- Email: [email protected]
A Simplified Method for Detubularization in the Construction of a Continent Ileocolic Reservoir (Miami Pouch)
GYNECOLOGIC ONCOLOGY ARTICLE NO.
64, 436–441 (1997)
GO964601
A Simplified Method for Detubularization in the Construction of a Continent Ileocolic Reservoir (Miami Pouch) JONATHAN A. COSIN, JONATHAN R. CARTER, PAMELA PALEY, M. DWIGHT CHEN, PETER JOHNSON, JEFFREY M. FOWLER, LEO B. TWIGGS, AND LINDA F. CARSON Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Women’s Cancer Center, University of Minnesota, Minneapolis, Minnesota 55455 Received April 1, 1996
METHODS AND RESULTS The development of continent urinary diversions was an important step forward in improving the quality of life of patients undergoing pelvic exenteration. While the technique is relatively simple, it can be very time-consuming and uses a significant portion of the patient’s colon in its construction. Here a modification of the technique for construction of a continent ileocolic reservoir which results in a similar reservoir that uses less colon and requires less time to construct is presented. We also report results of the use of this technique in seven patients. q 1997 Academic Press
INTRODUCTION
Despite recent advances in the early detection and treatment of cervical cancer, the management of recurrent cervical cancer continues to be challenging [1]. Pelvic exenteration remains the mainstay of curative treatment for patients with central recurrent disease. While the exenterative phase of the procedure has changed little over the years, there have been significant advances in the techniques employed during the reconstructive phase of the procedure [2]. With all the advances, consideration is given to both improvement in the patient’s quality of life and the ease of surgical technique and decrease in the operative time. One of the more important developments has been the continent urinary reservoir. Two types are chiefly in use at present, the continent ileal urostomy (Koch pouch) [3] and the continent ileocolic reservoir (Miami and Indiana Pouches) [4, 5]. The Miami pouch has been the primary type of continent reservoir used at the University of Minnesota. There have been several reports of the construction of urinary reservoirs using linear staplers in both the gynecologic and urologic literature [6, 7]. Here a modification of the technique for constructing the Miami pouch using a GIA instrument for detubularization which uses less colon and results in an equivalent pouch with a significant savings in operative time is presented.
436
0090-8258/97 $25.00 Copyright q 1997 by Academic Press All rights of reproduction in any form reserved.
AID
Gyn 4601
/
6d18$$$$$1
Between June 1993 and September 1995, seven patients underwent construction of a continent ileocolic reservoir at the University of Minnesota Hospitals and Clinics using this technique. Patient characteristics and indications for the procedure are summarized in Table 1. All patients underwent mechanical and antibiotic bowel preparations prior to surgery. The initial portion of the construction of the reservoir is as originally described by Penalver et al. [4]. Ten centimeters of distal ileum and the ascending and the proximal transverse colon is isolated and mobilized. In the original description by Penalver as well as in our early experience, the transverse colon was always interrupted distal to the middle colic artery [4, 5]. Our modification uses 32 cm of colon, which corresponds to four lengths of a GIA-80 stapler (U.S. Surgical Corp., Norwalk, CT). This has always resulted in the division of the transverse colon proximal to the middle colic artery, thus preserving an important blood supply to the colon. An ileotransverse enterocolostomy is performed in the standard fashion to restore bowel continuity. The appendix is removed at this time if it is present. The tenia of the colon are then skeletonized and defatted. The colon is then folded on itself in a ‘‘U’’ configuration, bringing the transected end of the transverse colon in approximation to the cecum (Fig. 1). Two interrupted stay sutures are used to maintain alignment of the colon. Electrocautery is then used to make two small colotomies (2–4 cm) in the center of each segment of colon. The PolyGIA device is then used to detubularize the colon. Each arm is passed into adjacent colon segments toward one end of the reservoir (Figs. 2 and 3). Once the stapler is articulated and fired, a common lumen is created with two rows of absorbable staples on each side of the incision line created by the knife within the instrument. A second instrument is then fired from this same point toward the opposite end of the reservoir, thus completing the
01-31-97 23:54:47
goas
AP: GYN
SIMPLIFIED DETUBULARIZATION OF CONTINENT POUCHES
437
TABLE 1 Patient
Age
Diagnosis
Indication for procedure
M.L. A.M.D. A.A.D. L.M. M.V.N. F.W. C.W.
82 70 54 60 51 72 48
Vaginal CA Post-RT vaginal cancer Recurrent cervical cancer Post-RT MMT of uterus Cervical cancer Persistent cervical cancer Recurrent cervical cancer
Part of total pelvic exenteration Part of anterior pelvic exenteration Part of total pelvic exenteration Vesicovaginal fistula due to recurrent tumor Vesicovaginal fistula due to radiation Part of anterior pelvic exenteration Part of total pelvic exenteration
Note. SCCA, squamous cell carcinoma; RT, radiation therapy; MMT, mixed mu¨llerian tumor.
detubularization process. It has not been necessary to place reinforcing sutures along the staple lines. Working through the unified colotomy in the center of the pouch, the ureters are then anastamosed to the pouch and the continence mechanism is constructed as has been previously described [4]. The method of ureteral anastamosis has been varied among physicians. In general, the ureters were not tunneled, but simply spatulated and anastamosed with mucosa to mucosa interrupted 4-O delayed absorbable sutures.
FIG. 1.
AID
Gyn 4601
/
Externally, the serosa of the bowel and the adventitia of the ureters are sutured together in a similar fashion. The colotomy is then closed using absorbable staples, which requires only a single additional firing of the instrument. The resulting pouch is anatomically identical to the pouches which we constructed using the standard technique. Single J ureteral stents and intraabdominal closed suction drains were placed in all patients. We no longer use a Malecot catheter as described by Penalver et al. [4], but instead
The proximal colon is folded on itself in a U configuration in preparation for detubularization.
6d18$$$$$1
01-31-97 23:54:47
goas
AP: GYN
438
COSIN ET AL.
FIG. 2.
The PolyGIA stapling device is shown overlying one end of the pouch. The terminal ileum can be seen at the far right.
use an 18-French triple lumen foley catheter which is exteriorized along with the ureteral stents via the ileostomy. Standard postoperative care was performed which included the use of regular pouch irrigation to prevent mucus accumulation. Of the seven patients who underwent the procedure, none had any operative complications. One patient experienced an increase in output of urine from an intraabdominal drain positioned behind the pouch on Postoperative Day 9. The drain was adjacent to the site of the ureteropouch anastamosis site and this was presumed to be the source of the increased output. The leak resolved with the use of continuous pouch drainage and a contrast study of the reservoir on Postoperative Day 30 was normal. Each patient had a contrast study performed between 2 and 6 weeks after the procedure which demonstrated all pouches to be free of leaks and able to hold at least 400 to 500 cc of contrast (Fig. 4). Two patients developed delayed ureteral strictures requiring prolonged stenting in one patient and ureteral reimplantation in the other. At the time of laparotomy, both ureters were noted to be stenotic, the result of inflammation from an adjacent infected lymphocyst. All patients were continent at
AID
Gyn 4601
/
6d18$$$$$2
01-31-97 23:54:47
last follow-up (mean 12.7 months, range 5 to 31) and able to self-catheterize with an interval of between 6 and 8 hr. Four patients are alive without evidence of disease, one is alive with persistent disease, one is dead of recurrent disease, and one is dead of intercurrent disease. DISCUSSION
The benefits of a continent urinary reservoir are well known [2–8]. The key to the construction of a successful reservoir from colon is the detubularization of the intestinal segment used. This interferes with the peristaltic action of the bowel and prevents the resultant intermittent pressure spikes. The previously described method for detubularization involves isolating a segment of colon up to and distal to the middle colic artery. The colon is then opened along the tenia using the cautery and folded into a U, and the legs of the U are anastamosed using absorbable staples [4]. This process often involves additional suturing to seal the leaks in the conduit that often occur between successive staple lines. The advantages of our method include a much faster detu-
goas
AP: GYN
SIMPLIFIED DETUBULARIZATION OF CONTINENT POUCHES
439
FIG. 3. (A and B) The PolyGIA device is inserted through the colotomy incisions toward the end of the reservoir with one arm in each limb of the folded colon, articulated, and fired, thus detubularizing one half of the reservoir. (A) Detubularization of the cecal end of the pouch. (B) Intraoperative photograph of the detubularization process.
bularization technique, necessitating only two firings of the stapler. Firing the stapler from the center of the pouch toward each end ensures that there are no successive staple lines used and there is therefore no possibility of leaks occurring in gaps between adjacent staple lines. A further advantage is that because the staple lines do not require oversewing, a smaller amount of bowel is taken up in the seam and therefore a shorter segment of colon can be used which still yields a reservoir of similar capacity. The use of absorbable staples
AID
Gyn 4601
/
6d18$$$$$2
01-31-97 23:54:47
significantly decreases the risk of postoperative stone formation [9]. While it is difficult to retrospectively separate the time required to perform the construction of a continent reservoir from the rest of the operative procedure, it is clear that our method involves fewer steps. The entire detubularization process takes approximately 10 min to complete. This is important since previously published data demonstrate a decrease in morbidity and mortality from pelvic exenteration
goas
AP: GYN
440
COSIN ET AL.
FIG. 4.
Contrast study of L.M.’s reservoir on Postoperative Day 18. Approximately 400 cc of contrast material is seen within the pouch.
with decreasing operative times [10]. We believe that in patients who are suitable for a continent urinary reservoir, this modified technique results in a similar reservoir with a significant time saving and allows the use of a smaller segment of colon. REFERENCES 1. DiSaia PJ, Creaseman WT: Clinical Gynecologic Oncology, 4th ed. St. Louis, MO, Mosby Year Book, 1993
AID
Gyn 4601
/
6d18$$$$$2
01-31-97 23:54:47
2. Wheeless CR, Jr: Recent advances in surgical reconstruction of the gynecologic cancer patient. Curr Opin Obstet Gynecol 4:91–101, 1992 3. Kock NG, Nilson AE, Nilsson LO, Nolan LJ, Philipsom BM: Urinary diversion via continent ileal reservoir: clinical results in 12 patients. J Urol 128(3):469–475, 1982 4. Penalver MA, Darwich EB, Averette HE, Donato DM, Sevin BU, Suarez G: Continent urinary diversion in gynecologic oncology. Gynecol Oncol 34:274–288, 1989 5. Rowland RG, Mitchell ME, Bihrle R, Kahnoski RJ, Piser JE: Indiana continent urinary reservoir. J Urol 137:1136–1139, 1987 6. Parra RO, Cummings JM, Boullier JA: Simple detubularization tech-
goas
AP: GYN
SIMPLIFIED DETUBULARIZATION OF CONTINENT POUCHES nique for construction of continent colonic reservoirs. Urology 44(1):35–37, 1994 7. Dottino PR, Segna RA, Jennings TS, Beddoe M, Cohen CJ: The stapled continent ileocecal urinary reservoir in the surgical management of gynecologic malignancy. Gynecol Oncol 55:185–189, 1994 8. Hartenbach EM, Saltzman AK, Carter JR, Fowler JM, Hunter DW, Carlson JW, Twiggs LB, Carson LF: Nonsurgical management strate-
AID
Gyn 4601
/
6d18$$$$$2
01-31-97 23:54:47
441
gies for the functional complications of ileocolonic continent urinary reservoirs. Gynecol Oncol 56:127–128, 1995 9. Hadda FS, Campbell OP: Lithiasis in the ileal conduit and the continent urinary pouch: two cases and a review. Urol Int 49:114–118, 1992 10. Ketcham AS, Deckers PJ, Sugarbush EV, Hoye RC, Thomas LB, Smith RR: Pelvic exenteration for carcinoma of the uterine cervix: A 15-year experience. Cancer 26(3):513–531, 1970
goas
AP: GYN
64, 436–441 (1997)
GO964601
A Simplified Method for Detubularization in the Construction of a Continent Ileocolic Reservoir (Miami Pouch) JONATHAN A. COSIN, JONATHAN R. CARTER, PAMELA PALEY, M. DWIGHT CHEN, PETER JOHNSON, JEFFREY M. FOWLER, LEO B. TWIGGS, AND LINDA F. CARSON Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Women’s Cancer Center, University of Minnesota, Minneapolis, Minnesota 55455 Received April 1, 1996
METHODS AND RESULTS The development of continent urinary diversions was an important step forward in improving the quality of life of patients undergoing pelvic exenteration. While the technique is relatively simple, it can be very time-consuming and uses a significant portion of the patient’s colon in its construction. Here a modification of the technique for construction of a continent ileocolic reservoir which results in a similar reservoir that uses less colon and requires less time to construct is presented. We also report results of the use of this technique in seven patients. q 1997 Academic Press
INTRODUCTION
Despite recent advances in the early detection and treatment of cervical cancer, the management of recurrent cervical cancer continues to be challenging [1]. Pelvic exenteration remains the mainstay of curative treatment for patients with central recurrent disease. While the exenterative phase of the procedure has changed little over the years, there have been significant advances in the techniques employed during the reconstructive phase of the procedure [2]. With all the advances, consideration is given to both improvement in the patient’s quality of life and the ease of surgical technique and decrease in the operative time. One of the more important developments has been the continent urinary reservoir. Two types are chiefly in use at present, the continent ileal urostomy (Koch pouch) [3] and the continent ileocolic reservoir (Miami and Indiana Pouches) [4, 5]. The Miami pouch has been the primary type of continent reservoir used at the University of Minnesota. There have been several reports of the construction of urinary reservoirs using linear staplers in both the gynecologic and urologic literature [6, 7]. Here a modification of the technique for constructing the Miami pouch using a GIA instrument for detubularization which uses less colon and results in an equivalent pouch with a significant savings in operative time is presented.
436
0090-8258/97 $25.00 Copyright q 1997 by Academic Press All rights of reproduction in any form reserved.
AID
Gyn 4601
/
6d18$$$$$1
Between June 1993 and September 1995, seven patients underwent construction of a continent ileocolic reservoir at the University of Minnesota Hospitals and Clinics using this technique. Patient characteristics and indications for the procedure are summarized in Table 1. All patients underwent mechanical and antibiotic bowel preparations prior to surgery. The initial portion of the construction of the reservoir is as originally described by Penalver et al. [4]. Ten centimeters of distal ileum and the ascending and the proximal transverse colon is isolated and mobilized. In the original description by Penalver as well as in our early experience, the transverse colon was always interrupted distal to the middle colic artery [4, 5]. Our modification uses 32 cm of colon, which corresponds to four lengths of a GIA-80 stapler (U.S. Surgical Corp., Norwalk, CT). This has always resulted in the division of the transverse colon proximal to the middle colic artery, thus preserving an important blood supply to the colon. An ileotransverse enterocolostomy is performed in the standard fashion to restore bowel continuity. The appendix is removed at this time if it is present. The tenia of the colon are then skeletonized and defatted. The colon is then folded on itself in a ‘‘U’’ configuration, bringing the transected end of the transverse colon in approximation to the cecum (Fig. 1). Two interrupted stay sutures are used to maintain alignment of the colon. Electrocautery is then used to make two small colotomies (2–4 cm) in the center of each segment of colon. The PolyGIA device is then used to detubularize the colon. Each arm is passed into adjacent colon segments toward one end of the reservoir (Figs. 2 and 3). Once the stapler is articulated and fired, a common lumen is created with two rows of absorbable staples on each side of the incision line created by the knife within the instrument. A second instrument is then fired from this same point toward the opposite end of the reservoir, thus completing the
01-31-97 23:54:47
goas
AP: GYN
SIMPLIFIED DETUBULARIZATION OF CONTINENT POUCHES
437
TABLE 1 Patient
Age
Diagnosis
Indication for procedure
M.L. A.M.D. A.A.D. L.M. M.V.N. F.W. C.W.
82 70 54 60 51 72 48
Vaginal CA Post-RT vaginal cancer Recurrent cervical cancer Post-RT MMT of uterus Cervical cancer Persistent cervical cancer Recurrent cervical cancer
Part of total pelvic exenteration Part of anterior pelvic exenteration Part of total pelvic exenteration Vesicovaginal fistula due to recurrent tumor Vesicovaginal fistula due to radiation Part of anterior pelvic exenteration Part of total pelvic exenteration
Note. SCCA, squamous cell carcinoma; RT, radiation therapy; MMT, mixed mu¨llerian tumor.
detubularization process. It has not been necessary to place reinforcing sutures along the staple lines. Working through the unified colotomy in the center of the pouch, the ureters are then anastamosed to the pouch and the continence mechanism is constructed as has been previously described [4]. The method of ureteral anastamosis has been varied among physicians. In general, the ureters were not tunneled, but simply spatulated and anastamosed with mucosa to mucosa interrupted 4-O delayed absorbable sutures.
FIG. 1.
AID
Gyn 4601
/
Externally, the serosa of the bowel and the adventitia of the ureters are sutured together in a similar fashion. The colotomy is then closed using absorbable staples, which requires only a single additional firing of the instrument. The resulting pouch is anatomically identical to the pouches which we constructed using the standard technique. Single J ureteral stents and intraabdominal closed suction drains were placed in all patients. We no longer use a Malecot catheter as described by Penalver et al. [4], but instead
The proximal colon is folded on itself in a U configuration in preparation for detubularization.
6d18$$$$$1
01-31-97 23:54:47
goas
AP: GYN
438
COSIN ET AL.
FIG. 2.
The PolyGIA stapling device is shown overlying one end of the pouch. The terminal ileum can be seen at the far right.
use an 18-French triple lumen foley catheter which is exteriorized along with the ureteral stents via the ileostomy. Standard postoperative care was performed which included the use of regular pouch irrigation to prevent mucus accumulation. Of the seven patients who underwent the procedure, none had any operative complications. One patient experienced an increase in output of urine from an intraabdominal drain positioned behind the pouch on Postoperative Day 9. The drain was adjacent to the site of the ureteropouch anastamosis site and this was presumed to be the source of the increased output. The leak resolved with the use of continuous pouch drainage and a contrast study of the reservoir on Postoperative Day 30 was normal. Each patient had a contrast study performed between 2 and 6 weeks after the procedure which demonstrated all pouches to be free of leaks and able to hold at least 400 to 500 cc of contrast (Fig. 4). Two patients developed delayed ureteral strictures requiring prolonged stenting in one patient and ureteral reimplantation in the other. At the time of laparotomy, both ureters were noted to be stenotic, the result of inflammation from an adjacent infected lymphocyst. All patients were continent at
AID
Gyn 4601
/
6d18$$$$$2
01-31-97 23:54:47
last follow-up (mean 12.7 months, range 5 to 31) and able to self-catheterize with an interval of between 6 and 8 hr. Four patients are alive without evidence of disease, one is alive with persistent disease, one is dead of recurrent disease, and one is dead of intercurrent disease. DISCUSSION
The benefits of a continent urinary reservoir are well known [2–8]. The key to the construction of a successful reservoir from colon is the detubularization of the intestinal segment used. This interferes with the peristaltic action of the bowel and prevents the resultant intermittent pressure spikes. The previously described method for detubularization involves isolating a segment of colon up to and distal to the middle colic artery. The colon is then opened along the tenia using the cautery and folded into a U, and the legs of the U are anastamosed using absorbable staples [4]. This process often involves additional suturing to seal the leaks in the conduit that often occur between successive staple lines. The advantages of our method include a much faster detu-
goas
AP: GYN
SIMPLIFIED DETUBULARIZATION OF CONTINENT POUCHES
439
FIG. 3. (A and B) The PolyGIA device is inserted through the colotomy incisions toward the end of the reservoir with one arm in each limb of the folded colon, articulated, and fired, thus detubularizing one half of the reservoir. (A) Detubularization of the cecal end of the pouch. (B) Intraoperative photograph of the detubularization process.
bularization technique, necessitating only two firings of the stapler. Firing the stapler from the center of the pouch toward each end ensures that there are no successive staple lines used and there is therefore no possibility of leaks occurring in gaps between adjacent staple lines. A further advantage is that because the staple lines do not require oversewing, a smaller amount of bowel is taken up in the seam and therefore a shorter segment of colon can be used which still yields a reservoir of similar capacity. The use of absorbable staples
AID
Gyn 4601
/
6d18$$$$$2
01-31-97 23:54:47
significantly decreases the risk of postoperative stone formation [9]. While it is difficult to retrospectively separate the time required to perform the construction of a continent reservoir from the rest of the operative procedure, it is clear that our method involves fewer steps. The entire detubularization process takes approximately 10 min to complete. This is important since previously published data demonstrate a decrease in morbidity and mortality from pelvic exenteration
goas
AP: GYN
440
COSIN ET AL.
FIG. 4.
Contrast study of L.M.’s reservoir on Postoperative Day 18. Approximately 400 cc of contrast material is seen within the pouch.
with decreasing operative times [10]. We believe that in patients who are suitable for a continent urinary reservoir, this modified technique results in a similar reservoir with a significant time saving and allows the use of a smaller segment of colon. REFERENCES 1. DiSaia PJ, Creaseman WT: Clinical Gynecologic Oncology, 4th ed. St. Louis, MO, Mosby Year Book, 1993
AID
Gyn 4601
/
6d18$$$$$2
01-31-97 23:54:47
2. Wheeless CR, Jr: Recent advances in surgical reconstruction of the gynecologic cancer patient. Curr Opin Obstet Gynecol 4:91–101, 1992 3. Kock NG, Nilson AE, Nilsson LO, Nolan LJ, Philipsom BM: Urinary diversion via continent ileal reservoir: clinical results in 12 patients. J Urol 128(3):469–475, 1982 4. Penalver MA, Darwich EB, Averette HE, Donato DM, Sevin BU, Suarez G: Continent urinary diversion in gynecologic oncology. Gynecol Oncol 34:274–288, 1989 5. Rowland RG, Mitchell ME, Bihrle R, Kahnoski RJ, Piser JE: Indiana continent urinary reservoir. J Urol 137:1136–1139, 1987 6. Parra RO, Cummings JM, Boullier JA: Simple detubularization tech-
goas
AP: GYN
SIMPLIFIED DETUBULARIZATION OF CONTINENT POUCHES nique for construction of continent colonic reservoirs. Urology 44(1):35–37, 1994 7. Dottino PR, Segna RA, Jennings TS, Beddoe M, Cohen CJ: The stapled continent ileocecal urinary reservoir in the surgical management of gynecologic malignancy. Gynecol Oncol 55:185–189, 1994 8. Hartenbach EM, Saltzman AK, Carter JR, Fowler JM, Hunter DW, Carlson JW, Twiggs LB, Carson LF: Nonsurgical management strate-
AID
Gyn 4601
/
6d18$$$$$2
01-31-97 23:54:47
441
gies for the functional complications of ileocolonic continent urinary reservoirs. Gynecol Oncol 56:127–128, 1995 9. Hadda FS, Campbell OP: Lithiasis in the ileal conduit and the continent urinary pouch: two cases and a review. Urol Int 49:114–118, 1992 10. Ketcham AS, Deckers PJ, Sugarbush EV, Hoye RC, Thomas LB, Smith RR: Pelvic exenteration for carcinoma of the uterine cervix: A 15-year experience. Cancer 26(3):513–531, 1970
goas
AP: GYN