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Complication with mechanical stapling device in creation of ileoconduit
COMPLICATION
WITH MECHANICAL
DEVICE IN CREATION
STUART HENRY NASSER
hl. BERGMAX. F. SEARS,
OF ILEOCONDUIT
M.D.
M.D.
JAVADPOUR.
From the Surgery National Institutes
STAPLING
\I.D.
Branch, National Cancer Institilte, of Health, Bethesda, Maryland
Autosuturt, Lvith stapling devices has 1~3211 gaining popularity for creating gastrointestinal anastomosis since its adaptation h,; Ravitch alrd RilmoIa in 1966. ’ Stapling devices ha\.e also l,tlen iised to c:reate the proximal end of ileal conduits.’ Thc~rc~ is an increased risk of c&wIi dc7~eIoping in the urinal-Jr tracts of patients M’ith ilthal cw~clllit ilrinar). diversion, and it is well known that fbreign bodies even in a norn~al urinary tract ~nay be calcmlogenic. The combination of a foreign My in an almornial iirinaq tract could incrr*ase the likelihood of calculous t~mnation arountl the foreign body. Dretler” re2 cases of formation of calculi in ileal ported conduits. one OI-J a piece of silk suture inaterial d another on a small piece of wood. Stainless an sttkel staples cm also serve as a nidus for c&uIOILS formation. Formation of caIculi aromd the stainless steel staples has been reported in 2 patients with ileal conduits.’ \vr have utilized the autostapling device to create ileal cwnduits on 2 patients undergoing prl\.ic exenteration for carcinoma of the w1Tix. OII~ died within several months I)ecausc’ of tlilnor rwurrenc’e. The second patient Iwgan passing ileal loop stones containing staples one \‘ear after creation of the ileal conduit. \Vt, reiwrt on this 1 patient and briefly review the es-
perience of the biational with urinal->. tract calcwli wncluit ilrinar\. diversion.
Illstitiite5 in patitw
of Health ts ,u-ith ilml
Carcinoma of the uterine cervix \\.hich ~1as treated Lvith radiation the-rap!. de\~elrq)c~cl in tliis sixtv-one-veal--old Caucasian woi~ian at age forti,-five. -The tremor recurr(~d ten years late1 (age fifty-fi\~c) at which time shy Iindl-r-went a total abdominaI hysterectomy Foilr !-CW.S later [age fifty-nine>) the tumor reciIrrc~c1 again at whit+ time she was referred to the National Institutes of Health where sh(: undrrw~nt total pelvic exenteration with creation of ,.III iltaal iirinar)- conduit. The intestinal anastomosi:, and tlrc proximal end of the ileal loop wt‘rtb uwtr~cl \vitll the GIL4 and the TA stapling cIe\i~es”’ md wew o\w-sewn with a supporting Ia)rer of in\rrrtilrg was invading the I~lacld~~r sut111-es. Thcl tumor ant1 rectum, hut all regional lyllph i io~les were free of metastasis on histologic: esaminatio~~. The patient suI~sryuently ~vas tronI)lecl with progressi\~e I~)-clrone~~lirosis, Esc*lir~rit~liia coli
FIGURE 1. Ikal loop calculus ize encased surgical staple.
hemisected
to uisual-
l)acteriuria, and persistent pyuria despite treatment with methenamine (Mandelamine) and ascorbic acid. This problem was attributed to ileostomy stenosis, and she underwent stoma1 revision at age sixty-one. Her creatinine remained normal, 1 mg./lOO ml., but she continued to have a loop residual of 100 cc. with a mild loop stenosis at the level of the fascia. Recently she reports having passed five small stones from her ileal loop, several stones contained staples partially visible at the surface (Fig. 1). Her urine culture at this time grew Proteus mirahilis which then changed to Pseudomonas aeruginosa on penicillin and gentamicin therapy. Stone analysis revealed magnesium ammonium phosphate and carbonate
. . .
8-
36 . .
32
-120
28
-110 ii P ; ;
24 $~lCQ
20
-90
16
Ca
PHOS
URIC ACID
apatite. Several months prior to passing these stones her serum calcium was 4.9 mEq., phosphorus 3.1 mEq., carbon dioxide 23 mEg., and chloride 106 mEq. per liter; blood urea nitrogen was 16 mg. and creatinine 1.2 mg.1100 ml. Comment
7-
.
FIGURE 3. Excretory urogram of patient with 4 by 7 mm. left ureteral calculus which passed within twenty-four hour,s.
CHLORIDES
CO?
FIGURE 2. Postoperative .scrum calcium, pho.sphate, uric acid, chlorides, and carbon dioxide in 14 patients with ileoconduit urinury dioersion and urinary tract calculi. .Yormal ualucs in shaded area.
From 1953 to 1973 there have been 296 ileal urinary conduits created in patients with pelvic malignancies at the Clinical Center of the National Institutes of Health. Of these 296 patients ureteral and renal calculi developed in 13 after urinary diversion. Of the 2 patients who had the proximal end of their ileal loop closed with staples, calculi in the ileal loop developed in one (see case report). As expected all 14 patients had chronic urinary tract infection kvith various organisms, mostly Proteus, E. coli, and Pseudomonas. A low to borderline low carbon dioxide reflecting a mild metabolic acidosis is the only abnormality seen in a majority of these patients, and even this is not seen in all in whom stones developed. The metabolic status of these 14 patients is summarized in Figure 2. The over-all rate of stone formation of 4.7 per cent in our patient population of 296 is in close agreement with that found by Dretlel-” of 4.8
pernts with rt~nill or urrteral calculi. 0fIe ~ac,ulrls passt‘d sJ)o~lt~~~l~ollsl\i, with ten recllking I)).elolithotolrl~, Thv c&ulus that passed measIIIWI 3 Ix 7 mi11. (Fig. :3). <:aIcuIi of this dimrnsion orclinaril! do not pass spontanc~ollsl!. in patients \vith iiorinaI urinq~ tracts. I-Io\vc>\vr. patients \I-ith iI,A umduits tend to ha\~c~ dilated colIc~c+ing s>,stelns and three of the four sites of‘ c~al~~~lous impaction (pelvic brim. uretvro\~esicxI jltliction, and ureteral orifice) have hen c~limicalcllli which ordinaril!, Ilated. Therefore. rrquire c\zstoscopic manipulation or kiret~~rolithotorn! ma)’ pass spontaneouslyitI patients with ilrwconduits. Thta associated problenx of residlul urine in the condiiit. nletalmlic xidosis, and chronic urinary tract infection for this series of l-1 patients w’yrv found to he in agreement with those found 1)~ others and 1iaL.e been extrnsi\,el) it should he stressed discllsscd. ‘-“’ EIowever. that the wnil)inatioii of chronic nit~taholic ac*idosis with the mobilization and increased e\;cretion of calcium and phosphate frown hone combined \vith chronic urinary tract infection and stasis in the loop is a pwfef’c’t rn\irollrntmt for c~alc111011s fiwmation. Adding to this milietl
WITH MECHANICAL
DEVICE IN CREATION
STUART HENRY NASSER
hl. BERGMAX. F. SEARS,
OF ILEOCONDUIT
M.D.
M.D.
JAVADPOUR.
From the Surgery National Institutes
STAPLING
\I.D.
Branch, National Cancer Institilte, of Health, Bethesda, Maryland
Autosuturt, Lvith stapling devices has 1~3211 gaining popularity for creating gastrointestinal anastomosis since its adaptation h,; Ravitch alrd RilmoIa in 1966. ’ Stapling devices ha\.e also l,tlen iised to c:reate the proximal end of ileal conduits.’ Thc~rc~ is an increased risk of c&wIi dc7~eIoping in the urinal-Jr tracts of patients M’ith ilthal cw~clllit ilrinar). diversion, and it is well known that fbreign bodies even in a norn~al urinary tract ~nay be calcmlogenic. The combination of a foreign My in an almornial iirinaq tract could incrr*ase the likelihood of calculous t~mnation arountl the foreign body. Dretler” re2 cases of formation of calculi in ileal ported conduits. one OI-J a piece of silk suture inaterial d another on a small piece of wood. Stainless an sttkel staples cm also serve as a nidus for c&uIOILS formation. Formation of caIculi aromd the stainless steel staples has been reported in 2 patients with ileal conduits.’ \vr have utilized the autostapling device to create ileal cwnduits on 2 patients undergoing prl\.ic exenteration for carcinoma of the w1Tix. OII~ died within several months I)ecausc’ of tlilnor rwurrenc’e. The second patient Iwgan passing ileal loop stones containing staples one \‘ear after creation of the ileal conduit. \Vt, reiwrt on this 1 patient and briefly review the es-
perience of the biational with urinal->. tract calcwli wncluit ilrinar\. diversion.
Illstitiite5 in patitw
of Health ts ,u-ith ilml
Carcinoma of the uterine cervix \\.hich ~1as treated Lvith radiation the-rap!. de\~elrq)c~cl in tliis sixtv-one-veal--old Caucasian woi~ian at age forti,-five. -The tremor recurr(~d ten years late1 (age fifty-fi\~c) at which time shy Iindl-r-went a total abdominaI hysterectomy Foilr !-CW.S later [age fifty-nine>) the tumor reciIrrc~c1 again at whit+ time she was referred to the National Institutes of Health where sh(: undrrw~nt total pelvic exenteration with creation of ,.III iltaal iirinar)- conduit. The intestinal anastomosi:, and tlrc proximal end of the ileal loop wt‘rtb uwtr~cl \vitll the GIL4 and the TA stapling cIe\i~es”’ md wew o\w-sewn with a supporting Ia)rer of in\rrrtilrg was invading the I~lacld~~r sut111-es. Thcl tumor ant1 rectum, hut all regional lyllph i io~les were free of metastasis on histologic: esaminatio~~. The patient suI~sryuently ~vas tronI)lecl with progressi\~e I~)-clrone~~lirosis, Esc*lir~rit~liia coli
FIGURE 1. Ikal loop calculus ize encased surgical staple.
hemisected
to uisual-
l)acteriuria, and persistent pyuria despite treatment with methenamine (Mandelamine) and ascorbic acid. This problem was attributed to ileostomy stenosis, and she underwent stoma1 revision at age sixty-one. Her creatinine remained normal, 1 mg./lOO ml., but she continued to have a loop residual of 100 cc. with a mild loop stenosis at the level of the fascia. Recently she reports having passed five small stones from her ileal loop, several stones contained staples partially visible at the surface (Fig. 1). Her urine culture at this time grew Proteus mirahilis which then changed to Pseudomonas aeruginosa on penicillin and gentamicin therapy. Stone analysis revealed magnesium ammonium phosphate and carbonate
. . .
8-
36 . .
32
-120
28
-110 ii P ; ;
24 $~lCQ
20
-90
16
Ca
PHOS
URIC ACID
apatite. Several months prior to passing these stones her serum calcium was 4.9 mEq., phosphorus 3.1 mEq., carbon dioxide 23 mEg., and chloride 106 mEq. per liter; blood urea nitrogen was 16 mg. and creatinine 1.2 mg.1100 ml. Comment
7-
.
FIGURE 3. Excretory urogram of patient with 4 by 7 mm. left ureteral calculus which passed within twenty-four hour,s.
CHLORIDES
CO?
FIGURE 2. Postoperative .scrum calcium, pho.sphate, uric acid, chlorides, and carbon dioxide in 14 patients with ileoconduit urinury dioersion and urinary tract calculi. .Yormal ualucs in shaded area.
From 1953 to 1973 there have been 296 ileal urinary conduits created in patients with pelvic malignancies at the Clinical Center of the National Institutes of Health. Of these 296 patients ureteral and renal calculi developed in 13 after urinary diversion. Of the 2 patients who had the proximal end of their ileal loop closed with staples, calculi in the ileal loop developed in one (see case report). As expected all 14 patients had chronic urinary tract infection kvith various organisms, mostly Proteus, E. coli, and Pseudomonas. A low to borderline low carbon dioxide reflecting a mild metabolic acidosis is the only abnormality seen in a majority of these patients, and even this is not seen in all in whom stones developed. The metabolic status of these 14 patients is summarized in Figure 2. The over-all rate of stone formation of 4.7 per cent in our patient population of 296 is in close agreement with that found by Dretlel-” of 4.8
per