Dieulafoy lesion of the ileal conduit: a case report

Late side effects of ileal conduit are uncommon. Here we report a case of ileal conduit hemorrhage in a 78-year-old woman 8 years after radical cystectomy and ileal conduit diversion. The patient presented with gross hematuria and abdominal dynamic computed tomography showed extravasation of contrasts in ileal conduit and the patient was diagnosed with ileal conduit hemorrhage. Clipping hemostasis was performed under gastrointestinal endoscope and revealed that Dieulafoy's ulcer was the cause of ileal conduit hemorrhage. This is the first case of Dieulafoy's ulcer occurred in ileal conduit. Hemorrhage from ileal conduit is an important late side effect.     

Urodynamic evaluation of ileal conduit function

Bilateral hydroureteronephrosis following ileal conduit urinary diversion is not uncommon. It may be owing to ureteroileal stenosis, stomal stenosis or a poorly compliant ileal conduit. The standard evaluation of stoma size, conduit residual urine and a loopogram often fail to allow determination of the cause of ureteral dilatation. In addition to these standard tests, we have used conduit urodynamics to study conduit function with a triple lumen urodynamic catheter to measure simultaneously conduit pressure proximal and distal to the fascia during filling under fluoroscopy. In 4 control patients with normal upper tracts who were studied with this technique conduit leak point pressures ranged from 5 to 20 cm. water pressure. Six patients with bilateral hydroureteronephrosis were studied to evaluate conduit function. We found abnormalities in 5 patients, including functional stomal stenosis in 2, an atonic loop in 1, segmental obstruction in 1 and a high pressure noncompliant distal segment in 1.     

Cavernous nerve reconstruction with a biodegradable conduit graft and collagen sponge in the rat

PURPOSE: We investigated the efficacy of a biodegradable conduit graft for axonal regeneration of the injured cavernous nerve in a rat model. MATERIALS AND METHODS: Bilateral cavernous nerves were resected in 8-week-old Sprague-Dawley rats. We interposed a nerve gap with a 4 mm poly L-lactic acid and E-caprolactone copolymer conduit. The 56 rats were divided into 4 groups, namely group 1-biodegradable conduit alone, group 2-biodegradable conduit plus collagen sponge, group 3-sham operation as a positive control and group 4-unconnected conduit as a negative control. RESULTS: Immunohistochemical study revealed that neuronal nitric oxide synthase positive nerve fibers significantly increased in all rats in the conduit graft groups at 3 months. In a retrograde tracing study with FluoroGold (Fluorochrome, Englewood, Colorado) at 3 months the conduit plus collagen group showed a significant increase in FluoroGold positive cells in major pelvic ganglia. Intracavernous pressure elicited by medial preoptic area stimulation significantly increased in all rats in the conduit graft groups, especially in the conduit plus collagen group. CONCLUSIONS: This study suggests that a biodegradable conduit is effective for axonal regeneration of the injured cavernous nerve. Moreover, a conduit with a collagen sponge facilitates axonal sprouting and re-projection to its target organ, and ensures functional recovery.     

Surgical management of occluded conduits after the Fontan operation in patients with Glenn shunts

Five complete conduit occlusions occurred in four patients with the Glenn shunt 2 months to 2 years after the Fontan operation. The possible reasons for complete conduit occlusion were severe dehydration, high pulmonary vascular resistance, and intraoperative manipulation of the conduit. In one patient in whom complete conduit occlusion developed twice, no possible cause could be identified. Surgical approaches included replacement of the occluded conduit in three patients and creation of an atrial septal defect and left aortopulmonary shunt in the fourth patient. All patients who had replacement of the occluded conduit survived. The fourth patient had severe cyanosis and hypoxemia from marked reduction of flow through the Glenn shunt because of reversal of flow through large venous collaterals. He subsequently died of Candida sepsis. A fifth patient (previously reported) who had complete conduit occlusion also died after a similar procedure. We believe that in patients with a Glenn shunt who develop complete conduit occlusion after the Fontan operation, conduit excision and a secondary Fontan operation, preferably without the use of woven Dacron, should be done instead of establishing an atrial septal defect and aortopulmonary shunt to the left lung.     

Aneurysmal dilatation of the Contegra bovine jugular vein conduit after reconstruction of the right ventricular outflow tract

An aneurysm of a 14-mm Contegra bovine conduit 5 years after a total repair of tetralogy of Fallot was confirmed by echocardiography, angiography, and magnetic resonance tomography. The conduit was replaced. Histologic examination of the explanted conduit revealed an acellular homogenous material with occasional elastic fibers, fragile, diffuse and complex collagenization throughout the conduit and mild foreign body reaction. Pannus formed over the top of all commissures and on the conduit wall, with extensive mineralization. Close follow-up is seen as mandatory for early detection of the bovine vein conduit aneurysm, particularly in patients in whom small-sized conduits are implanted.     

Reoperation cases long after Rastelli operation: right ventricular outflow tract reconstruction by means of a xenograft non-valved patch

Two cases who underwent the new procedure of treatment for extracardiac conduit stenosis after Rastelli operation are reported. They had undergone Rastelli operation 11 and 12 years ago. Because of stenotic Hancock valve of the conduit, they were reoperated. A longitudinal incision was made anteriorly over the conduit and the conduit was dissected free. The sides and posterior half of the conduit bed were preserved. The roof of the new right ventricular outflow tract was formed using a xenograft pericardium patch. Their postoperative courses were smooth.     

Acute urinary retention in ileum conduit urinary diversion

Three years after ileum conduit urinary diversion, a 68-year-old patient was referred to us with acute urinary retention. Ultrasound examination demonstrated an extremely dilated, urine-filled ileum conduit and dilated kidneys. Placing a catheter into the subfascial part of the conduit to drain the urine was impossible because of extreme kinking and compression of the conduit in the fascial level. Ultrasound-guided puncture of the conduit was performed, and 170 mL of urine was aspirated. Afterward, a 16F catheter was easily placed. Clear urine drained. At last follow-up, no further episodes of urinary retention had occurred.     

Esophageal conduit necrosis

A cumulative review of the prevalence of esophageal conduit necrosis is summarized in Table 4. The spectrum of conduit ischemia is broad and includes cases in which there is anastomotic leak or stricture as well as cases in which there is frank graft necrosis. Many of the studies that the authors reviewed do not specify the exact nature of postoperative ischemic complications or how they are defined. Therefore, postoperative conduit ischemia is reported globally. Based on the authors' review, average rates of ischemic complications for stomach, colon, and jejunum are 3.2%, 5.1%, and 4.2%, respectively. Results for colon and jejunum include results for both long- and short-segment grafting. Most reports that compare outcomes using different esophageal conduits demonstrate findings similar to the authors'. Davis and colleagues compared results with colon versus gastric conduit esophageal reconstruction. They found that operative mortality, anastomotic leaks, and conduit ischemia rates were all lower for the stomach than for the colon. Specifically, ischemia of the stomach conduit was 0.5%, compared with 2.4% for the colon conduit. Moorehead and Wong, in a large series of 760 esophagectomy patients in whom the stomach, colon, or jejunum was used for reconstruction, demonstrated that the stomach had the lowest incidence of conduit ischemia (1%), followed by jejunum (11.3%), then colon (13.3%). Some of the factors they identified as correlating with the risk of ischemia include length of conduit, technique of stomach graft preparation, whether anastomosis is in the neck or chest, and route of passage of the conduit. Mansour and colleagues compared their results using bowel interposition (either colon or jejunum) to reconstruct the resected esophagus. The authors report an overall mortality of 5.9%, and 3% conduit ischemia. All ischemia was noted in the colon conduits harvested from the left side. No ischemic complications were noted from jejunal segments. Briel and colleagues compared stomach versus colon conduit use after esophagectomy. They note an overall incidence of ischemia of 9.2%. In their series, the incidence of ischemia for stomach and colon was 10.4% and 7.4%, respectively. Anastomotic leak and stricture rates, both thought to be sequelae of ischemia, also were lower for colon conduit use than for stomach conduit. Multivariate analysis identified patient comorbidities as the only independent risk factor for conduit ischemia. The authors use their findings to support the preferential use of colon conduits rather than stomach conduits. The incidence of colon conduit ischemia (7.4%) is directly in line with all other published results, including the cumulative review by the authors of this article, whereas the rate of stomach conduit ischemia (10.4%) is considerable higher than in most other studies. Esophageal conduit necrosis is an uncommon but disastrous complication of esophageal surgery. Careful selection of patients for surgery, preoperative evaluation of the proposed conduit, and meticulous operative technique are the best defenses against conduit ischemia. Postoperatively, surgeons should have a high index of suspicion for this complication. Unexplained tachycardia, respiratory failure, leukocytosis, or any evidence for graft or anastomotic leak should prompt a search for conduit ischemia. The diagnosis is made by contrast esophagography, endoscopy, or direct operative inspection. There is no documented salvage technique once ischemia is identified. Treatment for mild cases may be supportive, with or without management of anastomotic leak. More severe cases of necrosis require débridement and conduit take-down with proximal esophageal diversion and placement of enteral feeding tubes. Reconstruction can be planned for later if possible. The majority of the data demonstrates that risk of ischemia is related to conduit type, length of conduit, comorbidities, and operative technique. The stomach has the lowest reported incidence of conduit ischemia, followed by the jejunum, and colon. In the future, methods to predict conduit ischemia more accurately at the time of surgery may further reduce the incidence of this disastrous complication.     

新型复合生物材料导管修复大鼠周围神经缺损的实验研究

目的 几丁糖、聚乳酸两种材料结合研制一种新的神经导管材料。方法 几丁糖、聚乳酸按照一定的比例反应后，制备内径1．5mm，管壁厚度为200μm的复合生物材料导管，用以桥接5mm的大鼠坐骨神经缺损。硅胶管桥接组及自体神经移植组作为对照组。术后12周进行大体观察(后肢活动、针刺收缩反应、足底溃疡)，组织学观察，肌电图，图像分析及小腿三头肌称重等检查。三组数据两两间进行分组t实验。结果 12周时大体观察结果表明：三组再生神经均成功通过导管，并支配远端肌肉。几丁糖-聚乳酸复合生物材料导管降解明显，但未完全吸收。肌电图、小腿三头肌称重、图像分析结果表明：几丁糖-聚乳酸复合生物材料导管组再生轴突数量及再生神经质量明显优于硅胶管组，与自体神经移植组效果相似。结论 几丁糖-聚乳酸复合生物材料导管能较好修复周围神经缺损，是一种较理想的神经导管材料。     

外消旋聚乳酸复合神经生长因子缓释导管促周围神经再生的形态学研究

目的 建立外消旋聚乳酸复合神经生长因子（poly-D，L-lactic acid／nerve growth factor，PDLLA／NGF）可吸收性缓释导管桥接修复大鼠坐骨神经缺损的动物模型，观察复合导管对大鼠坐骨神经缺损再生的促进作用。方法利用溶剂挥发法制备PDLLA单纯导管和PDLLA／NGF缓释导管，每根缓释导管含NGF450U。SD大鼠40只随机分成4组，每组10只，切除中段坐骨神经10mm之后分别行自体神经移植（A组）、单纯导管桥接（B组）、单纯导管加一次性给药（C组）、PDLLA／NGF缓释导管桥接（D组）修复坐骨神经，除A组外，均保留10mm缺损。术后3个月观察神经再生情况，比较各组光镜、电镜及图像分析等指标。结果术后3个月导管与周围组织粘连松，并开始降解，但外形仍保持完整。再生神经均顺利通过导管腔，组织学观察A组和D组内神经纤维数目多，大小均匀，成熟良好；B组和C组纤维结缔组织多，神经纤维细小，髓鞘薄。图像分析显示除神经纤维计数D组高于A组外，A组和D组在纤维直径、轴突直径和髓鞘厚度方面差异均无统计学意义（P〉0．05），并明显优于B组和C组（P〈0．05）。结论 PDLLA／NGF缓释导管能够有效促进大鼠坐骨神经缺损再生，组织学观察指标接近自体神经移植。     

A case report of complication liked jejunal conduit syndrome induced by reconstruction of ileal conduit

The patient was a 77-year-old man who underwent radical cystectomy and ileal conduit urinary diversion due to bladder cancer in 1989. A stenosis of the right uretero-ileal anastomosis occurred in 1992, and of the left uretero-ileal anastomosis in 1999. These were treated with indwelling of a ureteral stent and percutaneous nephrostomy, respectively. He was admitted to our hospital for progressive renal dysfunction due to frequent pyelonephritis. We performed a reconstruction of the ileal conduit urinary diversion and after the removal of the bilateral ureteral stent he complained of nausea and general malaise. The laboratory data showed hyponatremia, hyperkalemia and azotemia, which were diagnosed as complication liked jejunal conduit syndrome. He was treated with hydration and salt supplementation. With regard to this case, we considered that a long ileal conduit close to the jejunum and renal dysfunction caused the complication liked jejunal conduit syndrome. Careful observation and follow-up laboratory examination should be performed if the patient has renal dysfunction and a long conduit near the jejunum is used for the ileal conduit.     

Preservation of systemic tricuspid valve function by pulmonary conduit banding in a patient with corrected transposition of the great arteries

Systemic tricuspid valve regurgitation increases mortality and morbidity in patients with a corrected transposition of the great arteries. A 17-year old male with a physiologically corrected transposition after the closure of a ventricular septal defect and conduit placement between a morphological left ventricle and pulmonary artery presented with exertional dyspnoea. The transthoracic echocardiography showed a severe conduit stenosis, and cardiac catheterization revealed a pressure gradient of 114 mmHg. The patient underwent conduit re-replacement using a pulmonary heterograft. Intraoperative transoesophageal echocardiography revealed an acute severe tricuspid regurgitation after a conduit re-replacement. Pulmonary conduit banding was performed under transoesophageal echocardiography guidance, during which the left ventricular to right ventricular pressure ratio increased from 0.33 to 0.60 and the degree of tricuspid regurgitation decreased mildly. The patient was discharged uneventfully at postoperative day 16. Conduit banding might be a useful technique to preserve the systemic tricuspid valve function during conduit re-replacement in patients with a corrected transposition.     

Comparative study of two sites of colonic conduit placement in the treatment of constipation due to rectal evacuatory disorders.

BACKGROUND: Chronic constipation may be treated by antegrade colonic irrigation via a colonic conduit. METHODS: Two alternative sites of colonic conduit construction were evaluated for their effect on the symptoms of 21 consecutive women with intractable constipation primarily due to rectal evacuatory disorders. The conduit was constructed in the sigmoid colon in the first 11 patients and in the transverse colon in the subsequent ten. Symptomatic outcome was evaluated clinically and by questionnaires, with a prospective quality of life assessment in the transverse group. RESULTS: During a median follow-up of 12 (range 6-60) months, reflux or stenosis necessitated revision or dilatation in six patients. Irrigation with a median of 1.3 (0.8-2.0) litres of water achieved evacuation in all patients. Improvements in abdominal pain and bloating were reported by seven of the ten patients in the transverse conduit group, but benefit was found in only three of 11 in the sigmoid group. There was no significant improvement in quality of life scores. In the medium term, seven patients retained a transverse conduit compared with three with a sigmoid conduit. CONCLUSION: The transverse colonic conduit offers better relief from the symptoms of constipation due to rectal evacuatory dysfunction than the sigmoid conduit.     

The fate of the 12 mm porcine valved conduit from the right ventricle to the pulmonary artery. A ten-year experience

The 12 mm Dacron conduit containing a porcine valve is the smallest valved conduit manufactured and is used in the youngest infants with the most diminutive pulmonary arterial system. The outcome of patients with such a conduit is unknown. Between 1975 and 1985 there were 49 hospital survivors after placement of a 12 mm extracardiac valved conduit from the right ventricle to the pulmonary artery. Follow-up is available in 42 patients, aged 1 to 16 months (mean 3.5) and weighing 2.5 to 8.7 kg (mean 3.8). Twenty-eight patients (67%) have undergone subsequent conduit replacement, and 11 (26%) are alive and asymptomatic with a mean follow-up of 56 months. There were three late deaths. The interval between implantation and conduit change was 4.5 to 101 months (mean 44), allowing a weight gain of 2.7 to 23 kg (mean 10.4) before reoperation at age 12 to 117 months (mean 49). Despite elevated right ventricular pressures equaling systemic values, 37% of these patients were clinically asymptomatic. The gradient across the 12 mm valved conduit before explantation ranged from 30 to 173 torr (mean 83) with an almost equal predilection for stenosis at the proximal anastomosis, valve, conduit, distal anastomosis, and main pulmonary artery. The intervening pulmonary artery growth determined the size of the replacement conduit, 14 to 25 mm (mean 16), and was the main factor influencing the results of reoperation. This study demonstrates that the 12 mm porcine valve-containing conduit affords palliation in this difficult subset of patients with the smallest pulmonary arterial tree.     

Long-term outcome after right ventricle to pulmonary artery conduit surgery and reintervention

Background. Reconstruction of the right ventricular outflow tract with a conduit is an established surgical procedure in congenital heart disease and reinterventions are common. Objective. An increasing number of patients have a conduit, but there are few population-based studies of long-term outcomes after conduit surgery, reoperations, and transcatheter pulmonary valve replacement. Methods. In April 2015, all adult patients with a conduit were identified in the Swedish National Registry for Congenital Heart Disease (SWEDCON). Data on patients who died before age of 16 years are not included in the registry and thus not included in the study. Results. We found 574 patients with a mean age 36.1 years. The largest proportion had tetralogy of Fallot (45%). In total there were 762 operations and 50 transcatheter pulmonary valve replacements. Mean age at first conduit operation was 20.2 years. Long-term survival up to 48 years including perioperative mortality (<1%) was 93% at 20 years. The most common cause of death was cardiac-related. Higher age at first conduit operation was associated with increased mortality risk. Reintervention-free survival was 77% and 54% at 10 and 20 years, respectively. Conduit reinterventions were common. Ten-year reintervention-free survival after first conduit reintervention (n?=?176) was significantly lower than after first conduit operation (70% vs 77% p?=?.04). Higher age at first conduit operation was associated with a reduced risk of reintervention, whereas male sex and complex malformations were associated with increased risk of reintervention. Conclusions. The mortality of repeated conduit reinterventions is low. The need for reintervention of conduits is considerable, and reintervention-free survival after the first conduit reintervention is poorer than after first conduit implantation. The findings in this study only applies for patients reaching 16 years of age.     

Total cavopulmonary connection with straight conduit for apicocaval juxtaposition

If the heart is malpositioned with apicocaval juxtaposition (ACJ), what constitutes the ideal course for the conduit pathway of a total cavopulmonary connection must be considered. When the conduit is positioned between the inferior vena cava and the same side of the pulmonary artery behind the ventricle, potential stenosis of the conduit due to compression by the ventricle or obstruction of the pulmonary vein due to compression by the conduit must be recognized. We reported two cases of ACJ in which a straight conduit pathway behind the ventricle was accomplished. Comprehensive dissection of the heart, especially the posterior side of the ventricle, to make a wide opening into the thoracic cavity is needed to obtain enough space behind the ventricle. Postoperative catheter studies performed 6 months after the operations showed no obstruction or deformity of the conduit or the pulmonary veins, and the mean pulmonary artery pressure measured 9 mmHg in both patients.     

Primary Adenocarcinoma in an Ileal Conduit

Reports of primary small intestine malignancies are rare. Even more uncommon is primary carcinoma in an ileal conduit. Here, we report a case of primary adenocarcinoma in an ileal conduit that developed 14 years after radical cystectomy and diversion to an ileal conduit for transitional cell carcinoma of the bladder. To our knowledge, only one case of primary adenocarcinoma developing in an ileal conduit after a radical surgery for bladder cancer has been reported previously.     

Polytetrafluoroethylene conduits versus homografts for right ventricular outflow tract reconstruction in infants and young children: An institutional experience

Objective

Our institution uses a valved polytetrafluoroethylene conduit as an alternative to homografts. The objective of this study was to investigate the performance of bicuspid valved polytetrafluoroethylene conduits used for right ventricular outflow tract reconstruction in children aged less than 2 years and to evaluate risk factors for earlier conduit explant.

Midterm follow-up of the status of Gore-Tex graft after extracardiac conduit Fontan procedure

Objective: Extracardiac conduit Fontan procedure has some theoretical advantages over other types of Fontan procedures, such as optimized flow dynamics, a lower frequency of arrhythmias, and technical ease of procedure. However, lack of growth potential and thrombogenicity of the artificial conduit is the main concern and can possibly lead to reoperation for the conduit stenosis. In this study, we investigated the change and the status of the Gore-Tex graft used in extracardiac conduit Fontan procedure. Methods: Between 1996 and 2005, 154 patients underwent extracardiac conduit Fontan procedure using Gore-Tex graft. Among these, 46 patients underwent cardiac catheterization during follow-up period. We measured the internal diameter of the conduit and inferior vena cava angiographically. Results: Mean follow-up duration was 36.1 ± 19.7 months. The conduit diameter used was 16 mm in 10 patients, 18 mm in 16, 20 mm in 14, 22 mm in 4, and 24 mm in 2 patients. The mean conduit-to-inferior vena cava cross-sectional area ratio was 1.25 ± 0.33. According to the conduit size used, this ratio was 1.03 ± 0.17 for 16 mm conduits, 1.33 ± 0.37 for 18 mm, 1.33 ± 0.36 for 20 mm, 1.28 ± 0.26 for 22 mm, and 1.05 ± 0.06 for 24 mm conduits (p < 0.05, 16 mm vs 18 mm and 20 mm). The mean percent decrease of the conduit cross-sectional area was 14.3 ± 8.5%, and this did not differ significantly according to the conduit size (p = 0.82). Follow-up duration and the percent decrease of the conduit cross-sectional area did not show significant correlation (r = 0.22, p = 0.14). There was no reoperation due to conduit stenosis. Conclusions: During midterm follow-up of about 3 years, the conduit cross-sectional area decreased by 14%, and this did not differ according to the conduit size used. The extent of decrease of the conduit cross-sectional area remained stable irrespective of the follow-up duration. Sixteen millimeters conduit showed no evidence of clinically significant stenosis, but careful follow-up is warranted because of the possible conduit stenosis relative to the patients’ somatic growth.     

Resternotomy in patients with valved conduits adherent to the sternum

Twenty-two patients with valved conduits adherent to the sternum underwent resternotomy. Mean age was 10 +/- 6 years, and mean conduit age was 4 +/- 4 years. Diagnoses were D-transposition (7), truncus arteriosus (7), univentricular heart (6), Taussig-Bing anomaly (1), and corrected transposition (1). The majority of patients (68%) had reoperation for outgrown or degenerated conduits. In 17 patients, the sternum was opened with a chisel. Two of these patients sustained conduit neointimal collapse from manipulation, and 3 had conduit tear requiring immediate cardiopulmonary bypass through the femoral vessels. In the last 5 patients, the sternum was opened above and below the conduit, and the inner table was chiseled and left attached to the conduit avoiding injury and undue conduit manipulation. Cardiopulmonary bypass and operation were carried out uneventfully. We believe that the recent technique described provides a safe alternative approach to valved conduits adherent to the sternum.