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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

Purpose: To report the current status of Robotic approach to creation of Catheterisable channel (CC) with the author's personal experience compared to published literature on technical steps, follow up, and outcomes. Methods: CC data was extracted from the prospective database set up for all Robotic pediatric urology procedures performed by the author at his institution. A literature search was then performed to look at the evidence base. Results: Eighteen consecutive cases (8M:7F) of Robotic approach to creation of CC was identified and included. All attempted cases were successfully completed without any conversion to open approach. Median age at surgery was 10.75 years (IQR 6.9-16.5); Median OT 197 min (IQR 131-295) with concomitant procedures in 4 cases. Appendix was used in 14 cases as CC conduit and distal ureter in 4 cases. Median Length of stay (LOS) was 2.75 days (IQR 2-6) and Median FU 27.3 m. Whilst FU duration is comparable to published series, average OT and LOS was much lower in this series. The LOS in this robotic series is much lower than the author's experience with open approach (2.75 vs. 5.8 days). No major complications postoperatively except for one exit site wound infection managed conservatively. None of the CC have been revised in this series and all channels are patent with 12 F or 14 F admissible catheter size. There were no cases of incontinence related to technique of creation of CC and no incidence of exit site stomal stenosis with use of ACE stopper until channel matures and Clean intermittent catheterisation (CIC) is established. Conclusion: Robotic approach to CC is feasible, safe with excellent outcomes and minimum morbidity. Robotic complex bladder reconstructive surgery offers some advantages to children compared to open approach but is only currently performed in few tertiary centers with expertise.

Introduction: We aimed to describe the strategies of surgical revision for catheterizable channel obstruction and their outcomes, including restenosis and new channel incontinence.Methods: We retrospectively queried the charts of adults who underwent catheterizable channel revision or replacement from 2000‒2014 for stomal stenosis, channel obstruction, or difficulty with catheterization at the Universities of Minnesota, Michigan, and Utah. The primary endpoint was channel patency as measured by freedom from repeat surgical intervention. Secondary endpoints included post-revision incontinence and complication rates. Revision surgeries were classified by strategy into “above fascia,” “below fascia,” and “channel replacement” groupings.Results: A total of 51 patients who underwent 68 repairs (age 18‒82 years old; mean 45) were identified who met our inclusion criteria. Channel patency was achieved in 66% at a median 19 months post-revision for all repair types. There was no difference in patency by the type of channel being revised, but there was based on revision technique, with channel replacement and above the fascia repairs being more successful (p=0.046). Channel incontinence occurred in 40% and was moderate to severe in 12%. The type of channel being revised was strongly associated (p=0.003) with any postoperative channel incontinence. Surgical complications occurred in 29% of all revision procedures, although most were low-grade.Conclusions: Surgical revision of continent catheterizable channels for channel obstruction can be performed with acceptable rates of durable patency and incontinence; however, the surgeon needs to have experience in complex urinary diversion and familiarity with a variety of surgical revision strategies.

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.

Objectives: To find out the pattern of complications, frequency, risk factors and the management after total laryngectomy. Methods: It was a cross sectional study done in the Department of Otolaryngology & Head- Neck Surgery, Shaheed Suhrawardy Medical College Hospital, Dhaka from July 2007 to Dec 2009. 15 patients undergoing total laryngectomy for histologically proven Carcinoma larynx were included in this study. Patients were reviewed after surgery and any complication that occurred was recorded. The presentation, diagnosis and management of these complications were discussed after total laryngectomy. Results: There were 15 male patients, 3 non radiated cases and 12 post irradiated cases. Age of patients ranged from 35-75 years. Complications included wound infection (04), pharyngocutaneous fistula (03), flap necrosis (01), pharyngeal stenosis (01), stomal stenosis (01) and stomal recurrence (01). Conclusions: Wound infection and pharyngocutaneous fistula are most common complications after total laryngectomy. Preoperative radiotherapy is an important risk factor for development of pharyngocutaneous fistula in total laryngectomy patients. DOI: http://dx.doi.org/10.3329/bjo.v19i2.16366 Bangladesh J Otorhinolaryngol 2013; 19(2): 82-86

Background/Purpose The Malone antegrade continence enema (MACE) channel is an effective means to manage patients with neurogenic bowel; however, complications may occur that may require surgical revision. Specific reports of the outcomes of these interventions are limited. We describe our clinical results following revision of MACE. Methods We retrospectively identified patients undergoing MACE revision for at our institution between 1997 and 2009. Type of MACE (in situ appendicocecostomy (AC=247), ileocecostomy (IC=25), cecal flap (CF=10)) performed was recorded, time from creation to revision, site of revision, and need for repeat surgical revision were recorded. Results Of a total of 282 patients that underwent creation of MACE during the study period, 49 patients (17%) required surgical revision. Of these 49 patients, 42 had undergone AC, four had IC and three had CF. Mean time from MACE creation to revision was 19months. Sixty-eight revision procedures were performed in the 49 patients. Skin level or endoscopic procedures accounted for 52/67 (78%) procedures. Sixteen patients (33%) required more than one revision and three patients (6%) required more than two procedures. Conclusions Skin level revisions accounted for over three-fourths of MACE revisions. In our series, two thirds of patients requiring revision required only a single procedure, but one third required more than one revision.

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.

We previously reported catheterizable channel associated outcomes and concluded that the incidence of postoperative complications was greatest in the first 2 years after surgery. At that time our followup was short. In this series we sought to determine whether complications continued to accumulate with longer followup in an updated cohort of patients.We comprehensively reviewed the outcomes in 81 consecutive patients who underwent construction of a MACE (Malone antegrade continence enema) and/or a Mitrofanoff channel in association with complex genitourinary reconstruction. Mean followup was 80.1 months. Outcomes of these 119 stomas were classified by Clavien-Dindo grade and time to complication.The 48 unique, channel related events (40.3%) necessitated a total of 70 interventions with a mean 24.2 months to the first event. Difficult catheterization was the most common event, occurring in 20.1% of channels an average of 29.9 months after surgery. Stomal stenosis was also common, developing in 12.6% of channels at an average of 19.9 months after surgery. Unique complications clustered in the first 2 years, after which there was a statistically significant decline (p = 0.0013). High grade complications similarly clustered (p 0.0001). Channel composition was significantly associated with rates of difficult catheterization events.Compared to our previous cohort of patients with similar volume but shorter followup, our assumption that channel associated complications cluster postoperatively and then decrease significantly was correct. Our current and more detailed series demonstrates that the rate of postoperative complications decreases with time. However, with longer followup patients continue to experience lower grade events requiring fewer interventions.

Continent cutaneous urinary diversion can be employed after cystectomy when orthotopic diversion is not appropriate and a continent diversion is desired. It is a technically challenging operation and requires careful pre-operative and intra-operative planning as well as an experienced surgeon and ancillary staff. Overall, continent cutaneous diversion (CCD) carries a high rate of long-term continence and patient satisfaction, and is an important and widely accepted part of the urologist’s armamentarium. Many different types of CCD and efferent channels have been described with variable success. Complications are largely related to the stoma and catheterizable channel. These complications can usually be managed outside of the operating room although occasionally re-operation is required.

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.

Objectives: The cutaneous ureterostomy is the simplest urinary diversion method; however, it often causes stomal stenosis, requiring sustained catheterization with regular catheter exchange. In an attempt to prevent stomal stenosis after surgery, the fascia (S-U fascia) between the spermatic cords and the ureters, which is usually cut off, was preserved. The remaining capillaries in the fascia could supply blood to the ureters, which is one of the most important factors for ureter patency. Methods: In 58 patients (93 renal units) undergoing cutaneous ureterostomy, 36 patients (66 renal units) were treated by the modified technique. Results: The surgeries carried out with the modified technique were significantly different in the type of operation, the side relationship, and the catheter-free rate using the univariate analysis by means of the predicted tests, in comparison with 22 patients (27 renal units) that were treated with the conventional technique. Multivariate analysis for the type of operation determined that of the side relationship and the method, only the latter was a significant factor. The modified method allowed ∼90% of the patients to have a catheter-free life; otherwise 74% of the patients had stomal stenosis, followed by catheterization. Conclusion: The presented cutaneous ureterostomy technique to preserve the fascia is useful not only to prevent stomal stenosis and maintaining good quality of life without catheterization, but also to apply to other types of ureter surgery.

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.

Late complications of open gastric bypass can include malnutrition, weight gain, stomal stenosis, and recurrent bleeding ulcers. Herein, we describe the case of a woman who had recurrent bleeding ulcers, after an open revision of a stenotic gastric bypass. She now underwent an uneventful laparoscopic revision of her gastrojejunostomy and was discharged within 72 hours. Laparoscopic revision of a gastrojejunostomy, even after an open revision following an open gastric bypass, can be done safely.

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.

Esophageal speech is the first choice for vocal rehabilitation in laryngectomized patients. However, shunt speech is a needed alternative for patients who cannot succeed at esophageal speech. Many kinds of voice prostheses, with good results, have been reported. Provox was selected for 15 laryngectomized patients who were treated in our department. Voice rehabilitation was successful in 13 patients. However, removal of the prosthesis was required in one patient because of stomal stenosis. Voice rehabilitation was not successful in one patient who exhibited esophageal stenosis. The rate of voice rehabilitation was not influenced by the extent of surgery, the dose of radiation, etc.. The maximum phonation time was more than 10 minutes in the 13 patients who succeeded at shunt speech. Prosthetic rehabilitation was requested by two patients who had been successful at esophageal speech. These results suggest that prosthetic voice rehabilitation may be indicated for a wide range of conditions.

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.

To reevaluate the submucosally embedded in situ appendix as continence mechanism in a large single institutional series of ileocecal urinary reservoirs.Between November 1990 and June 1999 an ileocecal reservoir with appendico-umbilical stoma was created in 118 patients (84 men, 34 women) aged 3.9-82.7 (mean 56.8) years as a primary urinary diversion or after failure of previous reconstruction. The most common indication for urinary diversion was bladder replacement after anterior exenteration for pelvic malignancies (n = 98), followed by functional or morphological bladder loss due to various benign conditions. The patients were followed prospectively according to a standard protocol.There were no perioperative deaths. In 3 patients necrosis of the appendix resulted in total incontinence with subsequent replacement by an intussuscepted ileal nipple. Impaired catheterization due to stomal stenosis was observed in 19 patients with recurrence in 6 and a total of 25 minor revisions. With a mean follow-up of 60 months all patients are continent day and night.Over 10 years, the submucosally embedded in situ appendix has survived as a continence mechanism in the original technique reliably providing continence in ileocecal reservoirs.

We constructed Toyoda cutaneous ureterostomy with fixation between the anterior and posterior rectus sheath by four interrupted sutures to maintain the stability of the abdominal wall tunnel for the ureters. After the operation, the stent catheterswere placed in the renal pelvisthrough the stoma, and exchanged every 4 weeks. The stent catheters were removed 3 months after the operation, because the stomal conditions were unstable and obstructive in the early phase after the operation. Fifteen patients (27 renal units) with at least 6 months of follow-up were enrolled in this study. The follow-up period was 6 to 33 months(average 14.0±7.9). Radical cystectomy was performed for bladder cancer in these patients. There were 12 men and 3 women with an average age of 73.3±7.2 years. At the operation, the ureters were intact in all 27 renal units. Six monthsafter operation, 26 (96.3%) of 27 renal unitsachieved a tubeless condition, and 25 renal units (92.6%) had no hydronephrosis. Acute pyelonephritis had developed 2 (13.3%) of the 15 patientsboth within 3 monthsafter the operation and after thisperiod. In conclusion, our operative modification of cutaneousureteros tomy achieved a high catheter-free rate.

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.

1)1992年12月から1998年1月迄にMainz pouchによる尿路変向手術を30例に施行した. 2)術後6ヵ月以降の晩期合併症のうち処置を必要としない観察可能な水腎症は2例, 処置を要するものは3例であった. 3)ストーマ狭窄による, 導尿困難症例に対しては, 週1回前後の定期ブジーを施行していたが, 虫垂in situ embedding法で3例, 漿膜筋層剥離重積法での2例, 計5例に瘻孔ストッパー(腎瘻ボタン)の装着を試み導尿困難症状の改善をみた. 4)ストーマ狭窄に対しての瘻孔ストッパーの使用は, 患者のQOLから考えて有効な方法と考えられた, Thirty patients underwent Mainz pouch construction between December 1992 and January 1998. The post-operative observation period varied from 6 to 57 months (average, 38.5 months). A mechanism to ensure urinary continence was provided in 24 cases, while formation of a nipple valve by intussusception of the ileum with seromuscular stripping and submucosally embedded in situ appendix was performed in 6 cases. An umbilical stoma was adopted in all cases. Late-phase complications included 3 cases of hydronephrosis requiring treatment. Efferent limb of the stoma was observed in 8 cases, 6 of which were attributable to mild constriction of the stoma at the site of anastomosis of the navel cavity. In those cases in which stomal stricture occurred, difficulty in withdrawing urine was eliminated by providing a fistula stopper. Although few clinical methods to deal with stomal stricture have been reported, we found the fistula stopper to be useful providing good external appearance and patients' quality of life.

Objective To assess the use of a transverse tubularized segment(s) of ileum in the Mitrofanoff or Malone antegrade colonic enema (MACE) procedures. Patients and methods Eleven patients in three centres underwent the formation of a continent conduit to bowel (MACE, eight patients) and/or bladder (Mitrofanoff, four) using either a single segment of transverse tubularized ileum (10 patients) or two segments of ileum anastomosed and tubularized into a single conduit (two). Results Within a follow-up of 8 weeks to 6 months, all conduits were continent and catheterized easily. One stomal stenosis required a revision procedure. Conclusion This method for forming a continent catheterizing conduit, based on the Mitrofanoff principle, appears to be effective and is recommended in cases where the appendix cannot be used or where a second conduit is required.

Stomal stenosis is common following high gastric reduction or vertical banded gastroplasty for obesity. Open and laparoscopic approaches for reversal can be problematic due to expected adhesions from previous surgery. A technical description of a novel approach for reversal of stomal stenosis following high gastric reduction is provided. This minimally invasive technique combines both “trans-gastric” and “endoscopic” principles for intraluminal reversal via a single port site incision. We describe our early experience in eight cases with this technique, highlighting its advantages and discussing potential pitfalls to be avoided to maximise its use and efficiency. It appears to be simple, safe and widely applicable. The single port trans-gastric, laparo-endoscopic technique provides a simple and effective minimally invasive method of reversing gastric stapling procedures without the need for extensive adhesiolysis.

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.

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.

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.

Eight patients with bowel incontinence underwent an open Malone Antegrade Continence Enema (MACE) procedure between May 1997 to May 2000. Indications for the procedure included high anorectal malformation in 3, bowel dysmotility in 1. spinal dysraphism in 3 and presacral teratoma in 1. Age at presentation varied between 06 to 12 years. All but one patient claimed excellent results. Complications of the procedure included stomal stenosis in 1, stomal leak in 2 and inadequate emptying of effluent in 1. Patient selection was the key to success. All patients except one, were children who were literate and had access to a western toilet Whereas, for the vast majority in the Indian rural setting, the procedure may not be beneficial but for a select group of bowel incontinence children, this procedure may bring a dawn of hope.

Conversion of the failed vertical banded gastroplasty (VBG) to a Roux-en-Y gastric bypass (RYGB) is one of the most challenging revisionary operations in bariatric surgery. It is also one of the least reported remedial operations performed. This study describes the technical details necessary for a successful conversion in a variety of anatomical presentations ranging from near-total staple-line dehiscence to an intact VBG with or without stomal stenosis. Each step is analyzed along with the strategic options available should an intraoperative technical complication occur. The report is based on 20 conversion procedures in patients referred to us since 1983. Indications for conversion include: morbid obesity, intractable vomiting, and gastroesophageal reflux disease. Using the step-by-step method we have developed over the last 9 years, expeditious conversion from a failed VBG to an RYGB can be achieved safely and without the need for blood transfusions or multiple reoperations.

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.

Objective: To design inexpensive, easily fabricated stoma buttons for post-laryngectomy patients with stomal stenosis and patients who require prolonged tracheotomy. Methods: Design: Surgical Instrumentation Setting: Tertiary Government Hospital Participants: Tracheostoma buttons fabricated from 3 or 5 cc disposable plastic syringes were tested on two post-laryngectomy patients with stomal stenosis and a tracheotomized patient with bilateral vocal cord paralysis. Results: The tracheostoma buttons were inexpensive and relatively easy to fabricate. They were easily inserted and well tolerated by all three patients, compared to previously-used commercially-available tracheotomy tubes. Conclusion: In a developing country setting, improvised tracheostoma buttons made from disposable plastic syringes may be viable alternatives to commercially-available stoma buttons or tracheotomy tubes. Clinical trials on more subjects should be conducted to assess parameters for use and long-term efficacy and safety issues. Keywords: stomal stenosis, tracheostoma/stoma button

Name of Procedure: Continent Catheterizable Channel (Appendicovesicostomy and Monti Procedure)

SUMMARY In our hands, the Benchekroun hydraulic ileal valve has proved to be a very reliable continence mechanism. The patient is provided with a cosmetically acceptable stoma that creates diurnal and nocturnal continence and ease of catheterization. Stomal stenosis has occurred in several patients in our series and has been managed successfully with dilatation or minor surgical revision. The efferent limbs are readily accessed by endoscopic equipment, permitting treatment of stones and surveillance for malignancy. The need for surgical revision is moderate, as only 5 of 15 patients have required such intervention, compared with the revision rate of 58% with plicated ileal efferent limbs in our hands.8 The in situ Benchekroun technique represents an economy of time and energy, especially as a salvage procedure for failed plicated ileal limbs. Currently, the Benchekroun hydraulic ileal valve is our continence mechanism of choice.

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.