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Objectives To verify the utility of triangular extension of a hinge flap in buccal mucosal staged urethroplasty to resolve stomal stenosis after the first stage and ultimately prevent restenosis. Methods A total of 23 patients (triangular extension group) were studied in 2013-2019. In the first stage, buccal mucosa was transplanted, and an extended triangle portion of the mucosa was placed beside the proximal and/or distal stoma that was created when the stricture segment of the urethra was resected. In the second stage, during tubularization of the urethral plate, an incision was made at the stoma to increase the caliber to which the triangular extension was inserted. The procedure was considered successful when a 17-Fr flexible cystoscope passed through the reconstructed urethra at 6 months after the second-stage urethroplasty and no additional surgery or bougie dilation required. The clinical course of the triangular extension group was compared with 24 patients who underwent conventional staged urethroplasty (control group). Results In total, 20 patients from each group underwent second-stage surgery. No patients in the triangular extension group required additional revision surgery because of stomal stenosis after first-stage surgery, whereas five (20%) control patients did. Urethroplasty was successful in 19 patients (95%) in the triangular extension group and in 19 patients (95%) in the control group. Uroflowmetry after the second-stage surgery indicated that the mean maximum urinary flow rate was 21.5 and 15.8 mL/s after triangular extension and the control procedure, respectively (P = 0.027). Conclusions The triangular extension technique reduces the need for revision surgery and prevents postoperative restenosis.

Bariatric surgery is the most effective treatment for obese patients. Laparoscopic greater curvature plication (LGCP) is a good, effective and feasible surgical option for the treatment of obese patients. But it has some complications that should be considered such as gastric remnant distention, stomal stenosis and marginal ulcers. Here, we reported an extremely rare complication “gastro-gastric herniation”. This condition was diagnosed through upper gastrointestinal contrast imaging and treated through laparoscopy. The hernia was invaginated and firm continuous sutures were placed. We followed the patient for one year and the results were great. Thus, we can add gastro-gastric hernia to the medical literature as a rare complication of laparoscopic greater curvature gastric plication, and It is considered a serious condition that requires immediate treatment and follow-up., Highlights - Obesity is considered as an important risk factor for many serious diseases. - Bariatric surgery is the most effective treatment for obese patients. - Laparoscopic greater curvature plication (LGCP) is an effective and feasible surgical option. - Gastrogastric herniation is a rare complication of greater curve plication.

Key message Granulation tissue formation is one of the late complications of tracheostomy. It can cause stomal stenosis secondary to chondritis because of disproportionate excision of the anterior cartilage. Clinicians should carefully determine the incision point, which is typically located half way between the cricoid cartilage and the sternal notch., Tracheostomy requires an incision between the cricoid cartilage and sternal notch in critically ill patients who require an extended period of mechanical ventilation. This procedure can potentially increase the availability of intensive care unit beds in the coronavirus disease 2019 (COVID‐19) era. Granulation tissue formation can cause stomal stenosis secondary to chondritis because of the disproportionate excision of the anterior cartilage. Here, computed tomography (CT) imaging showed partial destruction of the cricoid cartilage, which is suggestive of chondritis and may lead to airway stenosis.

Highlights • Stomal stenosis can develop after repair of a traumatic abdominal wall hernia. • Abdominal wall repair with negative-pressure wound therapy may be effective. • Stomal patency must be evaluated during the abdominal wall hernia repair., Introduction Traumatic abdominal wall hernias are often accompanied by intra-abdominal injuries, and a stoma may be required. Although rare, stomal stenosis can develop after the repair of a traumatic abdominal wall hernia. Presentation of case A 65-year-old woman was in a head-on collision with a truck and was brought by ambulance to our facility. The findings of a physical examination and computed tomography scan suggested bowel perforation for which exploratory surgery was performed. The lacerated small bowel and sigmoid colon were resected and an ileostomy and colostomy were created. Abdominal wall reconstruction was impossible because of the large defect size. Repair of the abdominal wall was achieved by gradual closure of the fascia after surgery in combination with negative pressure wound therapy. Stenosis of the ileostomy occurred during this process and was surgically repaired. Discussion We reconstructed the abdominal wall using negative pressure wound therapy in combination with sutures while minimizing the risk of abdominal compartment syndrome. This approach did not increase the intra-abdominal pressure, but it deformed the abdominal wall, resulting in unexpected stenosis of the ostomy. Conclusion Gradual postoperative closure of a traumatic abdominal wall hernia with an ostomy in place may result in stomal stenosis. Stomal patency must be carefully evaluated during this process.

To demonstrate the surgical technique and outcomes of double posterior based flap technique in primary endoscopic dacryocystorhinostomy (DCR) with and without use of powered instrument. 28 patients of nasolacrimal duct obstruction were included in the study from September 2012 to February 2015. All underwent endoscopic dacryocystorhinostomy with double posterior based nasal and lacrimal flap technique. In patients of group A (14 patients), bone removal was done with the help of Smith-Kerrison punch forceps and in patients of group B (14 patients), powered drill has been used for the same. Patients were visited the endoscopic clinic at 1, 3, 6 months and 1 year after the surgery for post operative evaluation. Of 28 patients, 26(92.85%) were found free of symptoms at the end of 1, 3 and at 6 months. One from each group had recurrence of symptoms. At the end of 12 months of 25 patients, 3(12%) patients were found to have recurrence of symptoms of which 1(8.33%) patients was from group A and 2(15.38%) were from group B and failures were because of granulation tissue and stomal stenosis. Patients assisted with powered drill had more postoperative complications compared to cold instrument. Double posterior based flap technique in primary endoscopic DCR without the assistance of powered drill could be an effective surgical option for the patients of chronic nasolacrimal duct obstruction enabling early epithelisation by preventing peristomal granulation tissue resulting in encouraging surgical outcome with least postoperative complication.

Stomal stenosis and retraction are common problems. Retraction has been reported to affect up to 14% of colostomies and 12% of ileostomies whereas stenosis affects 2–15% of all stomas. Whilst meticulous surgical technique can reduce the incidence of such complications, the role of the stoma nurse before surgery is indisputably vital. With one series finding that 60% of stomal strictures could be managed conservatively, the ostomy nurses also have a role in the postoperative setting. Nevertheless, such complications often require reoperation. If this is the case, thorough surgical technique is required to refashion or relocate the stoma.

Objective To present the results of simultaneous creation of both Mitrofanoff stoma and Malone antegrade continence stoma (MACE) using simple division of the appendix and a cecal extension method. Materials and Methods Between June 2011 and November 2016, simultaneous Mitrofanoff and MACE was performed in 16 children (12 children—simple division of the appendix, 4 children—appendicovesicostomy and cecal extension of the appendix). Extension of the appendix was achieved by tubularization of the excised cecal flap next to the short appendicular stump. The new extended channel was then wrapped by cecal wall. Results Follow-up was 40 months (10-74 months). Currently, in all children, both stomas are easily catheterizable. Obstruction of MACE occurred in 5 children (4 with split appendix, 1 with extended appendix); Mitrofanoff stomal stenosis occurred in 1 child. Endoscopic revision and prolonged catheterization of stenotic stomas were effective in all cases. Wound infection and dehiscence was noted in 2 children (both with split appendix). Drainage and intravenous antibiotics were effective. All Mitrofanoffs are continent. In 4 children there is incident minor leakage of the MACE (3 with split appendix and in 1 with extended appendix). Conclusion The split appendix procedure is feasible. Cecal extension of the appendix seems to be a good option when the appendix is too short for a simple split procedure.

Background: Both elective and emergency tracheostomy as life saving procedure is frequently performed. Tracheostomy can be associated with numerous (per operative and post operative) complications.Methods: this was a cross sectional study 120 patients were studied age ranged from 9 years to 79 years in four different tertiary hospitals in Dhaka from July 2011 to June 2013.Results: Among 120 tracheostomized patients, 75 (62.5%) were patients of emergency tracheostomy group and 45 (37.5%) were patients of elective tracheostomy group. Laryngeal carcinoma and other head-neck malignancy were the common (67.34%) indications for emergency tracheostomy. Maxillofacial and laryngeal surgery (50.1%) was the common indications for elective tracheostomy. Haemmorage was the most common complication. The second most common complication were subcutaneous surgical emphysema and wound infection , Then tube displacement, pericondritis and stomal stenosis/ granulation tissue formation were the complications . In all stages (peroperative, immediate postoperative, early postoperative and late postoperative), the frequency of complications was more in emergency tracheostomy and it was statistically significant (p

Highlights • A case report of using a metal stent to manage ileal conduit stomal stenosis. • A stent can avoid the need for a refashion or reconstruction of the stoma. • Stent insertion is minimally invasive and does not require general anaesthesia. • The stoma regained full function after stent insertion. • There were no issues with stent migration, oxidation or calcification., Intoduction Ileal conduit stomal stenosis is a difficult complication to manage. Definitive treatment usually requires refashioning or a reconstruction of the conduit. There remains a need for minimally invasive procedures that can restore function to the stoma while avoiding the risks associated with a significant surgical procedure. This case illustrates a novel approach to the management of this complication. Presentation of case An 84 year old female with muscle-invasive bladder cancer underwent cystectomy with formation of an ileal conduit urinary diversion system. Her recovery was complicated by stomal stenosis leading to recurrent urinary tract infections. The Memokath Stent 045 is a thermo-expandable nickel–titanium stent designed for treatment of urethral strictures. The stent was inserted into the stoma under direct vision without the need for general anaesthesia or intraoperative radiography. The conduit remains patent 12 months after insertion and the metal stent showed no evidence of migration, calcification, oxidation or degradation. Discussion The use of a thermo-expandable nickel–titanium stent is able to provide the patency required to treat ileal conduit stomal stenosis. In this case, insertion of the stent was a simple procedure and no adverse events or degradation of the stent was identified at 12 months after insertion. The need for a significant surgical procedure such as a refashioning or reconstruction was avoided and general anaesthesia was not required to perform the procedure. Conclusion This case report highlights the possibility of using the thermo-expandable Memokath Stent 045 as an alternative to the long-term management of ileal conduit stomal stenosis.

Although vertical banded gastroplasty (VBG) is no longer performed in the USA, due to its popularity in 1980s, many patients still possess this anatomy with its inherent complications. The stomal stenosis secondary to tight ring or mesh is traditionally treated with surgical removal of the silastic ring or a complex revision, which was hampered by complications, technical complexity, and invasiveness. We described our experience of endoscopic management of this complex problem and the early outcomes. Retrospective study. Tertiary care center. Thirteen consecutive patients with gastric outlet obstruction who underwent endoscopic intervention after vertical banded gastroplasty (VBG). Endoscopic removal of silastic ring with self-expanding metal stent or endoscopic guided trans-gastric stapled stricturoplasty (TSS). Feasibility, safety, and efficacy of endoscopic approaches. Technical and clinical success in 11 patients (85 %) on first endoscopic attempt. Stent migrated in one patient, and another patient required second endoscopic intervention for recurring symptoms. Retrospective analysis, single-institution study, and small sample size. Endoscopic approach to gastric outlet obstruction secondary to VBG regardless of type of restrictive device is safe and feasible with possible short-term benefit. This technique may also be use as bridge toward future revision surgery.

Summary Introduction The Malone antegrade continence enema (MACE) procedure is effective in management of fecal incontinence and intractable constipation. Stomal incontinence and stenosis are the most common issues reported, and a recent large study of imbricated MACE procedures reports a surgical revision rate of 17%. The laparoscopic approach is now widely used and precludes imbrication. To date, few studies have reported revision rates in these patients who have undergone non-imbricated MACE creation. Objective Our goal was to report the long-term outcomes of our non-imbricated patients focusing on complication rates and need for revision. Study design Records of patients younger than 18 years of age who underwent non-imbricated MACE between January 2000 and March 2016 at our institution were reviewed. Patients with less than 2 years of follow-up or non-compliance with MACE usage were excluded from analysis. Patient age, ambulatory status, surgical technique, stomal site, and complications including stomal leakage, stomal stenosis, and need for revision were evaluated. Stomal leakage was classified based on our previously reported system. Results A total of 81 patients met inclusion criteria. Mean age at time of surgery was 8.4 years. Mean and median follow-up were 6.7 and 6.7 years, respectively. Overall revision rate, for stenosis or incontinence, was 16% with a mean time to any revision of 2.1 years (range 28 days to 7.8 years). Four patients required revision for stomal incontinence while others improved spontaneously without intervention. At the last follow-up, stomal leakage was grade 0 in 93.8% of patients, grade 2 in 2.4%, and grade 3a in 3.7% ( summary Table ). Stomal stenosis was noted in 11 patients, eight of whom required revision. Discussion Our study is limited by its retrospective nature with some component of recall bias. A single surgeon experience is also not representative of others' experiences. However, our results indicate that incontinence improves spontaneously in a majority of patients without need for revision in this non-imbricated cohort. Conclusions Our series shows a similar long-term revision rate in line with that reported in the literature. While imbrication is still recommended during open surgery when the anatomy is suitable, equitable success without imbrication supports the laparoscopic approach and a more liberal approach during open surgery if the anatomy does not permit imbrication. Table . Stomal continence. Grade 0 Grade 1 Grade 2 Grade 3a Grade 3b Initial classification 55.6% 18.5% 6.2% 14.8% 4.9% Final classification 93.8% – 2.4% 3.7% –

PURPOSE To assess hydronephrosis of tubeless cutaneous ureterostomy using Tc-99m mercaptoacetyltriglycine (MAG3) diuretic renogram. MATERIALS AND METHODS Cutaneous ureterostomy with a unilateral stomal creation was performed in 15 patients (27 renal units) with a minimum follow-up period of 6 months. Stomal obstruction was evaluated with Tc-99m MAG3 diuretic renography 3 months after the surgery. The data analyses were performed with half-times to tracer clearance (T1/2) after furosemide (0.5 mg/kg) administration. RESULTS T1/2 means were 7.27 +/- 7.11, 5.69 +/- 4.63, and 8.96 +/- 8.37 minutes for total, ipsilateral, and contralateral kidneys, respectively, in side relationships between ureter and stoma. There were no statistical differences among the groups. Six months after the surgery, of 26 renal units (96.3%) that had achieved a tubeless condition, and 25 renal units (92.6%) had no hydronephrosis. T1/2 was within 20 minutes in these 25 renal units, and of 25 renal units 23 (92%) revealed less than 15 minutes in T1/2, suggesting that the upper limit of T1/2 for nonobstructed systems after construction of a cutaneous ureterostomy might be 15 minutes. Mild hydronephrosis without the need for intervention was present in 1 renal unit (T1/2, 31.70 minutes). Catheterization was performed in one renal unit (T1/2, 21.04 minutes) due to acute pyelonephritis and persistence of grade 2 hydronephrosis 5 months after the surgery. Only these 2 renal units showed more than 20 minutes in T1/2, resulting in an obstructive pattern on diuretic renography. CONCLUSION Tc-99m MAG3 diuretic renography with T1/2 assessment is useful to evaluate stomal stenosis in tubeless cutaneous ureterostomy.

There are a variety of complications that can affect people who have a temporary or permanent stoma. This article discusses the complication of stomal stenosis, and the causes and predisposing factors that contribute to this occurrence. The article also explores a case study in which stoma stenosis resulted in peri−stomal fistula formation, and explains the stoma care management used to deal with this complex stoma complication.

Introduction Cutaneous ureterostomy is the simplest and safest method of all permanent urinary diversions. However, the procedure does carry a risk of stomal stenosis. We describe a simple technique for improving tubeless cutaneous ureterostomy. Technical Considerations Between June 1991 and June 2003, the Toyoda cutaneous ureterostomy was performed in 54 patients (102 renal units) with a minimum of 6 months of follow-up. Since 1998, we introduced a new technique, consisting of fixation between the anterior and posterior rectus sheath by four interrupted sutures to maintain the stability of the abdominal wall tunnel for the ureters. The ureteral patency rate was reviewed. Of the 79 renal units (77.5%) that achieved a tubeless condition, 70 (68.6%) had no hydronephrosis. The catheter-free rate improved from 60.5% (26 of 43 renal units) to 89.8% (53 of 59 renal units) with the introduction of the new surgical stabilization step for the abdominal wall tunnel. Conclusions This surgical modification is an effective and simple procedure that improves tubeless cutaneous ureterostomy performed with the Toyoda method.

Hypothesis Stenosis of the tracheostome is a frequent complication following total laryngectomy; the problems created by tracheostomal stenosis are the result of reduced airflow and consequent turbulence. Many authors have studied etiological factors for the onset of stomal stenosis, and a number of procedures have been recommended for the surgical correction of such stenosis. Study Design A prospective analysis of 12 patients who underwent surgical correction of stomal stenosis is presented. Methods At the Institute of Clinical Otolaryngology we have recently defined a surgical technique for the correction of stomal stenosis that combines radial incisions, V-shaped flaps, and interposing flaps. This technique enables us to correct all the types of stenosis, and we have treated 12 patients to date. Results To date, the average follow-up has been 17 months (range, 3–36 mo), and the results are encouraging. Early stenosis of the tracheostoma reappeared in one patient, who had successful repeat surgery with the same technique. Conclusions Early results suggest the routine use of this surgical technique in the treatment of stomal stenosis.

We report the effectiveness of an antegrade continence enema stopper device in preventing stomal stenosis in catheterizable channels.All cases in which a channel was created for clean intermittent catheterization during a 5-year period beginning in May 2002 were included in the analysis. For the first 31 months the catheterizable channels were used for clean intermittent catheterization but were not kept patent between catheterizations (group 1, 19 patients). For the next 29 months we began to use an antegrade continence enema stopper in the stoma between catheterizations for a period of 3 to 6 months postoperatively (group 2, 14 patients).A total of 33 catheterizable channels were studied. Six catheterizable channels in group 1 (32%) had to be revised within 6 months of reconstruction. No catheterizable channel in group 2 had to be revised. This difference is statistically significant (p = 0.02).An antegrade continence enema stopper inserted into the catheterizable channel for 3 to 6 months postoperatively effectively eliminates the incidence of stomal stenosis.

Bronchoplasty was extended to the segmental level and the effect of the multi-segmental surgery for the central non-small lung cancer was observed. The involved lobular bronchi and part of main bronchi were resected and single-layer continuous suture with 5-0 Prolene was used for suturing of the carina of the reconstructed segmental bronchi to form lobular bronchi. Then, single-layer continuous suture with 4-0 Prolene was employed to anastomose the "lobular bronchi" with main bronchi. Our results showed that the 15 bronchoplasties were successfully performed. The tumors were completely removed and postoperatively, the pulmonary functions of the patients were substantially improved. No broncho-pleural fistula and stomal stenosis took place in all the cases. The quality of life of the patients were obviously improved. It is concluded that multisegmental bronchoplasty can completely remove the tumor of central non-small-cell lung cancer and conserve more non-involved lung. The procedure is especially suitable for those patients with severely impaired lung functions and it expands the indications of surgical resection of lung cancer.

Objective The aim of our study was to review the management of stomal stenosis after the Malone antegrade continence enema (MACE) procedure at our center, and to describe and assess the early outcomes of 2 novel procedures used in the management of conduit stenosis: Maceoscopy and the rendez-vous . Subjects/patients and methods We retrospectively reviewed 45 consecutive MACE cases performed by 1 surgeon at St George's hospital over a 13-year period. Results Until April 2002, 5 cases presented with difficulty catheterizing their MACE. This was attributed to stenosis without further investigation, and the MACE revised surgically. Of 13 cases presenting with suspected stenosis since May 2002, 8 channels turned out to be patent when assessed and catheterized endoscopically via Maceoscopy. Two truly stenotic MACEs were revised; patency of the other 3 was reestablished by means of a new double-endoscopic procedure we have termed the rendez-vous.

Background Since the initial description of the antegrade colonic enema (ACE) procedure, stomal stenosis has been recognized as its most common complication. We previously reported that 44% of our patients required a dilatation for stomal stenosis, with 22% requiring surgical revision. We present our findings with the use of an ACE stopper (Medicina, Adlington, Lancashire, UK) as a means of avoiding this problem. Methods A retrospective review of the case notes of all patients who underwent an ACE procedure with a follow-up longer than 6 months was carried out over a 3-year period. Two weeks after the ACE procedure, an ACE stopper was sited in the conduit for at least 4 months and removed only for catheterization. Results Fourteen patients underwent an ACE procedure, 12 of whom received it laparoscopically. All patients received the ACE stopper. The patients' median age at surgery was 10 years (range, 5-16 years). Diagnoses included spinal dysraphism (n = 6) and anorectal malformation (n = 4), with soiling as the presenting complaint among all patients. The patients' median follow-up was 12 months (range, 6-39 months). There was no stomal complication, and 13 patients reported a marked improvement in soiling. Conclusions The use of an ACE stopper has abolished stomal stenosis on short-term follow-up. We recommend the stopper as an adjunct to the overall management of concerned patients. Longer follow-up is required to establish the true effectiveness of this simple device.

Background Tracheal stenosis can be a troubling consequence of laryngectomy. Some revision techniques disturb the posterior stoma site of a current or planned tracheoesophageal puncture (TEP). Methods A revision technique which advances the trachea out of the stoma, divides the anterior tracheal wall, and leaves the posterior tracheal wall undisturbed was designed. The paper describes the technique in detail. “Success” was defined as producing a stable, trouble-free stoma requiring no stenting; “partial success” as an improved stoma requiring some stenting; and “failure” as no improvement and continuous stenting. Results Fifteen patients underwent the procedure. Median time from laryngectomy to revision was 10 months. Preoperative to postoperative median stoma size increased from 63 mm2 to 135 mm2. Seven patients were classified as successful, six patients were partially successful, and two patients had no improvement. Conclusion The tracheal advancement flap is a safe technique for the laryngectomy patient who has undergone or might undergo voice restoration. © 1997 John Wiley & Sons, Inc. Head Neck 19: 211–215, 1997.

Continent lower urinary tract reconstruction is an invaluable tool to treat urinary incontinence, allow accessible intermittent catheterization, and protect the upper urinary tracts from high bladder pressures in children with neuropathic bladders. It has been used extensively in the past few decades around the world, and a large body of evidence has been accumulated as to its surgical outcomes and complications. The majority of these complications are manageable with a combination of medical and minimally invasive surgical interventions. This chapter will outline minimally invasive and injection techniques in the approach to complications such as stomal stenosis, acute inability to catheterize a channel, urinary incontinence, and bladder stones.

Complication rates of up to 86.6% have been reported after creation of an ileal conduit. In contrast to others, we construct an antirefluxing isoperistaltic colonic for incontinent diversion in children.Between 1968 and 1989 a colonic conduit was created in 105 patients up to age 20 years for neurogenic bladder (76), bladder exstrophy (16) and other reasons (13). Long-term followup (minimum 5 years, mean 16.3 years, range 5 to 26) was possible in 84 patients (159 renal units).Early and late stenosis at the ureterocolic anastomosis, and stomal stenosis occurred in 7.6 and 15.5% of the cases, respectively. Renal calculi developed in 8.2% of the renal units. Eight kidneys without function after recurrent pyelonephritis, calculi or stenosis at the ureterocolic anastomosis were removed during followup. Compared to preoperative status 3 of the remaining 151 renal units had increased dilatation of the upper urinary tract at the last followup. A total of 31 patients had complications during followup and 18 underwent conversion to continent urinary diversion.When incontinent urinary diversion is necessary in children, a colonic conduit with the option of continent conversion should be created before deterioration of the upper urinary tract.

Background: Tracheostomal stenosis following total laryngectomy for carcinoma of larynx is a challenging condition for an otolaryngologist, especially when the patient requires post-operative radiotherapy. Critical narrowing of the stoma needs surgical widening. Though there are few surgical techniques described for the same, re-stenosis has been observed in many. We conducted a comparative study of two widening techniques: Y-V advancement and two circular incisions technique.Methods: A prospective study was conducted, to assess the outcome of 2 surgical techniques: Y-V advancement and two circular incisions technique in patients with tracheostomal stenosis following total laryngectomy. Initially three patients were subjected to Y-V advancement technique for stomal dilatation. But all three patients presented with re-stenosis in a mean period of 8 months and were then subjected to stomal widening by the double circular incisions technique. The next five patients who presented with stomal stenosis underwent widening by two circular incisions technique. All 8 patients were followed up for one year postoperatively. Results: Among the 8 patients, 3 patients who presented initially underwent stomal widening by the Y-V advancement technique. All 3 patients presented with re-stenosis in a mean period of 8 months post-operatively. Stomal widening using the two circular incisions technique was adopted for these three patients and another 5 patients who presented with stomal stenosis. All 8 patients were found to be maintaining an adequate stoma on one year post-operative follow up.Conclusions: In our experience, stomal widening by the two circular incisions technique has found to be effective in maintaining an adequate stoma with no features of re-stenosis on a one year postoperative follow up. However a larger study is desirable to conclusion of the same.

The parastomal hernia is a very common complication after the creation of any ostomy [1]. Although it is generally believed that most patients with parastomal hernias do not suffer from symptoms, the contrary could be clearly shown in a recent publication [2]. In fact, more than 80 % of the patients with a clinically detectable hernia have problems that interfere with their daily activities because of the hernia. Today the repair should include the use of non-resorbable meshes. Nevertheless the results of clinical studies are discouraging because of recurrence rates between 10 and 50 % and a substantial frequency of wound complications [3]. However most studies only contain a limited number of patients and therefore do not allow definite conclusions.

Aim of the Study Stomal stenosis is the commonest complication of the antegrade colonic enema (ACE) procedure, reportedly occurring in 25–55% of patients. As such, a simple ACE stopper device (a small silicone plug sited in the ACE conduit between catheterisations) was designed to prevent stenosis. We performed a long-term follow-up study to determine the effectiveness of the stopper device. Methods A retrospective case note review was performed of all patients who successfully underwent a primary ACE procedure over an 8.5-year period (January 2002 to June 2010). The inclusion criteria were (i) a minimum of 6 months follow-up, (ii) simple appendicostomy, (iii) caecal/colonic flap. In all patients an ACE stopper was sited in the conduit for at least 4 months and removed only for catheterisation. Data are mean±SEM. Main Results 38 children were included in our study. Mean age at surgery was 9.6±0.5 years. Surgery was performed in 22 patients for incontinence and in 16 for chronic constipation. 31 underwent an appendicostomy and 7 had a caecal/colonic flap; all received an ACE stopper. The mean follow-up was 2.6±0.3 years. Only 3 patients (8%) developed stomal stenosis. The first occurred 6 months postoperatively, resulting from an ACE stopper which was too small and consequently persistently fell out. This conduit required dilatation. The second occurred at 27 months secondary to a stomal infection and required surgical revision. The third occurred 8 months postoperatively for no obvious cause, and was treated with dilation. 1 patient experienced stomal leakage. Conclusion The ACE stopper is a simple yet highly effective method of preventing stomal stenosis. We recommend using the stopper in all ACE patients.

We describe a reliable and simple technique of parastomal hernia repair using primary fascial repair with synthetic mesh that minimizes the known complications of infection and stomal stenosis while eliminating the need for peritoneal exploration, lysis of adhesions, and relocation of the stoma. We applied this technique to 6 patients (aged 65 to 83 years) with symptomatic, first-time parastomal hernias. The results are discussed.

As part of the Adelaide Obesity Surgery Study, we have reviewed all patients who have undergone revisional surgery. Of the 31 0 trial patients, 63 (20%) had revisions 1-69 (median 32) months following their original surgery-30% of all 105 gastrogastrostomy (GG) operations, 22% of 106 gastroplasty (GP) procedures, and 9% of 99 gastric bypasses (GB). Failure was due to stomal dilatation, 11% of all trial patients (71% of GG revisions), stomal stenosis, 6% (52% of GP revisions) and staple dehiscence, 4%. There was no mortality and a low hospital morbidity. Long-term success was only 23% (follow-up at least 3 years) and was achieved at considerable expense (3 reversals, 10 further revisions, 44 endoscopic procedures). Revisional surgery was successful in 45% of patients with stomal dilatation or dehiscence but in only 17% with stenosis. Overall, the most successful operation was revision of, or conversion to, gastric bypass (58% success rate), compared with gastroplasty (24%) and gastrogastrostomy (25%). Our long-term results following revisional surgery were disappointing, particularly for stenosis, and most failures followed revision to GG or GP. Roux-en-Y gastric bypass is the procedure of choice when considering revision.

Objective Stenosis of a permanent tracheostoma after total laryngectomy lowers postoperative quality of life (QOL), and its prevention is clinically important. Methods From April 2003 to March 2009, the authors performed 87 permanent tracheostomies. For the purpose of prevention of tracheostomal stenosis, we had applied new technique from October 2005. Results The incidence of the tracheostomal stenosis was retrospectively reviewed. Until September 2005, conventional permanent tracheostomy was applied for 33 cases and tracheostomal stenosis developed in 6 cases (18.2%). On the other hand, stenosis did not develop in any of the 54 cases in which the new technique was used. The triangular method was significantly superior to the conventional method in preventing stenosis. Stomal recurrence did not develop in either technique. Conclusion The key point of the new technique is as follows: at the upper end of trachea, the posterior part of tracheal cartilage is preserved and the anterior edge of the tracheostoma is made much lower. The shape of the tracheostoma approximates a triangle, and the area is greater than with other methods. From our experience, this technique is safe and effective for the prevention of tracheostomal stenosis.

Background: Adjustable gastric banding is a surgical approach to weight reduction. In this study we created a gastric banding model in rats to better understand the mechanism of body weight loss. Methods: Male Sprague-Dawley rats weighing 260 to 280 g were subjected to gastric banding (band group) (n=8) or to a sham operation (control group) (n=8). Body weights were monitored for 14 days, and daily food and water intake and nitrogen balance were monitored for 7 days. Results: Two rats in the band group died of malnutrition due to gastric stomal stenosis and obstruction caused by the gastric banding. Body weight gain during the 14 days after the operation was less in the band group than in the control group (p

Stomal stenosis after laryngectomy has a major impact on patient rehabilitation. The major contributory factor is the operative technique. The goal is to achieve a widely patent stoma. The objective of the study was to review the long-term results of the technique of stoma creation used by the senior author (CJW). The simple technique, using skin triangles for tracheostoma creation after laryngectomy, has been used by the senior author for past 6 years. Review of 59 cases of total laryngectomy with or without partial pharyngectomies in whom this technique was used for stomaplasty. The technique described for stoma creation after total laryngectomy has been used in 59 patients (48 male, 11 female) over 6 years. The follow-up of these patients varies from 6 months to 6 years. Of these patients 54/59 (91.5%) did not have any problems with the stoma. A total of 5/59 (8.5%) patients, the stoma was narrow. Amongst these patients with narrow stoma, only 1 patient (1.7%) has had dilatation done and the others are managing reasonably with a stoma button. None of the patients in this study has required revision procedures on the stoma. The simple technique of stoma creation described in this study has good long-term results.

Background: Stomal stenosis after laryngectomy is a common and distressing complication. Once sets in, it is generally progressive, causes problems and needs active intervention. Aim: To evaluate effectiveness of new simple method of stomaplasty in solving troublesome complication of stoma stenosis. Settings and Design: Charts of eight patients who underwent modified stomaplasty and completed 1 year were reviewed. Materials and Methods: A modified anterior advancement flap and lateral splaying of trachea for stoma plasty are described. This involves excision of scar tissue of the anterior two-third of trachea and interposition of the defect with an inferiorly based triangular skin flap. The tracheo-esophageal-prosthesis (TEP) site is left untouched. Statistical Analysis: Outcome were measured in relation with need for further stenting or any other revision procedure required and ability to use TEP for speech production. Results: Eight patients underwent stoma revision surgery. Median preprocedure stoma diameter was 10 mm vertically (range 8-12 mm) and 6 mm horizontally (range 5-10 mm). This could be improved to 25 mm (range 22-30 mm) vertically and 16 mm (range 14-20 mm) horizontally after stoma revision. At 1-year follow-up, the median measurements were 20 mm (range 16-26) vertically and 14 mm (range 12-18) horizontally. Postprocedure, one patient required intermittent stenting at nighttime. All patients could use the TEP effectively. One patient who underwent salvage laryngectomy following chemoradiotherapy developed flap dehiscence. Conclusions: This is a simple and effective technique for stomaplasty. All patients treated with this technique had adequately large stoma for breathing and use of TEP.

There is a need for operations by which the complications of ileal conduits can be prevented or corrected. The author details techniques to ensure the formation of a short conduit, to shorten a conduit through a peristomal incision, and to correct ileocutaneous stomal stenosis.

Stenosis of stomas sited at the umbilicus presents a surgical challenge. A paucity of literature exists on the surgical management of this problem, despite its relatively frequent occurrence. A simple technique is described, using scar incision and advancement of an umbilical skin flap, to accomplish stomal revision.

Background: Vertical banded gastroplasty (VBG) has been performed in our department as a restrictive operation for treatment of morbid obesity. We assessed efficacy, safety, and quality of life (QoL) after VBG, based on our 6-year experience. Methods: 101 patients with >1 year follow-up who underwent VBG between January 1998 and May 2003, were retrospectively studied. Mean age was 41 years, and mean preoperative BMI was 51.3 kg/m2 . Almost 60% of the patients suffered from hypertension, and 25% were diabetic. Postoperative QoL was determined with the BAROS questionnaire. Data concerning weight loss and co-morbidities were collected during the postoperative visits. Results: 87.2% of patients achieved ≥ 50% EWL. 86 patients (85.2%) responded to the BAROS questionnaire. >90% of the patients analyzed according to BAROS, reported improvement in QoL after VBG. No patient reported deterioration in health or well-being after the VBG. Anti-hypertensive medication was discontinued in 26 patients (56.5%) and decreased in the other 15 hypertensive patients (32.6%). 35% of diabetic patients did not require further treatment, while a further 40% had their insulin doses decreased or were switched to oral drugs. Early complications occurred in 4.65%, and consisted of an evisceration, pulmonary embolus and gastric leak. Late complications occurred in 20.9%, and included bleeding from peptic ulcer, incisional hernia, stomal stenosis and staple-line disruption (3.5%). There have been no deaths. Conclusion: VBG provided significant weight reduction and improved QoL in the vast majority of morbidly obese patients. Patients with diabetes and hypertension benefitted because these co-morbidities were improved or disappeared with the weight loss.

Patients presenting with recurrent bladder neck strictures or severe incontinence refractory to all forms of infravesical treatment usually require chronic catheterization or supravesical urinary diversion. As an alternative, we use a simple continent bladder stoma made from the bladder wall. After extraperitoneal bladder mobilization, a Lapides-like 4 x 8 cm U-shaped bladder flap is excised and sutured to a tube. Depending on the location of the stoma, the base of the flap can be chosen and/or the length of the flap can be adapted. After bladder neck closure the tube is reflected and, after incision and dissection of the detrusor in the middle of the base of the flap, embedded in Lich-Gregoir's technique. The distal end of the tube is then sutured to the stoma site. Five of our patients now have a minimum follow-up of 11 months (mean 17 months). All are continent with a bladder capacity between 250 and 560 ml. In two, stomal stenosis at the skin level required epifascial stomal revision.

Cutaneous ureterostomy is a simple procedure to perform, but has some morbidity owing to stomal stenosis. We describe a new and simple technique applied to the stomal stenosis for cutaneous ureterostomy.

Objectives. To describe a conduit-lengthening technique for use in continent cutaneous appendicovesicostomy (Mitrofanoff procedure). Methods. Fifteen consecutive patients (4 male, 11 female) with a mean age of 14.2 years underwent tubularized cecal augmentation as a means to lengthen the catheterizable conduit while performing continent cutaneous appendicovesicostomy. Results. All patients successfully underwent appendiceal lengthening by tubularizing the cecum, thus creating a continent cutaneous cecoappendicovesicostomy. With a mean follow-up of 18.7 months, all patients have a working catheterizable conduit. One case of stomal stenosis occurred, producing a 6.7% conduit-related complication rate. Conclusions. Cecoappendicovesicostomy is a safe and useful means of conduit lengthening for patients undergoing continent cutaneous appendicovesicostomy (Mitrofanoff procedure).

Background: Stomal stenosis (SS) and marginal ulcer (MU) are reported to occur in 9-20% and 2-13%, respectively, of patients undergoing gastric bypass for morbid obesity. It is hypothesized that decreasing tension on the gastrojejunostomy by performing limited small bowel resection (SBR) would decrease ischemia, thereby decreasing the likelihood of SS and MU. Methods: A retrospective review of 150 consecutive gastric bypass patients operated by one surgeon from 1993 to 1996 was performed. The incidence of SS and MU was compared in patients with and without SBR. Results: The overall rate of SS was 24.0% and that of MU was 9.3%: the incidence of both was 2.0%. The incidence of SS in patients without SBR was 26.9% and with SBR was 19.6%. The incidence of MU in patients without SBR was 8.9% and with SBR was 9.8%. Neither result was statistically significant by Fisher's exact test. Conclusion: There is a trend towards a decrease in the incidence of SS in gastric bypass patients with concomitant SBR although this did not reach clinical significance.

Indication Amongst late complications of stomas, stenosis can be difficult to treat. Repeated dilatations rarely achieve long-term resolution and re-fashioning is not always successful. Application of an existing plastic surgical technique to treat stomal stenosis is described. Method After marking the skin, a W-plasty is made with a number of consecutive small triangular flaps through the skin. The corresponding mucosal margin is then made to interdigitate with this configuration and fixed using a Gillies corner stich with 5/0 Vycril rapide on a compound curved needle. Results Five patients underwent W-plasty reconstruction for a stenotic stoma. Median follow up was 12.5 months (range 11–15). No patient had stenosis of the stoma on review and the patient satisfaction rate was high. Conclusion The W-plasty technique is a new treatment for stenotic stoma.

Stomal stenosis is a frequent complication after creation of a Mitrofanoff stoma for urinary diversion. We describe a new technique for achieving a skin-lined stoma opening that is easy to construct and decreases the risk of stenosis in the long term.

The Mitrofanoff urinary diversion is fraught with the complication of cutaneous stomal stenosis, which prevents catheterization. The authors report another sequel of stomal stenosis-acute appendicitis, a complication not reported hitherto.

Purpose: We present a new technique of cutaneous ureterostomy. The results of application of this method and its advantages over prior methods are discussed.Materials and Methods: We applied this method in 15 patients with tumors in the pelvic region and 3 with spinal cord injury between January 1992 and January 1994.Results: A tubeless state was achieved in more than 90 percent of the patients.Conclusions: The technique described has a wider range of indication than prior techniques and decreases the risk of stomal stenosis arising from postoperative ureteral tension.

Educational objectives: To tailor an adequate tracheostome after total laryngectomy, to guard against stomal stenosis, and to manage an already existing stenosis of the tracheostome.

Purpose Clean intermittent catheterization (CIC) is a cornerstone in the management of VBS. Sometimes, there is difficulty or pain during performing CIC per urethra which might affect patient compliance. Using appendicovesicostomy might allow better patient compliance and have a positive impact in the management of VBS. Material and Methods Appendicovesicostomy was performed in 10 boys with VBS to allow better implementation of CIC (group I). Other 10 boys with VBS performing CIC per urethra were used as a control group (group II). Both groups were followed regarding complications of catheterization (pain, difficulty, and false passage), rate of UTI, compliance and effect on upper tract dilatation. Stomal complications in addition to continence status were recorded in group I. Results Age range in both groups was 3-9 years and the follow up period is 2 years. No complications of catheterization encountered in group I. Pain was present in 6, false passage in 2 and difficulty in 3 boys in group II. As regards UTI, documented upper tract infection was present in one case in group I and in 4 cases in group II. Lower tract infection was present in 2 cases in group I and in 7 cases in group II. Two cases in group II had recurrent epididymitis. Compliance to CIC was 100% in group I while in group II was 70 %. At the last follow up, there was improvement in upper tract dilatation in 4 cases in group I compared to its status before performing the appendicovesicostomy. Only one case in group I had stomal stenosis that needed surgical revision. All stomas were continent in between the period of CIC. Conclusions Continent appendicovesicostomy is a valid procedure in the management of VBS when compliance in CIC is equivocal. It is a safe and easy procedure with long term success that obviates problems of urethral catheterization.

PURPOSE Cecal/colonic flap (CCF) has been suggested as an alternative to the appendix or Monti reconfigured ileum (MRI) for the Malone antegrade continence enema (MACE) procedure in children. The literature regarding its efficiency is scant. We, therefore, analyzed our results of MACE, and compared these 3 alternative techniques, regarding stomal incontinence, and stenosis/obstruction. MATERIAL AND METHODS We conducted a retrospective chart search. All patients who underwent the MACE procedures at our institute were included in our study. RESULTS Seventeen patients with fecal incontinence (11 males, 6 females; mean age 12.8 years) underwent the MACE procedure between 1998 and 2008. Diagnoses included myelodysplasia (8 patients), anorectal malformations (6), sacral agenesis (2), and pelvic trauma (1). The MACE conduits were constructed using the appendix in 5 patients, MRI in 8, and CCF in 4. One patient with an appendix-MACE underwent dilation of a stenosed stoma. In two of the patients with MRI revision was necessary for obstruction/stenosis. No appendix or MRI conduits leaked. All 4 patients with CCF conduits became incontinent 6 to 24 months following surgery. One of these patients also required dilation for stomal stenosis. Attempts to cure incontinence by submucosal injection of dextronomer/hyaluronic acid at the conduit-colon junction failed in 2 patients. Two CCF conduits were successfully replaced by MRI, 1 was replaced by button cecostomy, and 1 is awaiting reconstruction. CONCLUSIONS Our initial results reveal that CCF has failed as a conduit for the MACE procedure because of 100% stomal incontinence. We, therefore, abandoned this procedure, and recommend the appendix or MRI for MACE procedures.