus.

Problems with loss of correct orientation of the pull-through rectal pouch during posterior sagittal anorectoplasty (PSARP) for high imperforate anus can occur during laparotomy after perineal closure is complete. A simple modification of the de Vries-Peña technique is described that facilitates preservation of orientation and precise anatomical neomuscle construction. A slotted rubber tube preserves correct anatomical orientation of the neorectal pouch and allows accurate construction of the muscle complex around the tube.

Anus, Imperforate↗
PubMed1997

Coexistent Hirschsprung's disease and esophageal achalasia in male siblings.

Achalasia of the esophagus developed in two male siblings soon after birth, and they were successfully treated by surgery. Persistent signs resulted in the later diagnosis of Hirschsprung's disease. One required subtotal colectomy and ileoanal anastomosis, and the other is managing well on conservative treatment. Genetic analysis of the genes encoding the RET protooncogene, endothelin-3, and the endothelin-3 receptor did not show any defect. Familial achalasia of the esophagus in combination with Hirschsprung's disease has never been reported.

Colectomy↗
PubMed1999

Quality-of-life assessment after ileoanal pull-through for ulcerative colitis and familial adenomatous polyposis.

BACKGROUND/PURPOSE: The ileoanal pull-through procedure (IAP) is gaining increasing favor and use in the surgical treatment of children with ulcerative colitis (UC) and familial adenomatous polyposis (FP). Although physiological studies have been performed to assess the outcome of these children, no long-term quality-of-life assessment after the procedure has been performed. METHODS: Forty-three patients were identified who had an IAP at our institution in the last 10 years and were at least 6 months postsurgery. Thirty-four were contacted, and 32 agreed to participate in the survey, which was approved by the Human Studies Committee. Participants completed the standardized Medical Outcome Study Short Form-36 (SF-36), which has well-established normative values. Several supplemental questions were prepared in a similar format dealing with issues specific to the ileoanal pull-through procedure. RESULTS: Of the 32 participants, 19 (59%) were girls and 26 (81%) had ulcerative colitis. Mean age at the time of survey was 18.1 years with 12 less than 18 years and 20 > or =18 years. Data from the latter group could be compared with national normative values for this age. The study group was not statistically different from age-appropriate US population normal values on all assessable scales of physical and mental health in the SF-36 survey including physical functioning, role limitations-physical, bodily pain, general health, vitality, social functioning, role limitations-emotional, and mental health (all P>.05 or mean difference SD units <0.8). The supplemental questionaire demonstrated little adverse effect of the surgery. There was limited consumption of medications to control bowel frequency and little restriction of activity because of the frequency of bowel movements or fear of incontinence. The surgical scar was the sole negative factor of significance. CONCLUSIONS: The ileoanal pull-through procedure is an excellent surgical option for children with ulcerative colitis or familial adenomatous polyposis, and it produced minimal, if any, adverse effects on their long-term quality of life.

Adenomatous Polyposis Coli↗
PubMed1998

The T pouch: an orthotopic ileal neobladder incorporating a serosal lined ileal antireflux technique.

PURPOSE: At our institution the Kock ileal neobladder has been the primary form of urinary diversion after cystectomy. The few associated complications are primarily related to the intussuscepted antireflux afferent limb, including stones, stenosis and extussusception of the afferent nipple. We present a novel orthotopic ileal neobladder, the T pouch, with an innovative antireflux technique designed to prevent complications of the intussuscepted afferent nipple. MATERIAL AND METHODS: From November 1996 through August 1997, 40 patients an average of 67 years old underwent construction of an orthotopic ileal neobladder (T pouch). Mean followup is 10.5 months (range 8 to 14). The T pouch incorporates an antireflux mechanism using a serosal lined ileal tunnel technique. Urinary reflux is prevented without ileal intussusception and with complete preservation of the blood supply to the afferent ileal segment. Followup in all cases includes clinical and functional results, and radiographic evaluation of the urinary reservoir and upper urinary tracts. RESULTS: One perioperative death (2.5%) and 5 early complications (12.5%) were unrelated to urinary diversion. There have been no late complications. All T pouch reservoirs had excellent capacity without evidence of urinary reflux. The upper urinary tracts remain unchanged or improved in all patients. CONCLUSIONS: The T pouch is an orthotopic ileal neobladder that incorporates an effective, innovative antireflux mechanism created by a serosal lined ileal tunnel. Early clinical and functional results of this type of urinary diversion have been excellent. Furthermore, we suspect that this antireflux technique may eliminate the complications associated with an intussuscepted afferent nipple and maintain an effective antireflux mechanism.

Adult↗
PubMed1998

Does the option of the ileal neobladder stimulate patient and physician decision toward earlier cystectomy?

PURPOSE: The primary goal of bladder replacement is to attempt to improve patient quality of life, not to increase survival, affect cancer prognosis or decrease renal metabolic complications. Nevertheless, we retrospectively determined whether orthotopic bladder replacement has an impact on the decision to perform cystectomy. MATERIALS AND METHODS: From April 1986 to September 1994, 213 men a mean of 63 years old with stages pT2N0M0 to pT4N0M0 invasive bladder cancer were referred to our department for cystectomy. For 135 patients who underwent an ileal neobladder procedure and 78 who underwent conduit diversion median followup was 4.8 and 3.5 years, respectively. We evaluated the interval from the primary diagnosis of bladder cancer to cystectomy as well as the number of previous transurethral bladder resections. The 5-year cancer specific survival rates were calculated using the Kaplan-Meier method. The Wilcoxon and log rank tests, and the Cox proportional hazards model were used to determine statistical significance. RESULTS: In the neobladder and conduit groups an average of 2.1 (range 1 to 18) and 4.1 (range 1 to 15) transurethral bladder resections was performed, respectively. Interval from the primary diagnosis to cystectomy was 11.8 months in the neobladder and 16.7 months in the conduit group. Cystectomy was performed 4.1 months after the diagnosis of invasive cancer in the neobladder group, whereas radical surgery was delayed for 15.4 months in the conduit group. Cancer specific 5-year survival rates were 76.6 and 28.35% in the neobladder and conduit groups, respectively. After stratifying according to tumor stage the 5-year survival rate was significantly higher for all disease stages in the neobladder than in the conduit group. The proportional hazards model revealed that this difference was not due to patient age at disease stages pT3bN0 and pT4N0 or by American Society of Anesthesiologists score. Independent prognostic factors for survival were diversion type and age. Delayed cystectomy was a risk factor only in advanced disease stages. CONCLUSIONS: These data suggest that the ileal neobladder may decrease physician reluctance to perform cystectomy early in the disease process, increasing the survival rate. They also demonstrate that the ileal neobladder option significantly affects an earlier patient and physician decision in favor of cystectomy.

Adult↗
PubMed2002

Factors that influence outcomes of the Mitrofanoff and Malone antegrade continence enema reconstructive procedures in children.

PURPOSE: Surgical techniques that provide adequate urinary and fecal continence in children with neurogenic bladder and bowel dysfunction are becoming increasingly used. We reviewed our experience and discuss factors that influence outcome. MATERIALS AND METHODS: Between 1994 and 2000, 65 stomal procedures were performed in 47 patients. For the urinary continent catheterizable channel we used appendix in 60% of cases, a continent bladder tube in 20%, a Yang-Monti tube in 16% and ureter in 4%. For the antegrade continence enema continent catheterizable channel we used appendix in 85% of cases, a Yang-Monti tube in 5% and a cecal tube in 10%. In the 19 patients who underwent simultaneous Mitrofanoff and antegrade continence enema procedures the urinary continent catheterizable channel was appendix in 21%, a Yang-Monti tube in 32% and continent vesicostomy in 47%. Patients were divided into 2 groups based on compliance status. In addition, percentile body weight for age was evaluated. RESULTS: Stomal continence was achieved in 63 of the 65 cases (97%). Of the patients who underwent the antegrade continence enema procedure 95% achieved continence via the rectum. Except for ureter stenosis rates according to continent catheterizable channel type did not differ greatly, namely 19% for appendix, 11% for the Yang-Monti tube, 22% for the bladder tube, 50% for ureter and 0% for the cecal tube. Infectious complications developed in 16 patients and 4 had stones. The rates of infection (p = 0.004), stomal stenosis (p = 0.001) and revision (p = 0.004) were statistically lower in the compliant group and the stone formation rate showed a trend favoring the compliant group (p = 0.11). No significant difference was noted for incontinence. Percentile weight predicted a higher rate of stomal stenosis with the highest rate of stomal stenosis overall in the greater than 100th percentile group. CONCLUSIONS: The Mitrofanoff and antegrade continence enema procedures are reliable and effective. Proper patient selection and surgical technique with a tension-free anastomosis are essential. The choice of tissue for constructing the continent catheterizable channel is not as important as patient compliance, age and possibly body habitus. This report reinforces the importance of careful screening, and rigorous preoperative and postoperative teaching to achieve overall patient success.

Child↗
PubMed2001

Orthotopic bladder substitution after radical cystectomy: 5 years of experience with a novel personal modification of the ileal s pouch.

PURPOSE: We report a 5-year experience with 52 patients who underwent radical cystoprostatectomy for bladder cancer and orthotopic bladder substitution using a novel personal modification of the S pouch. MATERIALS AND METHODS: From September 1995 to December 1999, 52 men 36 to 72 years old (mean age 63) underwent bladder substitution with an S pouch. They were followed until September 2000. The pouch was constructed with a 36 cm. segment of ileum with the whole length used for the reservoir. The ureters were directly anastomosed with one above the other in the mid segment of the pouch without any antireflux procedure. Complications were documented and classified as early or up to 3 months postoperatively and late, and further subdivided by the relationship to neobladder construction. Continence and voiding pattern were evaluated by personal interview and neobladder function was urodynamically assessed. Mean followup in our patients was 30 months. RESULTS: The most common of the 5 early and 9 late neobladder related complications were persistent urine leakage and reflux, respectively. There was no reflux greater than grade III in the 4 patients with reflux (5 refluxing ureters) and no functional disorders. We observed 12 early and 5 late complications unrelated to the neobladder. Open reoperation was required in 5 cases. Good or satisfactory daytime and nighttime continence was reported by 95% and 88% of our patients, respectively. By year 1 postoperatively 91% of our patients voided at an interval of 3 to 5 hours during the day. Mean maximum neobladder capacity was 672 ml. and mean post-void residual was 30 ml. by year 3 postoperatively. Two patients required self-catheterization once daily and mild hyperchloremia without acidosis developed in 2. CONCLUSIONS: The advantages of our modified S pouch are technical simplicity, substantially shorter operative time and decreased bowel length required. It is associated with an acceptable complication rate and functional parameters with subsequent patient satisfaction and good quality of life.

Adult↗
PubMed1994

Lower urinary tract reconstruction following cystectomy in women using the Kock ileal reservoir with bilateral ureteroileal urethrostomy: initial clinical experience.

Since June 1990, 14 women 31 to 70 years old (mean age 57 years) have undergone lower urinary tract reconstruction by bilateral ureteroileal urethrostomy using a Kock ileal reservoir. Indications for cystectomy included transitional cell carcinoma in 9 patients, urachal adenocarcinoma in 2, cervical carcinoma in 1, mesenchymal tumor of endometrial origin in 1 and a fibrotic radiated bladder in 1. Early and late complications have been few, occurring in 2 patients and 1, respectively. Excellent continence has been achieved during the day and night in 100% of patients. Of the 14 patients 12 void volitionally per urethra without high residual volume, while 2 require intermittent catheterization. All patients are completely satisfied. Tumor recurred in the pelvis in 1 patient with an extensive mesenchymal tumor necessitating conversion to a continent cutaneous Kock reservoir. All patients are currently alive without evidence of disease. This initial experience with lower urinary tract reconstruction in women has yielded extraordinary results and we believe that the option of lower urinary tract reconstruction following cystectomy can be offered safely to selected female patients.

Adult↗
PubMed1996

Changing referral patterns for surgical treatment of ulcerative colitis.

OBJECTIVE: To determine whether referral patterns for surgical treatment among patients with chronic ulcerative colitis have changed in recent years, especially in view of the introduction of a new operation, the ileal pouch-anal anastomosis (IPAA). MATERIAL AND METHODS: Between January 1976 and December 1986, 981 patients underwent proctocolectomy at Mayo Clinic Rochester. Brooke ileostomy (N = 300), colectomy with ileorectal anastomosis (N = 33), proctocolectomy with Kock pouch (N = 180), or ileal pouch-anal anastomosis (IPAA) (N = 468) was performed. The indications for surgical intervention were categorized as emergent or elective, the latter including intractability, cancer, and cancer prophylaxis. For analysis, the duration from diagnosis of disease to operation, indications for surgical treatment, and types of operation were subdivided into pre-IPAA era (before 1981) and post-IPAA era (from 1981 onward) for the entire group and for distant versus local patients. RESULTS: More continence-preserving operations were done in 1981 and thereafter (76%) than before 1981 (46%). In the later segment of the study period in comparison with before 1981, fewer operations were done for emergent reasons (4% versus 8%) and a greater percentage of operations were done for elective indications, especially intractability (74% versus 61%). With the advent of IPAA in 1981, patients underwent operation sooner after the diagnosis was made (7.4 years versus 8.6 years before 1981). A smaller proportion of patients underwent operation for cancer prophylaxis during 1981 through 1986 (19%), however, than before 1981 (28%). CONCLUSION: Referral patterns for surgical treatment of patients with ulcerative colitis have changed in recent years--patients are being referred for operation sooner, before complications develop that necessitate emergent procedures. Although the changed referral pattern may be due to the availability of IPAA, other factors may also have a role.

Adult↗
PubMed1994

Pouchitis after ileal pouch-anal anastomosis: a Pouchitis Disease Activity Index.

OBJECTIVE: To develop a "Pouchitis Disease Activity Index" (PDAI) and to compare it with other diagnostic scoring systems for pouchitis. DESIGN: We compared patients who had an optimal outcome with those who had a poor result attributable to recurrent pouchitis after ileal pouch-anal anastomosis (IPAA) for ulcerative colitis at the Mayo Clinic. MATERIAL AND METHODS: We evaluated the applicability of a PDAI that quantitated clinical findings and the endoscopic and histologic features of acute inflammation in four groups of patients: (1) 10 who underwent IPAA for ulcerative colitis and had symptoms compatible with a clinical diagnosis of pouchitis, (2) 5 who underwent IPAA for ulcerative colitis and did not have pouchitis, (3) 5 who underwent IPAA for familial adenomatous polyposis and had no symptoms of pouchitis, and (4) 5 who had a Brooke ileostomy for ulcerative colitis (control group). RESULTS: The PDAI was significantly greater in patients with the clinical features of pouchitis than it was for patients in the other three groups. All 10 patients with pouchitis fulfilled the PDAI criteria for a diagnosis of pouchitis; in contrast, only 1 of these 10 patients met the diagnostic criteria for pouchitis by application of previously established scoring systems. No asymptomatic patient qualified for a diagnosis of pouchitis by the PDAI criteria. CONCLUSION: The PDAI provides simple, objective, and quantitative criteria for pouch inflammation after IPAA and is more sensitive than prior scoring systems.

Adenomatous Polyposis Coli↗
PubMed1993

Chronic pouchitis after ileal pouch-anal anastomosis: responses to butyrate and glutamine suppositories in a pilot study.

Nonspecific, idiopathic inflammation of ileal pouch mucosa ("pouchitis") after ileal pouch-anal anastomosis is a common complication of this surgical approach. The epithelium of the pouch is ileal, but variable degrees of colonic metaplasia are natural sequelae of construction of such a pouch. One hypothesis is that pouchitis is caused by a deficiency of epithelial nutrition. Thus, a lack of butyric acid (the principal metabolic fuel of colonocytes) or of glutamine (the main fuel of enterocytes) may develop. In this study, our aims were to determine the concentration of total short-chain fatty acids in random stool samples obtained from patients with an ileal pouch-anal anastomosis with and without pouchitis and to test the therapeutic effects of butyrate and glutamine suppositories on pouchitis. During the study, all conventional therapy for pouchitis was discontinued. For 21 days, 9 patients participated in a butyrate trial, and 10 patients were treated with glutamine. Total concentrations of fecal short-chain fatty acids were significantly less in patients with pouchitis than in those without pouchitis. During treatment, 6 of the 10 patients who received glutamine had no recurrence of symptoms, but only 3 of the 9 patients who received butyrate responded similarly. Hence, further studies of glutamine in the treatment of pouchitis seem warranted.

Adolescent↗
PubMed2000

Advances in inflammatory bowel disease.

Optimal management of patients with IBD requires a multidisciplinary approach involving primary care physicians, gastroenterologists, surgeons, radiologists, and nutritionists. The rapidly evolving medical armamentarium promises better quality of life for patients afflicted with these complex, chronic diseases. It is expected that future development of biologic agents will add to the therapeutic options, although it may complicate treatment algorithms. Surgical advancements, particularly in ileoanal anastomosis and bowel preservation by strictureplasty, have improved outcome dramatically. The focus on development of new therapies and refinement of older ones demands a constant attention to the latest peer-reviewed literature and that the clinician keep abreast of the various advancements that have been summarized here.

Algorithms↗