Colon interposition for esophageal replacement: an alternative technique based on the use of the right colon. (1/19)

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.  (+info)

Denervated stomach as an esophageal substitute recovers intraluminal acidity with time. (2/19)

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.  (+info)

Transperitoneal guide-wire or drainage catheter placement for guidance of laparoscopic marsupialization of lymphocoeles post renal transplantation. (3/19)

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.  (+info)

One-stage urethral reconstruction using colonic mucosa graft: an experimental and clinical study. (4/19)

AIM: To investigate the possibility of urethral reconstruction with a free colonic mucosa graft and to present our preliminary experience with urethral substitution using a free graft of colonic mucosa for treatment of 7 patients with complex urethral stricture of a long segment. METHODS: Ten female dogs underwent a procedure in which the urethral mucosa was totally removed and replaced with a free graft of colonic mucosa. A urodynamic study was performed before the operation and sacrifice. The dogs were sacrificed 8 to 16 weeks after the operation for histological examination of urethra. Besides, 7 patients with complex urethral stricture of a long segment were treated by urethroplasty with the use of a colonic mucosal graft. The cases had undergone an average of 3 previous unsuccessful repairs. Urethral reconstruction with a free graft of colonic mucosa ranged from 10 to 17 cm (mean 13.1 cm). Follow-up included urethrography, urethroscopy and uroflowmetry. RESULTS: Urethral stricture developed in 1 dog. The results of urodynamic studies showed that the difference in the maximum urethral pressure between the pre-operation and pre-sacrifice in the remaining 9 dogs was not of significance (P>0.05). Histological examination revealed that the colonic free mucosa survived inside the urethral lumen of the 10 experimental dogs. Plicae surface and unilaminar cylindric epithelium of the colonic mucosa was observed in dogs sacrificed 8 weeks after the operation. The plicae surface and unilaminar cylindric epithelium of the colonic mucosa was not observed, and metaplastic transitional epithelium covered a large proportion of the urethral mucosa in dogs sacrificed 12 weeks after the operation. Clinically, the patients were followed up for 3-18 months postoperatively (mean 8.5 months). Meatal stenosis was developed in 1 patient 3 months postoperatively and needed reoperation. The patient was voiding very well with urinary peak flow 28.7 ml/s during the follow-up of 9 months after reoperation. The other patients were voiding well with urinary peak flow greater than 15 ml/s. Urethrogram revealed a patent urethra with an adequate lumen with no significant graft sacculation. Neither necrosis of neourethral mucosa nor stenosis at the anastomosis sites has been observed on urethroscopy in 4 patients over 6 months after operation. CONCLUSION: Urethral mucosa can be replaced by colonic mucosa without damaging the continence mechanism in female dogs. Colonic mucosa graft urethral substitution is a feasible procedure for the treatment of complex urethral stricture of a long segment. The technique may be considered when more conventional options have failed or are contraindicated.  (+info)

Use of autologous buccal mucosa for vaginoplasty: a study of eight cases. (5/19)

BACKGROUND: Vaginal agenesis is a rare condition and treatment methods are varied. The difference between most of the surgical techniques is the graft material used. The purpose of this study was to describe the procedure and outcome of creating a neovaginal pouch lined with autologous buccal mucosa. METHODS AND RESULTS: Between August 2000 and February 2002, eight patients with Mayer-Rokitansky-Kuster-Hauser syndrome were admitted to our hospital. All of the patients successfully underwent neovaginoplasty with autologous buccal mucosa as graft material. The buccal mucosal wound completely healed 2 weeks after the operation and the neovaginal length and calibre were well formed. Follow-up ranged from 0.5 to 1.5 years. One patient encountered post-operative vaginal bleeding and another patient suffered from urinary bladder injury. CONCLUSION: This is the first reported procedure of vaginoplasty with autologous buccal mucosa as graft material. Our method is ideal in its simplicity, provides good cosmetic results, and improves the vaginal length of the patient.  (+info)

Anatomic and functional results of laparoscopic-perineal neovagina construction by sigmoid colpoplasty in women with Rokitansky's syndrome. (6/19)

BACKGROUND: The Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome is a rare congenital cause of primary amenorrhea, due to utero-vaginal agenesis. Several surgical techniques have been used to create a neovagina. Neovagina construction with a sigmoid graft appears to be the best option, as it offers adequate length and natural lubrication, allowing early intercourse. However, few data are available on the complications, anatomic and functional results of laparoscopic-perineal neovagina construction by sigmoid colpoplasty. METHODS: From September 1995 to November 2002, seven women with the MRKH syndrome underwent laparoscopic-perineal neovagina construction by sigmoid grafting. RESULTS: The mean operating time was 312 min (range 220-450 min). The mean fall in haemoglobin was 3.6 g/dl (range 2-4.4 g/dl). Blood transfusion was never necessary. The only perioperative complications were one urinary tract infection and one vulvar haematoma not requiring drainage. The mean hospital stay was 7.7 days (range 6-12 days). The mean length of the neovagina was 11.5 cm (range 7-15 cm), and no shrinkage occurred during follow-up. The neovaginal introitus admitted two fingers in breadth in five of the seven patients. Dilation of the introitus was required in the other two women. None of the four women who had intercourse experienced dyspareunia or discomfort. CONCLUSION: Our results confirm the feasibility of laparoscopic-perineal neovagina construction by sigmoid colpoplasty, when performed by surgeons with extensive experience in both gynaecological and gastrointestinal laparoscopic surgery. The anatomic and functional results were good.  (+info)

Use of artificial dermis and recombinant basic fibroblast growth factor for creating a neovagina in a patient with Mayer-Rokitansky-Kuster-Hauser syndrome. (7/19)

Vaginal agenesis is an uncommon, but not rare, condition. Although there are many methods for creating a neovagina, the optimal treatment is unknown. An 18-year-old woman with Mayer-Rokitansky-Kuster-Hauser syndrome received vaginoplasty with a modified Wharton procedure using an artificial dermis (atelocollagen sponge). From 10 days after the operation, the patient was administered human recombinant basic fibroblast growth factor (bFGF) spray to accelerate epithelialization on the neovagina. At 50 days after the operation, we confirmed histological squamous epithelialization of the vaginal epithelium. At 12 months after the operation, the neovagina was at least 3.5 cm in width and approximately 8 cm in length. In this case, use of artificial dermis and recombinant bFGF to create a neovagina was an easy, less invasive and useful method.  (+info)

Sexuality after laparoscopic Davydov in patients affected by congenital complete vaginal agenesis associated with uterine agenesis or hypoplasia. (8/19)

BACKGROUND: Several surgical techniques have been described for the treatment of patients with vaginal agenesis. The simplest intervention that gives good sexual results should be the surgical technique of choice. METHODS: We report anatomic and functional outcome in 28 women after vaginoplasty using laparoscopic Davydov operation. This surgery includes three steps: two laparoscopic and one perineal. The patient then has to use a mould or a vaginal dilatator for 1 month. The functional outcome was assessed by a brief and valid self-report questionnaire evaluating female sexual life (Female Sexual Function Index, FSFI). A control group was recruited to compare the results. RESULTS: Two intra-operative bladder and ureteric injuries were repaired without sequels. Two post-operative complications were observed: one abdominal migration of the mould, which was treated successfully with the laparoscope, and one vesico-vaginal fistula. No patient was lost to follow-up. The anatomical result was judged to be satisfactory (>6 cm) in 26 of the 28 patients: the mean vaginal length was 7.2 +/- 1.5 cm. Among the 28 operated women, 19 had a good or very good result. No statistical difference was found between our operated patients and French controls in all six domains of the FSFI. CONCLUSIONS: Laparoscopic Davydov may be considered a good option for the surgical treatment of women presenting vaginal agenesis. This technique offers advantages such as: short operating time and hospital stay, no particular instrumentation required and no external scars. Sexuality approaches so-called 'normal sexuality'.  (+info)