Free Antropyloric Valve Flap for End-Stage Fecal Incontinence as a Substitute to Permanent Colostomy.

BACKGROUND: Surgical removal of the anal canal and sphincter for carcinoma results in end-stage fecal incontinence (ESFI) and requires a permanent colostomy resulting in significant impact on quality of life. Presently, there are limited options for EFSI. The successful use of pedicled antropyloric valve (APV) based on left gastroepiploic artery as an alternative to permanent colostomy has previously been described. It is based on a long omental pedicle which at times is risky and is difficult to perform. A free APV flap could be the only solution in such cases. We assessed the vascular anatomy for the technical feasibility of a free APV flap, and report the first ever clinical application of free APV flap. METHODS: Bench dissection of 10 pancreaticoduodenectomy specimens was done to delineate the vessels of APV flap. It showed the consistent presence of right gastroepiploic and infrapyloric vessels in all specimens with sufficient diameters. After the technical feasibility, a free APV Flap transposition to perineum was done in a patient, where pedicled transposition was not feasible. RESULTS: The free APV flap with vagus nerve branch was harvested without extensive dissection along the greater curvature of stomach. A tension free anastomosis was achieved between the epiploic and left colic vessels. The flap survived well and had a definite tone on digital examination. It was evaluated by radiological and manometric methods. CONCLUSIONS: APV flap for EFSI can be done as a free flap with distinct advantages and it has the potential of becoming popular options for EFSI.

Dynamic article: composite antropyloric valve and gracilis muscle transposition for total anorectal reconstruction: a preliminary report.

BACKGROUND: Technique and functional outcomes of anorectal reconstruction using an antropyloric graft have been reported previously. This technique had reasonable initial outcomes but lacked voluntary function. OBJECTIVE: We hereby report the initial results of patients who underwent gracilis muscle wrapping around the perineally transposed antropyloric valve in an attempt to improve voluntary fecal control. SETTING: This study was conducted at a single tertiary care institution. PATIENTS: Eight adult patients (7 men and 1 woman) with a median age of 38 years (range, 19-51 years) underwent this procedure. Seven patients already had anorectal reconstruction with a transposed antropyloric valve, and 1 patient with severely damaged anal sphincter complex underwent single-stage composite antropylorus transposition with a gracilis muscle wrap. MAIN OUTCOME MEASURES: The primary outcome measures were anatomical integrity and functional status of the composite graft in the perineum. RESULTS: No operative mortality or serious procedure-related morbidity occurred in any patient. The median postoperative resting pressure was 29 mmHg (range, 22-38 mmHg) and squeeze pressure was 72.5 mmHg (range, 45-267 mmHg). There was a significant improvement in the squeeze pressure following surgery (p = 0.039). Also, the St. Mark's incontinence scores significantly improved in all patients and varied between 7 and 9 (p = 0.003). The ability to defer defecation and the reduced frequency of leakage accidents were the prime reasons for improved postgraciloplasty outcomes in these patients. On personal interviews, all patients who underwent this procedure were satisfied with the results of their surgery. LIMITATIONS: A longer follow-up with a larger sample size is required. Quality-of-life data have not been evaluated in this study. CONCLUSIONS: Gracilis muscle wrapping around a perineally transposed antropyloric valve is possible and improves the voluntary control and overall functional outcomes in a select group of patients with end-stage fecal incontinence requiring anal replacement (Supplemental Digital Content 1, http://links.lww.com/DCR/A173).

Neuromodulation of perineally transposed antropylorus with pudendal nerve anastomosis following total anorectal reconstruction in humans.

BACKGROUND: We have reported perineal antropyloric segment transposition with its pudendal innervation as a replacement for anal sphincter. Our aim herein was to neuromodulate this segment by electrical stimulation. METHODS: Eight patients with a permanent colostomy underwent perineal antropyloric segment transposition followed by neural anastomosis of its anterior vagus branch to pudendal nerve branch in the perineum. Perineal antropyloric graft was assessed for its functional integrity and electrophysiological effects. Nerve stimulation was done by surface stimulation technique, using a customized stimulation protocol for smooth muscle. Antral pressures were recorded on voluntary attempts and on nerve stimulation with simultaneous concentric needle electromyography of the perineal antropylorus. KEY RESULTS: The antral segment showed slow spontaneous contractions (2-3/min) on digital examination, endoscopy, and electrophysiology. Stimulated antropyloric electromyography showed a latency of 2-5 s with a differential rise in amplitude (mean range 58.57-998.75 µV) according to the frequency of stimulation (range 10-150 Hz). An average latency of 10 s in relation to rise in the antral pressure was observed on pudendal nerve stimulation. Triggering of the intrinsic rhythm was observed in patients where it was initially absent. Voluntary attempts at contraction also showed a rise in perineally transposed antral pressure. CONCLUSIONS & INFERENCES: Spontaneous rhythm, its generation after electrical stimulation, and response to voluntary contraction demonstrates the viability and functional reinnervation of the perineally transposed antropyloric segment. Rise in pressure on electrical stimulation shows evidence for its neuromodulation.

Neurovascular antropylorus perineal transposition using inferior rectal nerve anastomosis for total anorectal reconstruction: preliminary report in humans.

BACKGROUND: Technical feasibility of inferior rectal nerve anastomosis to the anterior vagus branch of the perineally transposed antropyloric valve for total anorectal reconstruction has been previously demonstrated in cadavers. To the best of our knowledge, the present study is the first report of using this procedure in humans. METHODS: Eight patients [mean age 35.5 years (range 15-55 years); (male/female = 7:1)] underwent the procedure. The antropyloric valve with its anterior vagus branch was mobilized based on the left gastroepiploic arterial pedicle. The antral end was anastomosed to the distal colon. The anterior vagus nerve was anastomosed by epineural technique to the inferior rectal nerve in the perineum. A diverting proximal colostomy was maintained for 6 months. Anatomical integrity of the graft (on magnetic resonance imaging scans), its arterial pedicle (on computed tomography angiogram) and neural continuity (on ultrasound and pyloric electromyography) were assessed. Functional assessment was performed using barium retention studies, endoscopy, manometry and fecal incontinence scores. RESULTS: Tension-free end-to-end anastomosis of the anterior vagus nerve to the right (n = 7) and left (n = 1) inferior rectal nerve was achieved. An intact left gastroepiploic pedicle, a healthy graft and neural continuity were visualized on perineal ultrasound. Electromyographic activity was noticed on neural stimulation. Endoscopy and barium studies showed voluntary antral contraction and contrast retention, respectively, in all patients. The mean resting and squeeze pressures were 26.25 mmHg (range 16-62 mmHg) and 50.25 mmHg (range 16-113 mmHg), respectively. St. Mark's incontinence scores varied between 7 and 12. There were no major surgical complications. CONCLUSIONS: Pudendal (inferior rectal) innervation of the perineally transposed antropylorus in total anorectal reconstruction is feasible and may improve outcomes in selected patients with end-stage fecal incontinence.

Anatomical basis of antropyloric transposition for fecal incontinence in humans: the infrapyloric approach.

PURPOSE: Antropylorus transposition in the perineum for end-stage anal incontinence has shown to be feasible in humans. Vascular anatomy of the antro-pyloro-duodenal area is critical in preventing complications and increasing pyloric graft survival. This study was undertaken to examine the vascular anatomy of antro-pyloro-duodenal area in an attempt to safeguard the graft blood supply and improve its survival. METHODS: After obtaining preoperative CT angiography to delineate the infrapyloric artery (IP a.), bench dissection of resected pancreaticoduodenectomy specimens was performed in 12 patients. Ex vivo angiography of these specimens were also performed. Subsequent to the information obtained from these dissections, the method of antropylorus mobilization during transposition was modified in terms of the site of division of the right gastroepiploic a. (Rt GEA). Perioperative outcomes (graft related complications, fecal incontinence scores, Doppler flow studies, and manometry studies of the graft) were compared between the two groups. RESULTS: IP a. originated only from the Rt GEA in 8 cases (66 %) and from both the gastroduodenal a. and the Rt GEA in the rest. However, its origin solely from the gastroduodenal a. was not observed. The pyloric graft survival, pyloric valve pressures and Doppler flow velocities were significantly (p < 0.05) better when the infrapyloric a. was preserved following this refinement. However, no immediate significant difference in incontinence scores was observed. CONCLUSIONS: Careful preservation of the pyloric valve vascularity by preserving the IP a. by dividing the Rt GEA at its origin increases vascularity, survival and contractility of the pyloric graft in perineum.

Pyloric valve transposition as substitute for a colostomy in humans: a preliminary report.

BACKGROUND: The purpose of this article was to show that a transposed pyloric valve (PV) can be mobilized to the perianal region and can function as a replacement for an excised rectal sphincter. Surgical research on animals has shown that a vascularized PV can be taken out of gastroduodenal continuity, transposed to the pelvic region with maintenance of fecal control when positioned in the anal area. METHODS: The surgical procedure has recently proved successful in humans in which the distal end of the left colon was anastomosed to the proximal end of the transposed PV with the distal end of the PV sutured to the skin in the perianal area as the replacement for an excised rectal sphincter. Fecal control was established after the operation. RESULTS: The PV healed in an anal position in humans with no apparent anatomic or physiological reasons to suggest that the operation might not be successful in the future as a substitute for a surgically excised or a severely damaged rectal sphincter. CONCLUSIONS: A vascularized PV supplied by the gastroepiploic artery within an omental pedicle can serve as a replacement for an excised rectal sphincter, thus eliminating the need for a permanent colostomy.

[Orthopic plastic repair of the urinary bladder with a gastric segment]. / Ortotopicheskaia plastika mochevogo puzyria segmentom zheludka.

Urinary bladder plastic repair with a gastric segment on a. et v. gastroepyploici dex was made in 22 patients (18 males, 4 females, mean age 58.2 years) from November 2001 to June 2003. Gastrocystoplasty was made in 17 patients after radical cystectomy for urinary bladder cancer, and in 5 patients with neurogenic and small urinary bladder. Three patients have undergone surgery in our modification with a complete cross resection of the gastric body with the lesser curvature. Lethal outcomes were absent. Follow-up for 2-22 months demonstrated that all the patients achieved positive functional results and good quality of life.

Fecal control following pyloric valve transposition after abdominoperineal resection.

BACKGROUND: The objective of this study was to learn if a transposed pyloric valve could be mobilized to the perianal area following an abdominoperineal resection and function as a replacement for the excised anal sphincter. METHODS: The study was performed in a surgical research laboratory. Eleven cats were used in the study: 9 served as experimental animals and 2 were controls. The operation involved mobilization of the pyloric valve based on an intact omental pedicle; the proximal side of the pyloric valve was anastomosed to the divided end of the left colon and the distal end of the pyloric valve was sutured to the perianal area. RESULTS: The excellent healing of the pyloric valve in its ectopic position was confirmed anatomically and histologically following the sacrifice of the animals. The pyloric valve was effective in maintaining complete fecal control in 4 cats and almost complete fecal continence in 2 other cats. Three other cats developed fecal incontinence due to a perianal fistula, and 2 control cats had complete fecal incontinence. CONCLUSION: There appears to be no anatomical or technical reason why the pyloric valve cannot be applied in the human as a replacement for an excised anal sphincter.

Transposition of the antropylorus for anal incontinence--an experimental model in the pig.

An experimental model in the pig rendered incontinent of feces was developed to assess the sphincteric activity of the transposed antropylorus. In the control group, normal defecation was studied clinically, radiologically, and manometrically. Nineteen 7- to 10-week-old pigs were rendered incontinent by resection of 20 cm of colon and rectum to below the dentate line. The antropylorus was prepared on its own blood supply and transposed to the anus, initially with a colostomy, which was closed 15 to 21 days later. Clinically these pigs passed semisolid stool in a piecemeal fashion. Contrast defecography showed hold-up at the pylorus, reflux of contrast into the colon, with pyloric contraction independent of antral stimulation. Manometry showed pyloric contraction with rise in antral pressure and independence. The authors conclude that transposition of an antropyloric segment to the anus provides a sphincter-like mechanism and could have application in fecal incontinence.

Autotransplantation of the pylorus sphincter at the terminal abdominal colostomy. Experimental study in dogs.

A method for constructing a continent colostomy has been tried in dogs. The pylorus sphincter with blood supply by the left gastroepiploic vessels was transposed around or anastomosed to the terminal abdominal colostomy in five dogs. One dog had a colostomy without pylorus transplantation. Evaluation was by clinical (consistency and weight of fecal material and number of defecations per day), radiologic, and manometry studies. There was no difference in the clinical data. In all the dogs, the radiologic study demonstrated emptying of the contrast medium to the peristomal skin. By manometry one high-pressure zone was demonstrated, and, in all dogs with a transposed or anastomosed pyloric segment, the average resting pressure was superior to that of the control dog. However, the transposed pylorus sphincter alone was not sufficient to control continence.

Experimental gastric ulcers in the fundic gland area following transplantation of the gastric-wall pedicles.

Using adult mongrel dogs, a portion of the anterior gastric wall of the pyloric gland area was transplanted into the fundic gland area using the Z-plastic procedure forming an islet. Three weeks postoperatively, 2 per cent histamine in sesame oil was injected intramuscularly in a daily dose of 2 mg/kg body weight. Ulcers developed in the graft in nine of 19 animals. The factors responsible to the development of the ulcers may well be circulatory disturbance and reduction of mucosal resistance following surgical insult, and continuous irritation caused by gastric juice. When a portion of the anterior gastric wall of the fundic gland area was transplanted into the fundic gland area followed by administration of histamine in sesame oil, ulcers developed in the graft only in four of 12 animals. Histological examination revealed the regenerated epithelium at the margin of the ulcers. Thus the ulcers presently induced may provide an useful experimental model for ulcers in the fundic gland area.