Pouch reconstruction after resection of the rectum

Pouch reconstruction after resection of the rectum. Functional results after low anterior resection of the rectum and straight end-to-end coloanal anastomosis are often poor. Patients are frequently troubled by the so called "anterior resection syndrome" which comprises faecal incontinence, urge, frequency and fragmentation. To investigate the potential functional benefit of a coloanal pouch reconstruction we conducted a prospective study. Some 55 patients [29 men; median age 66,4 (30-85)] underwent low anterior resection of the rectum followed by coloanal J-pouch reconstruction. Pouch size was 5-7 cm, a temporary stoma was fashioned in 32 patients. Indications for the operation were: 1. rectal cancer: n = 51, 2. recurrent adenoma n = 2, 3. recto-vaginal fistula n = 1 and 4. severe non-specific proctitis n = 1. We observed 5 anastomotic leakages of which two patients required reoperation. A pelvic abscess was encountered in three patients as well as one pelvic haematoma. Micturition was impaired in five patients. To date 47 patients have completed 12 months follow-up after reversal of the ileostomy. Patients were seen at three-monthly intervals. Mean stool frequency/day was 3.9 after 3 and 2.6 after 12 months. After 3 months 38 patients (69 %) reported complete continence which increased to 83 % at 1 year. 18 Patients (33 %) complained of urge defaecation initially, which decreased to 14.5 % after 1 year. Fragmentation was observed in 40 % at 3 and and 22 % at 12 months, respectively. In conclusion, our initial experience with colonic J-pouch reconstruction shows good functional results.     

Pouch and Roux-en-Y reconstruction after gastrectomy

We evaluated a reconstruction procedure of the upper gastrointestinal tract after total gastrectomy with the exclusive use of the EEA, GIA, and TA surgical stapling devices (United States Surgical Corp, Norwalk, Conn). Twenty patients with gastric carcinoma entered the study. A total gastrectomy and lymphadenectomy was performed in each patient and the upper gastrointestinal tract was reconstructed by the Roux-en-Y technique with the creation of a Hunt-Lawrence-Rodino pouch. For all operational steps, surgical staplers were used exclusively, as follows: (1) duodenal closure, GIA or TA; (2) Roux-en-Y anastomosis, EEA 25; (3) pouch construction, GIA (three to four times); (4) esophagojejunostomy, EEA 25; and (5) pouch closure, TA 55 or 90. There was a one-hour difference in operating time between patients operated on exclusively by the staple technique and TNM-matched patients operated on manually. Four patients suffered from general complications. Two patients had clinically relevant suture deficiencies. We concluded that current reconstruction methods after gastrectomy that fulfill the reservoir function (pouch) and reflux prevention (Roux-en-Y reconstruction) can be achieved by the combination and systematic use of straight and circular staplers. The advantages are intraoperative time saving and a relaxation of limitations imposed on an abdominal intervention by age and localization of the tumor.     

Tumors of the pelvis: complications after reconstruction

Introduction Complications after pelvic sarcoma surgery are frequent; however, the reports on complications are limited. Results of the authors' experience with 110 primary pelvic tumor resections and methods to achieve low complication rates for pelvic reconstruction are reported.Materials and methods From 1982 to 1996, 110 patients with pelvic sarcoma (42 Ewing sarcomas, 40 chondrosarcomas, 21 osteosarcomas, and 7 other malignant tumors) underwent surgery. Sixteen patients underwent implantation of a hemipelvic megaprosthesis, 13 patients had implantation of an allograft for sacroiliac arthrodesis, 12 patients had implantation of an autograft for sacroiliac arthrodesis, and 17 patients underwent hip transposition. There were 9 hindquarter amputations, 6 implantations of allograft and total hip endoprosthesis, 1 implantation of prosthesis with autograft, and 1 implantation of allograft and autograft. No skeletal reconstruction was done in 35 patients.Results Postoperative function was as follows: 37% in patients with prosthesis, 60% in allograft, 66% in autograft, 66% in hip transposition, 37% in amputation, and 79% without reconstruction. In total, 10/16 patients with prosthetic replacement, 9/13 with allograft implantation, 4/12 with autograft implantation, 7/17 with hip transposition, 5/9 with amputation, 6/6 with prosthesis and allograft, and 12/35 without skeletal reconstruction had complications. Frequent complications depending on the reconstruction were infection in 6/10 prostheses and in 5/13 allografts, leg length discrepancy in 2/12 autografts and 4/17 hip transpositions, hematoma in 3/9 amputations, and infection (6) and skin problems (5) in 6 prostheses with allograft.Conclusion Because of the small number of complications and good function, autograft implantation after iliac resection and hip transposition after acetabular resection are advisable.     

Myocutaneous flap reconstruction of the pelvis after abdominoperineal excision

Objective  Perineal wound complications after abdominoperineal excision (APE) for anorectal cancer represent a considerable source of morbidity for patients. Strategies to improve wound healing include reconstruction with myocutaneous flaps. This is an evidence-based review of reconstruction of pelvic defects after APE, using rectus abdominus (RAM), gracilis and gluteus maximus flaps.
Method  A Pubmed search was performed using MESH headings.
Results  Thirty-six studies reported outcomes of interest. Five controlled studies reported improved outcomes after APE and chemoradiotherapy with RAM reconstruction and two controlled studies reported improved outcomes with gracilis reconstruction. There were seven patients with total flap loss after RAM reconstruction, in a combined 300 patients. There were eight patients with complete cutaneous necrosis after gracilis reconstruction in a combined 83 patients.
Conclusion  Data from the controlled studies support the use of myocutaneous flaps for single-stage reconstruction after APE in the presence of chemoradiotherapy. Ultimately, the choice of flap depends on the goals of reconstruction, size of the defect and the availability of donor tissue. The implications of an expanding role for radiotherapy in the treatment of low rectal cancer and radical dissection to achieve negative circumferential margins, necessitate close co-operation between colorectal and reconstructive surgeons to achieve APE with reduced wound morbidity.     

Finite element analysis of the pelvis after modular hemipelvic endoprosthesis reconstruction

Purpose

The aim of this study was to investigate the biomechanics of the pelvis reconstructed with a modular hemipelvic prosthesis using finite element (FE) analysis.

Methods

A three-dimensional FE model of the postoperative pelvis was developed and input into the Abaqus FEA software version 6.7.1. Mesh refinement tests were then performed and a force of 500 N was applied at the lamina terminalis of the fifth lumbar vertebra along the longitudinal axis of the normal pelvis and the postoperative pelvis for three positions: sitting, standing on two feet, and standing on the foot of the affected side. Stress distribution analysis was performed between the normal pelvis and postoperative pelvis at these three static positions.

Results

In the normal pelvis, stress distribution was concentrated on the superior area of the acetabulum, arcuate line, sacroiliac joint, sacral midline and, in particular, the superior area of the greater sciatic notch. In the affected postoperative hemipelvis, stress distribution was concentrated on the proximal area of the pubic plate, the top of the acetabular cup, the connection between the CS-fixator and acetabular cup and the fixation between the prosthesis and sacroiliac joint.

Conclusions

Stress distribution of the postoperative pelvis was similar to the normal pelvis at three different static positions. Reconstruction with a modular hemipelvic prosthesis yielded good biomechanical characteristics.     

病灶刮除骨水泥充填术治疗骨盆四肢转移性骨肿瘤

目的 评价骨水泥病灶充填术治疗骨盆四肢转移性骨肿瘤的疗效和适应证。方法 52例骨盆四肢转移性肿瘤患者,34例采用肿瘤刮除加骨水泥病灶充填或加内固定治疗,18例采用植骨或截肢治疗。术后随访生存时间、疼痛改善程度和生存质量。结果 随访5～62个月,术后1、2、3年生存率骨水泥组分别为91．2％、82．4％、52．9％,非骨水泥组分别为44．4％、22．2％、11．1％。术后1个月疼痛改善有效率骨水泥组为88．2％,非骨水泥组为33．3％。术后生存质量提高和稳定率骨水泥组为76．5％,非骨水泥组为33．3％。经x^2检验两组差异有显著性（P〈0．05）。结论 骨水泥病灶充填治疗骨盆四肢转移性骨肿瘤能提高生存时间,改善生活质量。     

髂骨钉在腰骶骨盆重建中的临床应用

目的:观察髂骨钉在腰骶骨盆重建中的临床应用效果。方法:2004年1月至2010年2月,收治10例患者,其中L5S1椎体结核5例,骶骨骨巨细胞瘤2例,重度骨质疏松合并腰骶椎滑脱3例;男4例,女6例;年龄25～75岁,平均46.5岁。术前主要表现腰痛,腰部活动受限及排便困难等,应用髂骨钉及腰骶椎弓根钉技术进行腰骶骨盆重建,疗效评定采用Nakai评分标准,骨性融合情况采用Suk标准判断。结果:所有患者手术顺利,术中无大血管损伤,术后均按时拆线,手术切口Ⅰ期愈合。均获得随访,时间18～36个月,平均24个月。术后无双下肢感觉、运动减退,无脊髓损伤加重等并发症,均恢复正常负重及行走。按Nakai评定标准:优7例,良2例,中1例。植骨全部骨性融合,融合时间平均为3.5个月。结论:通过髂骨钉的应用使腰椎与骨盆间达到坚强的内固定,有效的解决了因腰骶部病变需要固定的难题。具有出血量及手术时间明显减少等优点,是较为理想的手术方法。     

Three-dimensional reconstruction of the scoliotic spine and pelvis from uncalibrated biplanar x-ray images

Current three-dimensional (3D) reconstruction methods based on explicit or implicit calibration procedure require a calibration object to generate calibrated x-rays for the 3D reconstruction of the human spine and the pelvis. However, to conduct retrospective studies where no 3D technology is available, 3D reconstruction must be performed from x-ray images where no calibration object was used. The current state of the art offers a variety of methods to obtain a personalized 3D model of a patient's spine, however, none have presented a clinically proven method which allows a 3D reconstruction using uncalibrated x-rays. The main objective of this study was to propose a self-calibration method using only the anatomic content of the x-ray images and evaluate its clinical feasibility on uncalibrated x-ray images for the 3D reconstruction of the scoliotic spine and pelvis. The rationale for proposing a 3D reconstruction method from uncalibrated x-rays is to allow access to 3D evaluation of spinal deformities in any standard clinical setup and to enable the conduct of retrospective studies of any kind. To assess the validity of the 3D reconstructions yielded by the proposed algorithm, a clinical study using 60 pairs of digitized x-rays of children was conducted. The mean age for this group of 60 patients was of 14+/-3 (range 8 to 18) years old. All the children in the study group had scoliosis, with an average Cobb angle on the frontal plane of 25 degrees (range 3 to 70 degrees). For each case, a 3D reconstruction of the spine and pelvis was obtained using both explicit and self-calibration methods, from calibrated and uncalibrated x-rays, respectively. Results show that 3D reconstructions obtained with the proposed method from uncalibrated x-ray images yield- geometrical models that exhibit insignificant differences for 2D and 3D clinical indices commonly used in the evaluation of spinal deformities. This allows a 3D clinical assessment of scoliotic deformities from standard x-rays without the need for calibration, and providing access to this technology in any clinical setup and allowing to perform retrospective studies, which were previously impossible.     

Vastus lateralis myocutaneous flap for reconstruction of defects around the groin and pelvis

We present our experience using the vastus lateralis myocutaneous flap for the repair of defects around the groin and pelvis. It is a relatively new technique, with many advantages over other flaps used in this area, though it has limitations. The history, anatomy and surgical technique of raising the flap are described and clinical cases are discussed. The importance of patient selection is highlighted.     

„To Pouch or not to Pouch“

Ohne Zusammenfassung     

Successful surgical reconstruction of ruptured renal pelvis following blunt abdominal trauma

A 25-year-old man with occult ureteropelvic obstruction presented with abdominal pain 3 h following blunt abdominal trauma. Isolated rupture of the right renal pelvis was promptly diagnosed and the patient underwent immediate pyeloplasty according to the Anderson-Hynes procedure. The patient made an uneventful recovery. One year after surgery, renal function was satisfactory.     

Resection of a peri-acetabular chondrosarcoma and reconstruction of the pelvis. A case report

We report a patient with a peri-acetabular chondrosarcoma which was treated by resection of part of the pelvis and the femoral head. This was followed by replacement with a custom-made titanium alloy pelvic portion and a conventional total hip prosthesis. The operation was carried out in two stages, and yielded a good functional and cosmetic result.