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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.

OBJECTIVES Severe bowel dysfunction often accompanies neurogenic bladder, and Malone antegrade continence enema procedures can lead to improvement in the quality of life for these patients. The most commonly reported complication has been stomal stenosis of the conduit. We report our experience with the use of the MIC-KEY gastrostomy button for the management of this complication. METHODS A retrospective cohort study of 53 consecutive children who had undergone the Malone antegrade continence enema (ACE) procedure from 2000 to 2006 was performed. The records of patients with stomal complications were assessed for presentation, management, and outcomes. RESULTS We identified 20 patients (38%) with stomal stenosis. Stomal dilation and stenting alone was successful in 4 patients, and stomal revision was necessary in 16 (30%). Six children required placement of the MIC-KEY gastrostomy button into the ACE stoma for recurrent stomal stenosis (n = 5) or a buried stoma (n = 1). All patients were successfully treated with placement of a MIC-KEY button to continue their bowel irrigation. The size of the button was determined by the endoscopic assessment of the length and width of the ACE stoma and was custom made by the manufacturer. The average time that the button was in place was 26 months, and it was generally changed every 3 months. CONCLUSIONS In the rare subset of patients with recurrent stomal stenosis or a buried stoma, the MIC-KEY gastrostomy button was found to be a practical and easy method for the management of these conditions and to preserve the ACE conduit.

OBJECTIVES The Monti catheterizable channel is used as an integral part of continent bladder reconstruction in children. We have updated our ongoing experience at Riley Children's Hospital with 199 patients. METHODS We identified 199 patients for retrospective review, including all patients for whom a Monti ileovesicostomy was created from January 1997 to August 2004. We assessed the complications, surgical procedures, and stomal continence. RESULTS At mean follow-up of 28 months, we found that 194 of 199 patients (97.5%) continued to use their Monti catheterizable channel for bladder drainage. Early surgical complications occurred in 7 patients (3.5%), usually in those who had undergone simultaneous bladder augmentation (5 of 7). Revision was required in 16 patients (8%) for stomal stenosis (n = 11), prolapse (n = 2), or superficial stomal problems (n = 3). Of the 199 patients, 17 (8.5%) required 19 bladder or channel revisions. The primary indications were related to elongation and angulation of the channel in 7 and deficient tunnel length in 8. Minor difficulty with catheterization was noted in 16 patients (8%), and endoscopy with minor procedures was required in 4 patients (2%). Leakage from the channel was uncommon, occurring in only 4 of 115 patients (3.5%). CONCLUSIONS With increasing demand for simultaneous appendicocecostomy for stool continence at bladder reconstruction, we continue to use the Monti ileovesicostomy for bladder drainage. Our experience with nearly 200 patients has demonstrated the durability and success of this technique.

The Monti ileovesicostomy provides an excellent substitution for an appendicovesicostomy when the appendix is unavailable or suitable for use. The spiral Monti is a useful modification to the traditional Monti as it allows creation of a longer channel when needed. In 2007, the short-term outcomes were reported; they compared traditional and spiral Monti in 188 patients with an average follow-up of 43 months. In the present population, a total of 25 subfasical revisions were performed in 21 patients: nine (8.3%) subfascial revisions in the traditional Monti (TM) patients and 12 (15.2%) subfascial revisions in the spiral Monti (SM) patients. The study found an increased risk of subfascial revisions of either TM or SM when the stoma was located at the umbilicus versus right lower quadrant (16.8% vs 6.3%, P0.05). On subgroup analysis, this increased subfascial revision rate appeared to be driven by SM channels to the umbilicus rather than other stomal locations, but this trend was not statistically significant.It was hypothesized that with longer follow-up, the spiral Monti would require more subfascial revisions due to progressive lengthening of the channel.A retrospective chart review was performed for all patients undergoing a traditional Monti (TM) or spiral Monti (SM) procedure at the present institution (1997-2013). Patient demographics, bowel segment used, stomal location, channel or stomal revisions, number of anesthetic endoscopic procedures performed, and indications for revision were reviewed. Kaplan-Meier analysis and Cox proportional hazards modeling was used for analysis.Of the 296 patients identified, 146 had Monti procedures and 150 had spiral Monti procedures (median follow-up 7.7 years). Median age at surgery was 10.6 years. Myelomeningocele was the most common underlying cause of neuropathic bladder, totaling 169 (57.1%) patients. Stomas were located at the umbilicus (106, 35.8%), right lower quadrant (183, 61.8%) and left lower quadrant (seven, 2.4%). Median follow-up for the entire cohort was 7.7 years (range: 1 month-15.7 years). Stomal stenosis rate was 7.4%, and 96.6% of the channels were continent. A total of 87 revisions were performed in 74 patients (25.0%). Of these, 55 were subfascial revisions in 49 patients (16.6%). The umbilical spiral Monti on univariate and multivariate analysis was found to be over twice as likely to undergo subfascial revision.The majority of patients with a Monti channel had durable results and did not require further channel surgery with long-term follow-up. Spiral Monti channels to the umbilicus were more than twice as likely to undergo subfascial revision compared to all other Monti channels. Overall, one in three umbilical SM channels required a subfascial revision at 10 years after the initial surgery, compared to one in six of all other Monti channels. The study was limited by being a retrospective, single-center series; however, it does represent the largest series of pure SM and TM patients. It focused only on surgical interventions, thus was likely to underestimate the overall risk of complications, as some complications were managed conservatively. As in all studies, some patients were lost to follow-up and inevitably some of these may have had complications. Correction for this was attempted through survival analysis.The present study reported durable and reliable long-term results with Monti and spiral Monti procedures based on a large patient cohort. Spiral Monti to the umbilicus was more than twice as likely to require a subfascial revision.

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.

Objective Continent urinary diversion (CUD) may be required for refractory incontinence in children with various malformations. We review our experience with CUD to identify determinants of success and ongoing challenges. Methods Retrospective chart review of 43 consecutive patients undergoing CUD since 1991 at British Columbia Children's Hospital. Results Our preferred surgery was intestinal cystoplasty and either appendicovesicostomy (77%) or ileal-vesicostomy. Concomitant bladder neck surgery was performed in 67%. Mean follow-up was 2.5 years. There was a 16% revision rate for persistent leakage, the most common being cystoscopic injection of bulking agents. Continence was ultimately achieved in 88%. Early major and minor postoperative complications each occurred in 21% of cases. Delayed minor complications requiring surgical intervention occurred in 30% including stomal stenosis in 6 patients and stomal prolapse in 2. Urolithiasis required intervention in 5 patients. Conclusions Pediatric CUD is a challenging endeavor. Most patients achieve continence although many require additional minor procedures to do so. Early major and minor complications are common. A significant minority of patients require reoperation for delayed minor complications. Patients and families should be informed of these frustrations as part of their preoperative counseling. A high degree of family motivation and commitment is essential.

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.

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.

Purpose: Antegrade continence enemas (ACE) are an efficacious therapeutic option for patients with fecal incontinence. The authors review their institution's experience with a variation of the Monti-Malone ACE procedure using the left colon as a source of an intestinal conduit and enema reservoir. Methods: From 2000 to 2002, 18 patients with fecal incontinence or intractable constipation underwent left-colon ACE (LACE) procedure. Concomitant Mitrofanoff appendicovesicostomy was performed in 15 patients and bladder augmentation in 9. The majority of patients had neural tube defects. A segment of left colon was tubularized, tunneled into the muscular wall of the distal colon, and exteriorized through the left upper quadrant or midabdomen. Stomal catherization and enema installation were started one month postoperatively. Results: Fifteen patients (83%) achieved fecal continence, 2 remain incontinent of stool, and 1 experienced stomal closure (mean follow-up was 24 ± 9 months). Two patients had stomal stenosis that required revision. The mean enema volume in patient's achieving continence was 360 ± 216 mL, and the mean transit time was 18 ± 12 minutes. Conclusions: LACE is an efficacious procedure for fecal incontinence that can be performed safely at the time of major urologic reconstruction. Administration of enemas into the left colon has several physiologic advantages that result in predictable bowel evacuation.

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.

Cutaneous ureterostomy is a minimally invasive urinary diversion procedure but postoperative stomal stenosis is a major problem. We describe a simple stomal reconstruction technique using a skin flap for the correction of deep ureteral stomal obstruction after cutaneous ureterostomy.

The case is reported of incarcerated intestinal hernia in a hernia sac of reversed ileal conduit wall protruding through the stoma. An 82-year-old woman presented with suspected parastomal intestinal hernia. The patient had undergone total cystectomy with ileal conduit construction 3 years previously, followed by stomal reconstruction surgery for stomal stenosis 2 years later. She had been taking various kinds of purgatives for severe constipation. Initially, this case was diagnosed as parastomal hernia, but emergency surgery demonstrated that incarcerated intestinal hernia in a hernia sac of reversed ileal conduit wall was protruding through the stoma. This case was apparently caused by high abdominal pressure and thinning of the ileal conduit wall.

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: The two main reasons for reoperation after vertical banded gastroplasty (VBG) in the treatment of obesity are staple-line disruption and stomal stenosis. PATIENTS: Seven morbidly obese patients of mean (+/-SEM) body mass index (BMI) 43.7 +/- 1.9 kg/m2 treated with an adjustable vertical banded gastroplasty (AVBG). RESULTS: No complications of the band system were reported. Weight-loss [BMI at 2 years follow-up 33.9 +/- 6.9 kg/m2 (n = 5)] was equivalent to that seen after VBG with a fixed band. Two of the patients developed staple-line disruption at 18 and 24 months after surgery. CONCLUSION: AVBG allows adjustment of the stoma, but staple-line disruption was common in this small series. It is possible that an excessive filling of the band in order to achieve excess weight loss results in a high pressure in the upper pouch which increases the risk of staple-line disruption.

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.

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.

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 To assess the long-term outcome of continent diversion in children with structural or neurogenic cause for incontinence with special interest in differences between closed or open bladder neck. Material and Methods A cohort of 63 children with intractable incontinence treated with continent diversion between january 1998 and january 2008 was reviewed for underlying disease, type of surgery, complications and outcome. Results 40 patients have had a continent diversion with bladder neck reconstruction (group 1), 23 patients have had their bladder neck closed (group 2: 11 primarily closed=2A, 12 secondarily closed =Group 2B). There was no difference in patient's characteristics, in surgical complications or reinterventions or in stone formation ( table 1 ). The continence rate however was significantly better in group 2 (95.7% vs 78.5%). Table 1 . Surgical interventions following continent diversion with and without BN closure. Closed BN (n=23) #procedures (#patients) Open BN (n=40) #procedures (#patients) p-value Cystotomy for stones 2 (2) 3 (3) Ns Endoscopic stone treatment 4 (3) 6 (4) Ns Bladder neck revision 4 (4) 3 (3) Ns Open revision for stomal stenosis 6 (4) 13 (8) Ns Endoscopic revision for stomal stenosis 1 (1) 7 (5) Ns External stomal orifice revision 6 (5) 11 (8) Ns Revision for stomal leakage 2 (1) 7 (6) Ns Other related surgery (augmentation, ureter reimplantation, bladder perforation, …) 7 (2) 11 (10) Ns Total 31 (14) 61 (16) P=0,04 Conclusions In children treated with a continent diversion for intractable incontinence, bladder neck closure as primary or as salvage procedure does not result in extra morbidity and has high success ratio. Good urodynamic evaluation of bladder function is an important key to success in therapy planning for these children and thus minimizing the need for reintervention.

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.

Weight Gain Following Bariatric Surgery As a Result of Large Gastric Stoma: Endotherapy Using Sodium Morrhuate (SM) to Induce Stomal Stenosis May Prevent Need for Surgical Revision Marc F. Catalano, Thomas Y. Chua, Oscar A. Batista, Goran T. Rudic Obesity is a chronic medical condition associated with increased morbidity & mortality. Affects 250 million world-wide & 300 thousand deaths/yr. Surgery appears to be the best long-term Rx option, with high success. The most popular procedure is the Roux-Y gastric bypass (RYGB) which takes advantage of both restrictive (small pouch) & malabsorptive surgery. Complications following RYGB have been well described. Those which may be amenable to endotherapy include dilation of gastric stoma. These pts present with wt gain following initial wt loss. Aim: Determine efficacy of SM injection of large gastric stoma in pts with RYGB presenting with wt gain. Methods: Over 4-yrs, 31 pts (10 M, 21 F, age 27-58) with morbid obesity & recent RYGB presented with wt gain following initial wt loss, all with large gastric stoma (stoma size S15 mm) by EGD or x-ray. Rx included injection of SM circumferentially along the dilated stoma to induce tissue retraction and scarring. A total of 1-3 injection sessions were performed. Amount of SM injected per session ranged 8-20 cc (mean 14.5). Successful endotherapy was defined: stoma size S1.2 cm, loss of &75% of wt that was regained following initial wt loss. F/U range 6-25 mo (mean 18). F/U visits were at 4-8 wks. Wt was recorded and compared to historical wt. Results: A mean of 2.3 sessions were performed in 31 RYGB pts. Successful endotherapy as defined at entry, was seen in 19/31 (61%). Mean pre surg wt was 322 lbs, mean post surg wt of 179 lbs. In this group, wt gain was a mean 65 lbs. Following completion of SM endotherapy, wt loss was a mean of 49 lbs at 18 mo F/U. Estimated mean stoma diameter at study entry was 17 mm (range 14-20). Following Sclerotherapy, mean stoma diameter was 10 mm (range 5-16). Of the 12 pts with unsuccessful endotherapy, 5 had revision of their RYGB. Remaining 7 pts continued post bariatric diet & life modification. At subsequent endoscopy, 11 pts had shallow circumferential stomal ulcers & were treated with PPI. All ulcers healed at 8 wks. Presence of ulcer formation resulted in higher success of endotherapy 82% (9/11) compared to those w/o ulcer 50% (10/20). Conclusions: Endoscopic injection of SM surrounding a dilated gastric stoma complicating RYGB surgery appears to be a successful, less invasive therapeutic alternative to surgical revision. The presence of a stomal ulcer, following endotherapy, is a positive predictor for successful outcome.

Purpose: We describe creation of a modified umbilical stoma as part of continent urinary diversion using appendicovesicostomy.Materials and Methods: Umbilical stomas were created using the eversion-inversion principle in 25 patients undergoing appendicovesicostomy.Results: Mean followup was 3 years. Cosmesis of the umbilical stoma was good in all cases. Stomal stenosis required surgical revision in 8 percent of cases.Conclusions: We recommend our modified umbilical stomal technique for appendicovesicostomy because it allows good cosmesis without compromising stomal function.

A review of our experience with the Mitrofanoff catheterizable channel, with emphasis on patient acceptance and preference, is presented. Continent catheterizable channels using the Mitrofanoff principle were created in 35 patients (mean age 9.1 years, range 2 to 21). Mean followup was 22 months (range 1 to 60). Followup data are available for 33 patients. We used the appendix, ureter, fallopian tube and tube of stomach to construct the channel. All 33 patients used the Mitrofanoff catheterizable channel without difficulty for at least 3 months postoperatively. A total of 16 patients (48%) can empty the bladder only by Mitrofanoff catheterization and do so without difficulty. All 11 patients (33%) who have the potential to catheterize either the Mitrofanoff channel or urethra choose to catheterize the Mitrofanoff channel preferentially. The patient not using Mitrofanoff catheterization had stomal stenosis 12 months postoperatively and elected to perform urethral catheterization rather than undergo surgical repair. Five patients (15%) can void but all use the Mitrofanoff catheterizable channel to monitor post-void residual volumes. This study shows a high acceptance rate for patients receiving a continent catheterizable stoma.

We evaluated 77 consecutive patients who had undergone horizontal gastroplasty over a 2 year period. Mean follow-up was 26 months (88 percent of patients) and ranged from 15 to 45 months. There were no operative deaths. Early complications were common. Stomal dilatation resulting in cessation of weight loss or in weight regain occurred in 19 patients (25 percent). Stomal stenosis occurred in four patients. Among patients with an intact gastroplasty, the percentage excess weight decreased from a preoperative mean of 142 +/- 46 percent to 80 +/- 38 percent at 1 year, 68 +/- 30 percent at 2 years, and 83 +/- 45 percent at 3 years. Fewer than 25 percent of the patients weighed less than 50 percent above ideal body weight at 2 or 3 years. In our experience, horizontal gastroplasty was associated with an unacceptably high mechanical failure rate. Using strict criteria, weight loss was generally inadequate at 2 years and not sustained, even in patients with intact gastroplasty.

There are three types of tracheal stenosis following intratracheal intubation and tracheostomy. They are; stomal stenosis which occurs at the site of tracheostomy, cuff level stenosis which occurs at the site of an inflated cuff of an intratracheal tube and tip stenosis at the site of a canula tip by irritation of a tracheal tube.Up to date we have treated 3 cases of stomal stenosis, 3 cases of cuff level stenosis and one case of tip stenosis by means of tracheal reconstruction. In one case of stomal stenosis, tracheal stenosis recurred after reconstruction. This was due to an inadequate resection of the lesion of tracheal malacia. Operative results were satisfactory in the other cases.Oblique tomography and flow-volume curve to diagnose tracheal stenosis and high speed ci ne tracheography to evaluate the state of postoperative airway passage were useful.This paper deals with the methods of diagnosis and surgical technique for tracheal stenosis and also deals with methods to evaluate the airway passage following reconstruction of tracheal stenosis.

To prevent dermal invasion which causes gradual stomal stenosis in cutaneous ureterostomy, transplantation of autologous vaginal vestibular mucosa around the ureteral opening was examined in 9 female dogs. Results of a full-thickness graft to a full-thickness skin bed were hopeful. Though surface keratinization occurred, the thick graft survived well on the abdomen without obvious shrinkage, and the ureteral patency was maintained through the follow-up period with an average of 18 months. This method seemed to be applicable to clinical patients and to dog experiments as a model for separate renal function study.

Urinary diversion plays an important role in the therapeutic repertoire of urologists. The stoma is often the weak link of any diversionary procedure. Some of the more common stomal problems include peristomal dermatitis, stomal stenosis, parastomal hernias, malposition, prolapse, and retraction. Depending on the nature and severity of the problem, it may be treated by local wound care, urinary appliance adjustment, dilatation, or surgical intervention. Careful site selection and stomal creation will keep stomal problems to a minimum.

Sixty patients with urethral strictures at the bulbous and membranous levels were treated with Turner-Warwick urethroplasty. Initially, there were significant difficulties with restenosis of either the proximal or distal st-ma following the first-stage urethroplasty. Use of nitrofurazone-hydrocortisone (Furacin-Hc) urethral suppositories practically eliminated recurrent stomal stenosis after the first stage. Several additional modifications were made in the original technique; these included placement of urethral sutures prior to scrotal mobilization and abandonment of the suprapublic cystotomy for frainage at the second stage of the procedure. These modifications increased the chances of achieving a successful result while facilitating the actual surgery and improving the patients' comfort. The over-all success rate was approximately 90 per cent. Patients with urethral stricture surgery subsequent to prostatectomy had problems with urinary control, but not so if prostatectomy was done after the first stage of urethroplasty. It appears that the Turner-Warwick urethroplasty is good one, and predictably good results can be expected on selected patients with urethral strictures.

An improved technique of tubeless cutaneous ureterostomy through a single stoma was devised by modifing the traditional cutaneous ureterostomy. Using this method, urinary diversions were performed on 12 cases with malignancies: 6 had radical cystectomy and the other 6 had pelvic exenteration. Normal bilateral ureters were observed in 11 cases in preoperative intravenous pyelography. Stomal stenosis was found in 1 case (8.3%) requiring operative stomal revision. Generally satisfactory results were obtained. This method could lower the incidence of complications. A long-term follow-up is needed, but 2 cases who have survived for more than 4 years since the operation have shown excellent results. It was thought that it would be difficult to perform tubeless cutaneous ureterostomy on normal-sized ureters, but our clinical results indicate that this method may be able to provide permanent urinary diversion.

The bioCarbon ureterostomy device is a stomal prosthesis for upper tract urinary diversion that has had preliminary successes in animal and human trials in Europe and Peru. Implantation of a pure carbon stomal prosthesis offers the potential advantages of high biocompatibility, lack of encrustation, and elimination of stomal stenosis which is frequently associated with cutaneous ureterostomy. Nine bioCarbon ureterostomy devices were implanted from August, 1984 through July, 1985. Although successful implantation was achieved in 2 patients, the complication rate was high. The bioCarbon ureterostomy device has potential as an alternative form of urinary diversion. However, significant problems need to be remedied before it can be recommended for routine clinical application.

At our institution, 100 patients had ileal conduit diversion using the Pyrah technic between 1959 and 1975. The results of this technic compare favorably with those of other ileal conduit diversions, and it has the advantage of being somewhat shorter than the standard Bricker procedure. Sixty-seven were done because of benign lesions of the urinary tract and 33 were done as part of the planned treatment of various malignant conditions. We did 56 diversions in patients with neurogenic bladder dysfunction. There were 67 early and 69 late complications, and the complication rate was much higher in patients having preoperative irradiation. The most common complications were wound infections, pyelonephritis, ureteroileal anastomotic leaks or stricture, and stomal stenosis. The upper urinary tracts showed signs of progressive deterioration after diversion in 19% of patients. The operative mortality was 6%. The mortality was four times greater in the group with malignant conditions.

The stoma is the weak link of external urinary diversion. Improper stomal position or configuration produces the unnecessary burden of leakage for the patient with diversion. Stomal bleeding, incrustation and peristomal dermatitis cause inconvenience and expense. Stomal stenosis is the most common reason for repeat operation of an ileal conduit. The Turnbull loop stoma obviates many of these problems. We have performed 100 urinary diversions using this stoma with minimal stomal complications and no episodes of stomal stenosis from 1 to 7 years postoperatively. The significant complication has been parastomal hernia. Minor modifications of the technique have lowered the incidence of hernia. Loop stomas are our principal form of stomal construction.