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OBJECTIVE Although tracheal stomal stenosis can be life-threatening, factors associated with the occurrence of stomal stenosis remain unknown. This study was performed to evaluate these factors in adult patients. METHODS We retrospectively identified adult patients who underwent tracheostomy from 2010 to 2016 using a Japanese national inpatient and outpatient database. We performed Cox proportional hazard regression analyses to evaluate factors associated with the occurrence of tracheal stomal stenosis. RESULTS We obtained data on 25,436 eligible patients. The proportion of tracheal stomal stenosis was 0.9%. Tracheal stomal stenosis was significantly less likely to occur in patients with regular use of oral steroids [hazard ratio (HR), 0.28; 95% confidence interval (CI), 0.09-0.88; P = 0.03] and in male patients (HR, 0.75; 95% CI, 0.57-0.97; P = 0.03). The occurrence of tracheal stomal stenosis was significantly associated with use of a mechanical ventilator at home (HR, 2.54; 95% CI, 1.55-4.15; P < 0.001) and a body mass index of

Objectives This article aimed to report on the short- and long-term outcomes after transpelvic urethrostomy (TPU) as a first-line surgery to treat obstructive lower urinary tract disease (OLUTD) in male cats. Methods A retrospective review and follow-up owner telephone questionnaire for cats with OLUTD undergoing TPU as a first-line surgery between 2013 and 2019, at a single referral hospital, were performed. A minimum follow-up period of 1 year was required to be included in the study. Short- and long-term complications were defined as those that occurred, respectively, within or after the first 4 weeks postoperatively. Results Thirty-eight male cats were included. The short-term complication rate was 18%. Idiopathic lower urinary tract disease (ILUTD) and stomal stenosis (SS) were the two most frequent short-term complications. Long-term complications were reported in 34% of the cats and included ILUTD, urinary tract infection and SS. The mortality rate was 5%. Eighty-two percent of the owners were satisfied with the postoperative outcome. The most common reason for owner dissatisfaction was the occurrence of SS, especially because these complications required multiple surgical revisions to be definitively managed. The long-term quality of life was considered to be good to very good by 89% of the owners. Ninety-one percent of the cats were free of clinical urinary signs at the time of the questionnaire completion. Conclusions and relevance TPU can be an acceptable first-line surgical technique to treat cats with OLUTD. Most cats experienced a good to very good quality of life after TPU. Most complications were transient or manageable medically. Most of the major complications were SS, which can be technically challenging to address and may require multiple revision surgeries.

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.

Objectives To provide a detailed step-by-step operative technique, and to report on long-term functional and metabolic outcomes in secondary continence mechanisms in the form of secondary intussuscepted ileal nipple valves in revisional surgery of ileocecal pouches. Methods From May 1997 to May 2015, 18 female and 10 male patients suffering from dysfunctional primary continence mechanisms of their ileocecal pouch underwent revisonal surgery to create a secondary ileal nipple valve at our tertiary referral center. The average follow-up period was 65.4 months. Results After surgery, 24 patients were continent by day and night, and four patients showed minor incontinence with the use of a safety pad. The average frequency of clean intermittent catheterization decreased both during the day and at night. The diameter of the catheters used for clean intermittent catheterization increased significantly. No patient showed stomal stenosis, change of stool habits or metabolic situation in the follow-up period. Furthermore, the creation of the secondary ileal nipple valves did not affect the capacity of the reservoir. In the long-term follow up, two patients required the construction of a third continence mechanism, making for an overall success rate of 92% in the study group. Conclusion To our knowledge, this is the first study of long-term results after the creation of secondary ileal nipple valves. We provide evidence that the creation of a secondary ileal nipple valve is a safe and reliable procedure for continence restoration in ileocecal pouches with excellent functional and metabolic long-term outcomes.

Background After laparoscopic Roux-en-Y gastric bypass many patients present with complaints for which an upper endoscopy is performed. However, often no abnormalities are found. Objectives To investigate the incidence of relevant findings at upper endoscopy and identify patient characteristics associated with a relevant finding. Setting A high-volume bariatric center. Methods A retrospective cohort study was performed. All patients presenting with complaints after laparoscopic Roux-en-Y gastric bypass who consequently underwent a diagnostic upper endoscopy were identified from a prospective endoscopic database. Primary outcomes were the number and type of relevant findings at upper endoscopy and its association with patient characteristics. Relevant findings were defined as abnormalities requiring treatment. Results Ninety-eight (39.2%) of 250 patients had a relevant finding at upper endoscopy, mostly marginal ulcer and stomal stenosis. Male sex (odds ratio [OR] 3.47 [1.12–10.76]), alcohol consumption (OR 7.27 [1.58–33.36]), dysphagia or suspicion of bleeding as referral reason (OR 3.62 [1.54–8.52] and 39.93 [4.96–321.47], respectively, compared with abdominal pain), an abnormal upper gastrointestinal series (OR 6.81 [2.06–22.48]), and no abdominal ultrasound (OR 7.41 [1.48–37.08] compared with a normal ultrasound) were significantly associated with a relevant finding at upper endoscopy. Conclusions In this study sex, alcohol consumption, referral reason, and prior imaging studies were associated with a relevant finding at upper endoscopy after laparoscopic Roux-en-Y gastric bypass.

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.

PURPOSE:Stomal stenosis has been reported to occur in 12% to 45% of patients following Malone antegrade continence enema and Mitrofanoff appendicostomy. The standard stoma technique entails excision of the distal appendix. We evaluated a novel technique with preservation of the appendiceal tip and vessels, and opening the lumen in a more proximal and vascular area to determine whether the incidence of stenosis would be decreased. MATERIALS AND METHODS:Medical records of patients who underwent appendicostomy for Malone antegrade continence enema or urinary diversion were retrospectively evaluated. We included cases with a minimum of 1 year of followup and those in which the distal portion of a complete appendix was oriented for use as the stomal end in the umbilicus. Variables such as age, gender, body mass index, antegrade continence enema or urinary diversion, open or laparoscopic approach, cecal and appendiceal adhesions, retrocecal position, cecal imbrication, technique and stenosis were recorded. Cox proportional hazards analyses were performed to determine association of covariates. RESULTS:A total of 123 patients met inclusion criteria. The incidence of stenosis following standard stoma technique was 13% (12 of 93 patients) with a median followup of 9.4 years. Of these cases 75% occurred within 1 year of surgery. Stomal stenosis did not occur after the new stoma technique in 30 patients with a median followup of 3.3 years. Only technique cohort (standard vs new) was associated with stenosis (p=0.04). CONCLUSIONS:Stomal stenosis of appendicostomy may be lessened by preservation of the distal appendiceal vasculature and tip, and opening the lumen in a more proximal location.

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.

Ileostomy or colostomy formation is an important component of many surgical procedures performed for a wide range of disorders of the gastrointestinal tract. Despite the frequency with which intestinal stomas are created, stoma-related complications remain common and are associated with significant morbidity as well as cost. Some of the most prevalent complications of stoma formation which will be detailed in this article include peristomal skin complications, retraction, stomal necrosis, stomal stenosis, prolapse, bleeding, dehydration from high ostomy output, and parastomal hernia. The authors will review these common complications, detail means to avoid or prevent them, and outline recommendations for management.

INTRODUCTION AND OBJECTIVES:Cutaneous ureterostomy is an option for urinary diversion in selected patients, however stomal stenosis remains a limiting factor. To reduce the stoma related complicati...

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.

Most of the complications related to continent catheterizable channels can be resolved by minimally invasive interventions that can be performed by adult general urologists.Few patients need surgery to revise or replace the channel, and referral to a specialist trained in reconstructive urology would be appropriate in such instances.Conversion to an incontinent urinary diversion should only be considered as a last resort.

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 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.

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.

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.