History and present situation of seromuscular flap anastomosis in proximal gastrectomy / 中华胃肠外科杂志

With the increasing detection rate of early upper gastric cancer and adenocarcinoma of esophagogastric junction, the safety of proximal gastrectomy with clear indications has been verified, and function-preserving proximal gastrectomy has been widely used. However, proximal gastrectomy destructs the normal anatomical structure of esophagogastric junction, resulting in severe postoperative gastroesophageal reflux symptoms and seriously affecting the quality of life. Among various anti-reflux surgery methods, reconstruction of "cardiac valve" has always been the focus of relevant scholars because its similarity with the mechanism of normal anti-reflux. After years of development, evolution and optimization, the designed seromuscular flap anastomosis includes tunnel muscle flap anastomosis, Hatafuku valvuloplasty, single muscle flap anastomosis and double muscle flap anastomosis. The double muscle flap anastomosis has become a research hotspot because it shows good anti-reflux effect in clinical application. This paper reviews the history, research status and hot issues of seromuscular flap anastomosis of esophageal remnant stomach at home and abroad.

Transplantation of Autologous Peritoneum Using Ileal Seromuscular Flaps for Orthotopic Neobladder Reconstruction / 中国医学科学院学报

To develop an ideal surgical procedure for neobladder reconstruction in experimental porcine models. Six experimental female pigs weighting 28-33 kg underwent transplantation of autologous peritoneum for bladder reconstruction under general anesthesia.The flaps were used to reconstruct the orthotopic neobladder by suturing with the edges of the triangle and neck of the remnant bladder.The ureteral catheters were removed on the 5 postoperative day and the balloon catheter was removed on the 7 postoperative day.Voiding behaviour was monitored.The animals were euthanized at week 12 for routine pathology,immunohistochemistry,and electron microscopy. All the pigs survived after the surgery,and no postoperative complication such as peritonitis,intestinal obstruction,or urinary fistula was observed.All the peritoneum-ileum composite free valves survived after transplantation.Voiding behaviour was normal after catheter removal,and the urine was clear.At autopsy,reconstructed bladders were healthy.Pathological examination showed the neobladder had been covered by continuous urothelium while the peritoneum disappeared and showed no ileal mucosa regrowth and residual.Scanning electron microscope showed the transitional cells of neobladder were complete and orderly,and the urothelium around suture border was continuous and showed no malposition. Reconstruction of bladder by autologous peritoneum and ileal seromuscular flaps is an ideal approach in the experimental pigs as it can prevent regrowth of ileal epithelial cells and avoid the complications of conventional enterocystoplasty.Its clinical application deserves further investigations.

Impact on treatment safety and efficacy of seromuscular-layer injury after HIFU ablation for uterine fibroids / 中国介入影像与治疗学

Objective: To investigate the impact on treatment efficacy and safety of seromuscular-layer injury after ablation with HIFU for uterine fibroids. Methods: A total of 400 patients with uterine fibroids who underwent HIFU ablation were enrolled. All patients had completed MRI data before and after ablation. According to postoperative enhanced MR T1WI showing whether there was perfusion defect of seromuscular-layer on sagittal or axial images of whole myometrial perfusion period, the patients were divided into injured group and intact group. The patients' age, body mass index (BMI), location of uterine fibroids, type (subserous, submucous or intermural myoma), volume, distance from anterior margin of myoma to anterior abdominal wall, parameters of ablation (power and total energy), non-perfused volume (NPV) after ablation, ablation rate, energy efficiency factor (EEF), postoperative complications and pregnancy rate were compared between the two groups. Results: There were 90 cases in injured group and 310 cases in intact group. No statistical difference of patients' age, volume of uterine fibroids, distance from anterior margin of myoma to anterior abdominal wall, power of ablation nor NPV was found between the two groups (all P>0.05).There were statistical differences of location and type of uterine fibroids (both P0.05). The postoperative pregnancy rate of the injured group and the intact group was 5.56% (5/90) and 2.26% (7/310), respectively. And there was no statistical difference (χ2=1.596, P=0.206). No adverse event related to pregnancy and deliver was observed. Conclusion: HIFU ablation for uterine fibroids may lead to uterine seromuscular-layer injury, which can be observed in patients with high BMI, subserosal fibroids at the fundus of uterus and easy to ablate fibroids (low ablation energy and EEF, high ablation rate). The postoperative pregnancy and delivery are not obviously affected by seromuscular-layer injury.

An initial experimental model of reconstruction bladder by ileal seromuscular with transplantation of autologous peritoneum / 重庆医学

Objective To develop an ideal substitution material for bladder defect ,which can reduce serious complications of urinary intestinal diversion ,we establish experimental rabbit model of reconstruction the new bladder by ileal seromuscular with transplantation of autologous peritoneum .This animal research provides the basical ground for the experimental model and further clinical application of replacement bladder .Methods Randomly ,seven experimental female rabbits were chosen ,and their body weight was 4 .0-5 .0 kg .By intravenous anesthesia ,the bladder substitute operation was carried out (to transplant the peritoneum to an ileum segment which mucosa had been removed .These flaps were used to mend and reconstruct the bladder by composite cys‐toplasty) .Animals were euthanized at 4 ,8 weeks for routine pathology and immunohistochemistry .Results Seven rabbits under‐went reconstruction ,but three were lost to complications .The length of ileum was 4 .0 cm ,and the area of substitute peritoneum was 4 .0 cm × 2 .5 cm .Voiding behaviour was normal ,and urine was clear in the remainder .At autopsy ,reconstructed bladders were healthy .Pathological examination showed that the technique was successful in creating seromuscular segments with no epithelial remnants .When applied surgically ,the seromuscular flaps with peritoneum survived at 4 weeks and the peritoneum was substituted by transitional epithelium at 8 weeks .Conclusion In this experimental rabbit model ,reconstruction bladder by autologous peritone‐um and seromuscular segment is an ideal approach for which can prevent regrowth by ileal epithelial cells and overcome the compli‐cations of conventional enterocystoplasty .Voiding behaviour is normal in the remainder .This animal study provides the basical ground for the large experimental model and further clinical application of the new enterocysplasty .

Outcome of de-mucosalized ileocystoplasty combined with strengthened pelvic floor in patients with neurogenic bladder / 中华泌尿外科杂志

Objective To assess the outcome of de-epithelialied ileocystoplasty combined with strengthened pelvic floor in patients with neurogenic bladder.Methods Twelve patients (9 male,3 female) aged from 18 -27 years (averaged 25 years) with neurogenic bladder received de-mucosalized seromuscular ileocystoplasty combined with strengthened pelvic floor,and were evaluated by urodynamic parmeters,upper urinary tract image appearance,and serum creatinine before and one year after operation.Results After operation,the max cystometric capacity (412 ± 32 ml),bladder compliance (26.2 ± 4.0ml/H2O),relative safety cystometric capacity (368 ±26 ml) and max flow rate (20 ±3 ml/s) were respectively significantly higher than those preoperation(247 ±27 ml,4.4 ± 1.2 ml/cm H2O,206 ±24 ml,11 ±2ml/s,P ＜ 0.05).Moreover,the post voided residual (26 ± 8 ml) and detmsor leakage point pressure (17.8 ±3.6 cm H2O) were significantly lower than those of preoperation (136 ± 25 ml,63.1 ± 4.9cm H2O,P ＜0.05).The vesicoureteral reflux disappeared in five (63％) cases,and was relieved in the remaining three cases.Of the five cases with renal insufficiency,three (60％) cases had normal serum creatinine level,none had increased serum creatinine levels.After operation,late healing occurred in two ( 17％ ) cases,intestinal obstruction in one (8％),vesicoabdominal fistula in one (8％),and no cases had mucous urine.Clean intermittent self-catheterization was performed in one case (8％) to empty the bladder due to a fever resulting from urinary tract infection,the remaining 12 (92％) cases could empty their bladders through abdominal pressure.Conclusions De-mucosalized seromuscular ileocystoplasty combined with strengthened pelvic floor results in a good outcome for the patients with neurogenic bladder.

Pancreaticoyeyunostomía ducto-seromuscular término-lateral en la operación whipple: experiencia en 27 casos / Seromuscular end pancreaticojejunostomy-duct-side in the whipple operation: experience with 27 cases

Presentar la experiencia con la anastomosis ductoserosa termino-lateral en la pancreaticoyeyunostomía del Whipple, en el Servicio de Cirugía General del Instituto Autónomo Hospital Universitario de Los Andes, Mérida-Venezuela. Estudio prospectivo, descriptivo en pacientes sometidos a duodenopancreatectomía por patología maligna a nivel pancreático y región periampular entre los años 2003 a 2007. En todos los casos se realizó preservación pilórica con anastomosis ducto-serosa termino-lateral del remanente pancreático, con colocación de stent intraductal, excepto en un caso donde se realizó la técnica invaginante término-terminal. Se evaluaron las complicaciones postoperatorias inherentes a la técnica quirúrgica, haciendo especial énfasis en la fístula pancreática. Un total de 27 pacientes durante el período 2003 a 2007 fueron sometidos a duodenopancreatectomía cefálica en forma electiva por etiología maligna tales como: ampuloma II casos, colangiocarcinoma distal 2 casos, cáncer de páncreas 12 casos, tumor neuroendocrino 1 caso, adenoma velloso malignizado de colédoco 1 caso. Las edades estuvieron comprendidas entre 42-81 años con promedio de 61 años, predominantemente del sexo femenino en una proporción 4:1. Entre las complicaciones posquirúrgicas relacionadas con la técnica encontramos 4 casos (14.8 por ciento) dado por: 2 fístulas pancreáticas (una de ellas por la ligadura accidental del stent intraductal), 1 dehiscencia de la duodenopancreatectomía, siendo la causa de muerte, y finalmente un caso de atonía gástrica manejado médicamente en forma satisfactoria. La anastomosis ducto-serosa en el manejo del remanente pancreático del Whipple constituye una técnica de fácil ejecución y con buenos resultados, ya que ofrece menos morbimortalidad.

Pedicled Ileal Seromuscular Flap-A New Technique for Protection of Intestinal Anastomosis in Patients with Peritonitis

Pedicled ileal seromuscular flap- a new technique for protection of intestinal anastomosis in patients with peritonitis. This method involves raising a seromuscular flap on a pedicle from the stump of intestine to be anastomosed. The anastomosis is performed, and then covered with seromuscular flap. The submucosa due to its inherent properties, promotes better healing and reduces the tension on the anastomosis. There has been no previous study to assess the usefulness of this technique. We used a pedicled ileal seromuscular flap in twenty consecutive patients with peritonitis who required an ileo-ileal or an ileo-colic anastomosis. Anastomotic leak occurred in two out of twenty patients. The safety and efficacy of this technique involving autologous tissues to reinforce intestinal anastomosis has been demonstrated.

Alça intestinal invertida como substituto do ureter: estudo experimental em cães

OBJECTIVE: To investigate the outcome of ureter replacement with inverted seromuscular tube in dogs. METHODS: 40 adult mongrel dogs were divided in 5 groups of 8 animals. Each group was divided in 2 subgroups: 1 - sacrifice on 12-15 postoperative days, and 2 - sacrifice on the 60th postoperative day). In group A ureter longitudinal incision 2cm long was sewed with an inverted ileal seromuscular patch 2cm long. In group B ureter incision and patch size were 4cm long. In the remaining groups a ureter segment was replaced by an inverted ileal seromuscular tube 2cm long (group C) or 6cm long (groups D and E). In all groups, except E, ileal mucosa was removed by a grasping maneuver with a scalpel. In group E the ileal mucosa was trimmed away by blunt dissection with a scissors. The ureter permeability was tested by an intravenous urogram, and after sacrifice by anatomic exploration with a catheter. All ureter segment removed through the necropsy were analyzed by histology after hematoxilin-eosin coloration. RESULTS: The number of animals with normal urogram after the followup was: A - 2, B - 2, C - 3, D - 2 and E - 2. Histology revealed that ileal serosa was covered by ureteral mucosa grown from the ureter buds. CONCLUSION: The inverted ileal seromuscular tube or patch does not work well for ureter replacement.

OBJETIVO: Pesquisar a viabilidade da alça ileal invertida como substituto ureteral. MÉTODOS: Quarenta cães foram divididos em 5 grandes grupos de 8 animais, cada um subdividido em 2 subgrupos de acordo com a data do sacrifício (I - sacrifício em 12-15 dias de pós-operatório, e II - 60 dias de pós-operatório). Nos grupos A e B fez-se a substituição ureteral parcial com selo de íleo invertido, após abertura lateral do ureter direito com 2 (Grupo A) ou 4 cm (Grupo B) de extensão. Nos demais grupos fez-se a substituição do segmento completo do ureter usando-se um tubo de íleo invertido de comprimento equivalente ao segmento do ureter ressecado com 2cm (Grupo C) e 6cm (Grupos D e E) de extensão. A mucosa ileal foi removida por raspagem ou diérese. A permeabilidade ureteral foi testada por urografia excretora e por exploração anatômica com cateter após o sacrifício. As peças foram estudas histologicamente após preparação e coloração com hematoxilina-eosina. RESULTADOS: O número de animais com urografia normal após o seguimento foi: A-2, B-2, C-3, D-2 e E- 2. A histologia revelou que a serosa ileal se reveste com urotélio, não como decorrência de metaplasia, mas do crescimento a partir da borda da mucosa ureteral. CONCLUSÃO: Conclui-se que o íleo invertido não é um bom substituto ureteral.

Availability of Reversed Seromuscular Flaps in the Enterocystoplasty in Rats / 대한비뇨기과학회지

PURPOSE: Enterocystoplasty is the method commonly used in clinical practice. The use of intestinal segments in the urinary tract for the reconstructive purposes has been reported numerous complications: urinary tract infection, stone formation, hyperchloremic acidosis, hypokalemia, urinary obstruction secondary to mucus plugs, and malignancy developing. We studied on the feasibility of creating an enterocystoplasty with a reversed seromuscular ileal segment to decrease the likelihood of recognized complications in cases of standard bowel replacement. MATERIALS AND METHODS: Augmentation enterocystoplasty was performed in 21 male, 400-450gm, Sprague-Dawley rats with a patch of ileum. There were 3 groups, including 1 group of 9 rats that underwent augmentation conventionally, while another group of 8 rats were augmented using reversed seromuscular flaps and the other rat was died for postoperative ileus. The other group of 3 rats were sham operated. The animals survived without significant complications and were sacrificed at 4 or 12 weeks. RESULTS: The bladder capacities in both group were no significant differences. The size of the intestinal patchs were markedly decreased in reversed seromuscular flaps. The urine white blood cells and mucus production were much higher in the conventional type, but intraperitoneal mucus production and postoperative adhesion were seen mostly in reversed seromuscular types. CONCLUSIONS: Reversed seromuscular flaps showed little mucus production in urine and urinary infection compared to those animals with flaps undergone conventional method. Unfortunately, intraperitoneal mucus production and graft contracture were much higher in those procedures. Further studies would be needed for clinical availability of reversed flap.

Intestinal muscular layer ablation in extensive small bowel resection: An experimental study using cats

PURPOSE: To determine if intestinal valves through seromuscular ablation can retard intestinal transit time, improve absorption and nutrition in short-bowel syndromes with very short small-bowel remnant METHODS: Six domestic cats were assigned for the experimental and control groups. Pre-operative and post-operative determination of weight, character of stools, transmit time, and TPAG were done. All the cats underwent 80 percent resection of the small bowel. An intestinal valve through seromuscular ablation was made proximal to the anastomosis for the experimental group. Comparison of weight, character of stools, transmit time, and TPAG between the two groups were done post-operatively. T-test was used for statistical analysis with alpha 0.05 for level of significance RESULTS: All the cats in the experimental group survived, however, there were 4 mortalities noted in the control group. The average preoperative transit times were 209 minutes and 216 minutes for the control and experimental groups respectively. There was a significant decrease in TPAG post-operatively for the control CONCLUSION: Intestinal valves through seromuscular ablation can retard intestinal transmit time, improve absorption and nutrition in very short small-bowel remnant. (Author)