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The Ileocecal Segment: An Antirefluxing Colonic Conduit Form of Urinary Diversion
Symposium on Surgery at the Lahey Clinic
The Ileocecal Segment An Antirefluxing Colonic Conduit Form of Urinary Diversion
Leonard Zinman, M.D.,* and John A. Libertino, M.D.*
After two decades of experience with the freely refluxing ileal conduit, reports of a significant incidence of delayed complications from this form of diversion are beginning to accumulate. 7 , 14, 19 Stomal obstruction, excessive conduit length, and ureteroileal conduit stenosis have contributed to the upper urinary tract deterioration observed in many patients. However, comparison of short-term and long-term follow-up groups continues to reveal an increasing deterioration of the upper urinary tract in patients who initially had normal results on intravenous pyelography in the early postoperative period with no obvious source of obstruction and free unobstructed refluxing ureters. These delayed complications are being reported with greater frequency in children with neurogenic bladders in whom the incidence of stomal stenosis and prediversion upper urinary tract damage is high. 20 , 21 A review of the literature reveals a 25 per cent incidence of stomal stenosis in children, which is related to the growth rate with respect to the fixed aperture in the abdominal wall.1 6 Experimental data comparing antirefluxing colonic conduits to refluxing ileal conduits suggest that ileoureteral reflux of the infected urine may be responsible for these delayed long-term upper urinary tract complications,17 Studies of loop manometric pressures and retrograde cinefluoroscopy suggest that ureteroileal reflux is a constant occurrence and that a poorly fitting device, stomal stenosis, positional changes ofthe stoma, and excessively redundant loops may impede conduit emptying and enhance ureteral reflux. 2. 10 The significance of an antirefluxing ureterocolic anastomosis is emphasized in a reported series of patients undergoing ureterosigmoidostomy by effective antireflux technique compared to those patients undergoing the old Coffey technique which was associated with significant deterioration of renal function. Results of long-term follow-up of comparative groups of children with exstrophy with refluxing and antirefluxing ureterocolic anastomoses reveal a sig':'Department of Urology, Lahey Clinic Foundation, Boston, Massachusetts
Surgical Clinics of North America-Vol. 56, No.3, June 1976
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LEONARD ZINMAN AND JOHN
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LIBERTINO
nificant improvement in renal preservation in the latter group.1 Attempts to construct an antirefluxing anastomosis in the ileal conduit have achieved only limited success, and follow-up information about the ability to prevent renal complications is lacking. 8 , 13 Interest in the colonic conduit as another concept in intestinal diversion has emerged over the past few years as a possible answer to the prevention of the late complications being reported with the refluxing ileal conduit technique. The thick colonic wall appears to lend itself effectively to a tunnel type of antireflux anastomosis, and the colonic stomas, like those seen in patients. with fecal colostomies with large lumens, rarely become stenotic. The colonic conduit can be constructed from sigmoid, transverse, or ileocecal intestinal segments. The first segment of colon used as a conduit diversion was the sigmoid loop introduced in Germany in 195224 and popularized by Moggll in 1965 who first brought attention to the significance of an antirefluxing ureteral anastomosis in the conduit urinary diversion. He reported results in 40 children .with myelodysplasia in whom diversion was achieved with a sigmoid conduit; his modification used an antirefluxing nipple-like ureterocolic mucosa-to-mucosa anastomosis. The stoma was placed in the left lower quadrant using the loop in an antiperistaltic direction in the early cases. Retrograde sigmoidography with moderately high pressures revealed reflux in 13 of the 24 renal units studied. His follow-up period ranged from six months to 10 years. Ofthis unselected population, 17 per cent showed some radiologic evidence of pyelonephritis postoperatively, and 20 per cent of patients had stomal obstruction. Five patients with nonrefluxing conduits did not have any pyelonephritic changes. A higher incidence of upper urinary tract complications in patients with refluxing sigmoid conduits was noted by two other groups reporting similarly sized series and follow-up periods for two to eight years during the same period. 4 • 22 Cook et al 4 reported findings in a comparative group of 57 myelodysplastic children undergoing refluxing sigmoid and ileal conduits with a similar per cent of renal and ureteral complications in both groups but with a lower incidence of stomal stenosis and intestinal complications with a colonic loop. Other reports of smaller groups of antirefluxing sigmoid conduits using the combined mucosal tunnel anastomotic technique appear promising in both adults and children with a lower incidence of stomal stenosis and intestinal obstruction. 9 The sigmoid loop is technically a difficult segment of intestine to isolate in adults with thickened short mesenteries containing precarious and variable blood supplies. The combined tunnel mucosal antirefluxing anastomosis is not consistently successful, and this procedure has greater inherent risks when employed in patients with dilated ureters. Approximately 30 to 40 per cent of reported groups of patients continue to show reflux on retrograde conduitographic studies using the tunnel mucosal ureterocolic anast(!mosis. Our main indication for the use of the sigmoid conduit continues to be in patients undergoing pelvic exenteration when simultaneous fecal and urinary diversions are required; no bowel anastomosis is necessary, and a defunctionalized segment can safely be used for urinary diversion. The
THE ILEOCECAL SEGMENT
735
distal part of the sigmoid flexure has already been divided; it is merely necessary to isolate the terminal 6 or 8 inches of left lower colon preserving the blood supply which is derived from the sigmoid branches of the inferior mesenteric artery without concern that the distal colon will become ischemic. The transverse colon conduit was introduced by Wallace 25 in 1966 as a means of achieving high urinary diversion when anastomosis to the renal pelves was required. Its location in the upper part of the abdomen protects it from radiation damage and allows the use of a shorter and higher segment of ureter or renal pelvis for the anastomosis. 12, 18 Its primary indication today is in diversion for patients who have had extensive previous pelvic irradiation. It is also suitable when the lower part of the abdomen is scarred or unsatisfactory since the transverse colon can be placed ideally in the left upper quadrant in an isoperistaltic direction. It is technically an easy segment to isolate because the transverse colon is often redundant and the colocolostomy is easily performed. The conduit is routinely placed inferior to the restored transverse colon except for high pelvic anastomosis in which the conduit is placed above the transverse colon. The ureters are mobilized and brought lateral to the duodenum after disconnecting the ligament ofTreitz for the ureterocolic anastomosis. The ideal intestinal segment for antirefluxing colonic conduit urinary diversion is the ureteroileal cecostomy or the cecal loop, which we have called it since 1969. 26 The ileocecal segment was first used for urinary diversion as a reservoir with the appendix as a stoma in 1908. The ileocecal segment was again employed as a continent substitute bladder by Gilchrist et al 5 in 1950; the ileum was used as stoma and the ureters were implanted into the cecal segment with a tunnel mucosal type of anastomosis. Gil Vernet 6 first brought attention to the ileocecal valve in the urinary system when he constructed ureteroileal cecocystoplasty to prevent ileoureteral reflux in the augmented bladder. This intestinal segment has certain anatomic advantages as a conduit over other colonic segments. 23 The ileocolic vessels which supply it are constant and are easily mobilized with a long mesentery providing an abundant blood supply to the bowel. They can be almost blindly isolated in obese patients with very thick mesenteric attachments by palpation of the ileocolic and right colic arteries. The cecum is rarely involved in compromising disease, such as diverticulitis, and its location under the right lower quadrant makes construction of the proximal ascending colonic stoma easy to accomplish without undue tension. The cecum and ascending colon require no refashioning for reversal cecocystoplasty and have been found to tolerate voiding pressures more effectively than the ileum. Patients with benign lower urinary tract problems requiring urinary diversion today might possibly be candidates for future reconstructive surgery and undiversion with this segment using the ileocecal valve as an antirefluxing mechanism. The ileocecal junction has been considered a valve because of its anatomic appearance, but manometric and pharmacologic studies demonstrate the characteristic of a true alimentary tract sphincter analogous to the motility patterns of the esophagogastric junction. 3 In 1956
736
LEONARD ZINMAN AND JOHN
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LIBERTINO
Nissen successfully corrected gastroesophageal reflux by completely wrapping the fundus of the stomach 360 around the distal esophagus in a collar-like fashion. ls Motility studies demonstrated a high pressure sphincter zone and a significantly low pressure area in the proximal esophageal lumen. This operation has been used widely with good clinical results and confirms its effectiveness as a nonobstructive antireflux technique in the lower esophageal sphincter. In 1969 we first adapted a modification of this technique to produce a competent ileocecal sphincter by partially wrapping the cecum around the distal 4 cm .. of terminal ileum. 0
OPERATIVE TECHNIQUE The patients are prepared with a mechanical, three-day bowel program including colonic lavage and orally administered neomycin. The stoma is sited in the right lower quadrant with the patient in the lying, sitting, and standing positions to ensure proper location. A generous midline incision is used for good access to the lower and upper parts of the abdomen (Fig. 1 A). The right colon and hepatic flexure are mobilized to release the mesentery for inspection and for isolation of the appropriate blood supply. At this time, the right ureter is easily identified behind the cecum and is isolated down to just below the pelvic brim. The ileocecal intestinal segment with its mesentery is isolated, containing the ever-
Figure 1. A, Stomal site is first constructed in right lower quadrant and a generous midline incision is used for right colon access. B, The ileocecal segment of intestine is isolated with the ileocolic vascular pedicle.
r 737
THE ILEOCECAL SEGMENT
constant ileocolic vessels that will be the vascular pedicle to the conduit (Fig. IB)' The ileum is sectioned obliquely 10 cm. proximal to the ileocecal valve and is supplied by the distal ileal branch of the ileocolic artery. The ascending colon is divided proximal to the right colic artery. The paracolic arcade is divided, and the mesocolon is incised down to the base of the mesentery parallel to the ileocolic vessels. The isolated segment is irrigated with saline in an antegrade and retrograde fashion. (The ileocecal valve was tested by retrograde high pressure irrigations through the colonic opening and was found to be incompetent in all the patients studied. ) A no. 30 French whistle-tip catheter is introduced into the proximal end of the ileal portion through the ileocecal valve emerging through the colonic stoma. The antirefiux mechanism is obtained by plicating the cecum around the terminal ileum in a collar-like fashion similar to the Nissen fundoplication esophagogastric junction procedure. The catheter is used as an obturator across the ileocecal junction during the plication to avoid too much narrowing of the distal ileum. The ileum is then intussuscepted into the cecum for 2 cm. with three seromuscular sutures of 3-0 Tevdek (Fig. 2A). The anterior and posterior wall of the cecum is wrapped like a collar around the terminal 4 cm. of ileum in a 200 encircling fashion with four appropriately placed seromuscular nonabsorbable sutures incorporating ileum and cecum on either side of the mesentery (Fig. 2B and C). A complete plication of the cecum around the ileum is not possible because of the presence of the mesenteric attachment to the ileocecal area. 0
Figure 2. A, The ileum is intussuscepted into the cecum for 2 cm with three seromuscular sutures of 3-0 Tevdek. B and C, The anterior and posterior wall of the cecum is wrapped like a collar around the terminal 4 cm of ileum in a 200' encircling fashion with four appropriately placed seromuscular nonabsorbable sutures incorporating ileum and cecum on either side of the mesentery. D, The conjoint ureteroureterostomy is sutured to the open proximal ileal portion of the conduit.
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LEONARD ZINMAN AND JOHN
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LIBERTINO
The left ureter is then isolated and brought behind the sigmoid mesocolon in the usual fashion coming out through the parietal peritoneal opening on the right side. A conjoint ureteroureterostomy is constructed by incising the ureters on their anterior surface for 1.5 inches. Their medial walls are then approximated with interrupted sutures of 5-0 chromic catgut, and the conjoint single opening is sutured to the open proximal ileal portion ofthe conduit. This is accomplished with interrupted 4-0 chromic catgut sutures. The anastomoses are splinted with No.8 feeding tubes (Fig. 3). The stoma has been constructed by excising a circle of skin 3 to 4 cm. from the previously designated site in the right lower quadrant. A wide cruciate incision is made in the rectus fascia, the muscle is separated and displaced, and the peritoneum is incised comfortably to allow the transfer of the distal colonic opening through the abdominal wall. Five appropriately placed 2-0 chromic catgut sutures are placed first at the peritoneal level of the opening and sutured to the serosal portion of the cecum as the first layer in the construction of the stoma, and an everting nipple-like stoma is fashioned. The ileocecal segment with its vascular pedicle has sufficient length and mobility to allow the distal end of the colonic portion to be brought through the right lower quadrant without tension (Fig. 4). A
A
Figure 3. A, The ureters are incised for 3 em on their medial sides avoiding significant vessels. B, The medial edges are approxi· mated with interrupted 5-0 chromic catgut sutures. C, The proximal anterior wall is approximated with three interrupted sutures before the ureters are anastomosed to the intestine. D, The conjoint ureteroureterostomy is sutured in watertight fashion to the open end of the ile al portion of the conduit.
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THE ILEOCECAL SEGMENT
Figure 4. The colonic portion is brought out to the right lower quadrant and the bowel is reconstituted with a two-layer ileo-ascending bowel anastomosis.
restorative two-layer end-to-end anastomosis between the spatulated end of the ileum and the ascending colon is a simple procedure, resulting in a wide lumen with well-vascularized ends. The bowel contents of the right side of the colon are liquid, and there are fewer complications with this anastomosis than with the anastomosis of the sigmoid colon.
RESULTS From 1969 to June 1975,32 patients have undergone this procedure. Most of the diversions were performed for Jewett stage C carcinoma of the bladder. The remainder underwent operation for benign lesions, six of which were potentially reversible forms of urinary diversion. Two patients have undergone undiversion from cecal loops to augmentation cecocystoplasty one and two years after diversion (Table 1). Two patients who previously underwent diversion for benign disease with an ileal loop procedure had serious intractable stomal stenosis with short loops and have undergone conversion to cecal colonic stomas by the addition of ileoileocecostomy. Retrograde conduitography revealed no reflux through the valve in the entire group studied. In one patient a bilateral ureteroileal stricture developed when the Bricker anastomosis was performed. In one patient an upper left postoperative extrinsic ureteral stricture developed. Both of these strictures have been revised with satisfactory results on pyelography (Table 2), No
740
LEONARD ZINMAN AND JOHN
A.
LIBERTINO
Table 1. Indications for Ileocecal Conduit Diversion in 32 Patients, 1969-1975 NUMBER
Malignant Cancer of bladder Cancer of prostate Benign Neuropathic bladder Interstitial cystitis Tuberculosis of bladder Vesicovaginal fistula Bladder outlet (congeintal)
15
9 4
strictures have developed in the 25 patients who have undergone diversion using the Wallace conjoint anastomosis, and no stomal problems have been noted in the entire group. In one patient who had small bowel obstruction, stomal prolapse developed three days after the onset of bowel obstruction, and exploratory laparotomy was required for reduction and release of small bowel adhesions. No urinary leaks and no episodes of nonobstructive pyelonephritis have been noted. Patients have been monitored every 6 to 12 months with interval excretory urography and creatinine clearances (Table 3). Two patients who had ureteral strictures now have normal upper urinary tracts. The status of one patient with severe preoperative bilateral hydronephrosis has not changed. Three patients with azotemia have normal serum creatinine levels, and no electrolyte disturbances have been observed in any of the patients studied, including the two patients who had reversal augmentation cecocystoplasty. The two patients who underwent conversion to cecal colonic stomas by ileoileocecostomy had improvement in upper urinary tract dilatation.
Table 2. Complications in 32 Ileocecal Conduits NUMBER
Ureteroileal stricture Left upper ureteral stricture Small bowel obstruction Wound infection Pelvic abscess Stomal prolapse Stomal bleeding Bilateral ureteral bleeding with clot obstruction
4
741
THE ILEOCECAL SEGMENT
Table 3. Pyelographic Status of63 Renal Units in 32 Patients with Ileocecal Antireftuxing Conduit, 1969-1975 PREOPERATIVE
POSTOPERATIVE INTRAVENOUS
INTRAVENOUS
PYELOGRAM
PYELOGRAM
Same Normal Mild dilat ation Severe dilatation Total
Better
22
Worse 2
1
2 5
23
7
2
CONCLUSION In the unclear perspective of the short follow-up experience with colonic loop conduit urinary diversion the incidence of stomal problems appears to be decreasing in the period available for review. The ileocecal loop is a viable alternative to the suspect ileal loop with consistently successful antirefiux qualities, but we are not completely convinced that it will necessarily protect the upper urinary tract. It will take another two decades before the various antirefiuxing intestinal conduits can thoroughly and judiciously be appraised.
REFERENCES 1. Bennett, A. H.: Exstrophy of bladder treated by ureterosigmoidostomies. Long term evaluation. Urology, 2:165-168 (Aug.) 1973. 2. Campbell, J. E., Oliver, J. A., McKay, D. E.: Dynamics of ileal conduits. Radiology, 85 :338-342 (Aug.) 1965. 3. Cohen, S., Harris, L. D., Levitan, R.: Manometric characteristics of the human ileocecal junctional zone. Gastroenterology, 54:72-75 (Jan.) 1968. 4. Cook, R. C., Lister, J., Zachery, R. B.: Operative management of the neurogenic bladder in children: diversion through intestinal conduits. Surgery, 63:825-831 (May) 1968. 5. Gilchrist, R. K., Merriks, J. W., Hamlin, H. H., et al : Construction of a substitute bladder and urethra. Surg. Gyneco!. Obstet., 90:752-760 (June) 1950. 6. Gil Vernet, J. M.: Technique for construction of a functioning artificial bladder. J. Uro!., 83:39-50 (Jan.) 1960. 7. Harbach, L. B., Hall, R. L., Cockett, A. T., et al: Ileal loop cutaneous urinary diversion: a critical review. J. Uro!., 105:511-514 (April) 1971. 8. Kafetsioulis, A., Swinney, J.: A study of the function of ileal conduits. Br. J. Uro!.,42:33-36 (Feb.) 1970. 9. Kelalis, P.: Urinary diversion in children by the sigmoid conduits: Its advantages and limitations. J. Uro!., 112:666-672 (Nov.) 1974. 10. Minton, J. P., Kiser, W. S., Ketcham, A. S.: A study of the functional dynamics of ileal conduit urinary diversion with relationship to urinary infection. Surg. Gyneco!. Obstet., 119:541-550 (Sept.) 1964. 11. Mogg, R. A. : The treatment of neurogenic urinary incontinence using the colonic conduit. Br. J. Uro!., 37:681-686 (Dec.) 1965. . 12. Morales, P., Golimbu, M.: Colonic urinary diversion: 10 years of experience. J. Uro!., 113 :302-307 (March) 1975. 13. Mount, B. M., Susset, J. G., Campbell,J., etal: Ureteral implantation into ileal conduits. J. Uro!., 100:605-609 (Nov.) 1968.
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14. Murphy, J. J., Schoenberg, H. W.: Survey oflong-tenn results of total urinary diversion. Br. J. Urol., 39:700-703 (Dec.) 1967. 15. Nissen, R: Eine einfache Operation zur Beinflussung der Refiuxoesophagitis. Schweiz. Med. Wochenschr., 86:590-592 (May 18) 1956. 16. Richie, J. P.: Intestinal loop urinary diversion in children. J. Urol., 111 :687-689 (May) 1974. 17. Richie, J. P., Skinner, D. G.: Urinary diversion: The physiological rationale for nonrefiuxing colonic conduits. Br. J. Urol., 47:269-275 (June) 1975. 18. Schmidt, J. D., Hawtrey, C. E., Buschsbaum, H. J.: Transverse colon conduit: A preferred method of urinary diversion for radiation-treated pelvic malignancies. J. Urol., 113 :308-313 (March) 1975. 19. Schmidt, S. D., Hawtrey, C. E., Flocks, R H., etal: Complications, results, and problems of ileal conduit diversion. J. Urol., 109:210-216 (Feb.) 1973. 20. Schwarz, G. R, Jeffs, R D.: Ileal conduit urinary diversion in children: Computer analysis offollowup from 2 to 16 years. J. Urol., 114 :285-288 (Aug.) 1975. 21. Shapiro, S. R., Lebowitz, R., Colodny, A. H.: Fate of 90 children with ileal conduit urinary diversion a decade later: Analysis of complications, pyelography, renal function, and bacteriology. J. Urol., 114:289-295 (Aug.) 1975. 22. Symmonds, R E., Gibbs, C. P.: Urinary diversion by way of sigmoid conduit. Surg. Gynecol. Obstet., 131 :687-693 (Oct.) 1970. 23. Turner-Warwick, R I., Ashkin, M. H.: The functional results of partial, subtotal and total cytoplasty with special reference to ureterocaecocystoplasty, selective sphincterotomy and cecocystoplasty. Br. J. Urol., 39:3-12 (Feb.) 1967. 24. Ubelhor, R.: Die Dannblase. Arch. KIin. Chir., 271 :202-210, 1952. 25. Wallace, D. M.: Ureteric diversion using a conduit: a simplified technique. Br. J. Urol., 38:522-527 (Oct.) 1966. 26. Zinman, L., Libertino, J. A.: Ileocecal conduit for temporary and penn anent urinary diversion. J. Urol., 113:317-323 (March) 1975. Lahey Clinic Foundation 605 Commonwealth Avenue Boston, Massachusetts 02215
The Ileocecal Segment An Antirefluxing Colonic Conduit Form of Urinary Diversion
Leonard Zinman, M.D.,* and John A. Libertino, M.D.*
After two decades of experience with the freely refluxing ileal conduit, reports of a significant incidence of delayed complications from this form of diversion are beginning to accumulate. 7 , 14, 19 Stomal obstruction, excessive conduit length, and ureteroileal conduit stenosis have contributed to the upper urinary tract deterioration observed in many patients. However, comparison of short-term and long-term follow-up groups continues to reveal an increasing deterioration of the upper urinary tract in patients who initially had normal results on intravenous pyelography in the early postoperative period with no obvious source of obstruction and free unobstructed refluxing ureters. These delayed complications are being reported with greater frequency in children with neurogenic bladders in whom the incidence of stomal stenosis and prediversion upper urinary tract damage is high. 20 , 21 A review of the literature reveals a 25 per cent incidence of stomal stenosis in children, which is related to the growth rate with respect to the fixed aperture in the abdominal wall.1 6 Experimental data comparing antirefluxing colonic conduits to refluxing ileal conduits suggest that ileoureteral reflux of the infected urine may be responsible for these delayed long-term upper urinary tract complications,17 Studies of loop manometric pressures and retrograde cinefluoroscopy suggest that ureteroileal reflux is a constant occurrence and that a poorly fitting device, stomal stenosis, positional changes ofthe stoma, and excessively redundant loops may impede conduit emptying and enhance ureteral reflux. 2. 10 The significance of an antirefluxing ureterocolic anastomosis is emphasized in a reported series of patients undergoing ureterosigmoidostomy by effective antireflux technique compared to those patients undergoing the old Coffey technique which was associated with significant deterioration of renal function. Results of long-term follow-up of comparative groups of children with exstrophy with refluxing and antirefluxing ureterocolic anastomoses reveal a sig':'Department of Urology, Lahey Clinic Foundation, Boston, Massachusetts
Surgical Clinics of North America-Vol. 56, No.3, June 1976
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LEONARD ZINMAN AND JOHN
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LIBERTINO
nificant improvement in renal preservation in the latter group.1 Attempts to construct an antirefluxing anastomosis in the ileal conduit have achieved only limited success, and follow-up information about the ability to prevent renal complications is lacking. 8 , 13 Interest in the colonic conduit as another concept in intestinal diversion has emerged over the past few years as a possible answer to the prevention of the late complications being reported with the refluxing ileal conduit technique. The thick colonic wall appears to lend itself effectively to a tunnel type of antireflux anastomosis, and the colonic stomas, like those seen in patients. with fecal colostomies with large lumens, rarely become stenotic. The colonic conduit can be constructed from sigmoid, transverse, or ileocecal intestinal segments. The first segment of colon used as a conduit diversion was the sigmoid loop introduced in Germany in 195224 and popularized by Moggll in 1965 who first brought attention to the significance of an antirefluxing ureteral anastomosis in the conduit urinary diversion. He reported results in 40 children .with myelodysplasia in whom diversion was achieved with a sigmoid conduit; his modification used an antirefluxing nipple-like ureterocolic mucosa-to-mucosa anastomosis. The stoma was placed in the left lower quadrant using the loop in an antiperistaltic direction in the early cases. Retrograde sigmoidography with moderately high pressures revealed reflux in 13 of the 24 renal units studied. His follow-up period ranged from six months to 10 years. Ofthis unselected population, 17 per cent showed some radiologic evidence of pyelonephritis postoperatively, and 20 per cent of patients had stomal obstruction. Five patients with nonrefluxing conduits did not have any pyelonephritic changes. A higher incidence of upper urinary tract complications in patients with refluxing sigmoid conduits was noted by two other groups reporting similarly sized series and follow-up periods for two to eight years during the same period. 4 • 22 Cook et al 4 reported findings in a comparative group of 57 myelodysplastic children undergoing refluxing sigmoid and ileal conduits with a similar per cent of renal and ureteral complications in both groups but with a lower incidence of stomal stenosis and intestinal complications with a colonic loop. Other reports of smaller groups of antirefluxing sigmoid conduits using the combined mucosal tunnel anastomotic technique appear promising in both adults and children with a lower incidence of stomal stenosis and intestinal obstruction. 9 The sigmoid loop is technically a difficult segment of intestine to isolate in adults with thickened short mesenteries containing precarious and variable blood supplies. The combined tunnel mucosal antirefluxing anastomosis is not consistently successful, and this procedure has greater inherent risks when employed in patients with dilated ureters. Approximately 30 to 40 per cent of reported groups of patients continue to show reflux on retrograde conduitographic studies using the tunnel mucosal ureterocolic anast(!mosis. Our main indication for the use of the sigmoid conduit continues to be in patients undergoing pelvic exenteration when simultaneous fecal and urinary diversions are required; no bowel anastomosis is necessary, and a defunctionalized segment can safely be used for urinary diversion. The
THE ILEOCECAL SEGMENT
735
distal part of the sigmoid flexure has already been divided; it is merely necessary to isolate the terminal 6 or 8 inches of left lower colon preserving the blood supply which is derived from the sigmoid branches of the inferior mesenteric artery without concern that the distal colon will become ischemic. The transverse colon conduit was introduced by Wallace 25 in 1966 as a means of achieving high urinary diversion when anastomosis to the renal pelves was required. Its location in the upper part of the abdomen protects it from radiation damage and allows the use of a shorter and higher segment of ureter or renal pelvis for the anastomosis. 12, 18 Its primary indication today is in diversion for patients who have had extensive previous pelvic irradiation. It is also suitable when the lower part of the abdomen is scarred or unsatisfactory since the transverse colon can be placed ideally in the left upper quadrant in an isoperistaltic direction. It is technically an easy segment to isolate because the transverse colon is often redundant and the colocolostomy is easily performed. The conduit is routinely placed inferior to the restored transverse colon except for high pelvic anastomosis in which the conduit is placed above the transverse colon. The ureters are mobilized and brought lateral to the duodenum after disconnecting the ligament ofTreitz for the ureterocolic anastomosis. The ideal intestinal segment for antirefluxing colonic conduit urinary diversion is the ureteroileal cecostomy or the cecal loop, which we have called it since 1969. 26 The ileocecal segment was first used for urinary diversion as a reservoir with the appendix as a stoma in 1908. The ileocecal segment was again employed as a continent substitute bladder by Gilchrist et al 5 in 1950; the ileum was used as stoma and the ureters were implanted into the cecal segment with a tunnel mucosal type of anastomosis. Gil Vernet 6 first brought attention to the ileocecal valve in the urinary system when he constructed ureteroileal cecocystoplasty to prevent ileoureteral reflux in the augmented bladder. This intestinal segment has certain anatomic advantages as a conduit over other colonic segments. 23 The ileocolic vessels which supply it are constant and are easily mobilized with a long mesentery providing an abundant blood supply to the bowel. They can be almost blindly isolated in obese patients with very thick mesenteric attachments by palpation of the ileocolic and right colic arteries. The cecum is rarely involved in compromising disease, such as diverticulitis, and its location under the right lower quadrant makes construction of the proximal ascending colonic stoma easy to accomplish without undue tension. The cecum and ascending colon require no refashioning for reversal cecocystoplasty and have been found to tolerate voiding pressures more effectively than the ileum. Patients with benign lower urinary tract problems requiring urinary diversion today might possibly be candidates for future reconstructive surgery and undiversion with this segment using the ileocecal valve as an antirefluxing mechanism. The ileocecal junction has been considered a valve because of its anatomic appearance, but manometric and pharmacologic studies demonstrate the characteristic of a true alimentary tract sphincter analogous to the motility patterns of the esophagogastric junction. 3 In 1956
736
LEONARD ZINMAN AND JOHN
A.
LIBERTINO
Nissen successfully corrected gastroesophageal reflux by completely wrapping the fundus of the stomach 360 around the distal esophagus in a collar-like fashion. ls Motility studies demonstrated a high pressure sphincter zone and a significantly low pressure area in the proximal esophageal lumen. This operation has been used widely with good clinical results and confirms its effectiveness as a nonobstructive antireflux technique in the lower esophageal sphincter. In 1969 we first adapted a modification of this technique to produce a competent ileocecal sphincter by partially wrapping the cecum around the distal 4 cm .. of terminal ileum. 0
OPERATIVE TECHNIQUE The patients are prepared with a mechanical, three-day bowel program including colonic lavage and orally administered neomycin. The stoma is sited in the right lower quadrant with the patient in the lying, sitting, and standing positions to ensure proper location. A generous midline incision is used for good access to the lower and upper parts of the abdomen (Fig. 1 A). The right colon and hepatic flexure are mobilized to release the mesentery for inspection and for isolation of the appropriate blood supply. At this time, the right ureter is easily identified behind the cecum and is isolated down to just below the pelvic brim. The ileocecal intestinal segment with its mesentery is isolated, containing the ever-
Figure 1. A, Stomal site is first constructed in right lower quadrant and a generous midline incision is used for right colon access. B, The ileocecal segment of intestine is isolated with the ileocolic vascular pedicle.
r 737
THE ILEOCECAL SEGMENT
constant ileocolic vessels that will be the vascular pedicle to the conduit (Fig. IB)' The ileum is sectioned obliquely 10 cm. proximal to the ileocecal valve and is supplied by the distal ileal branch of the ileocolic artery. The ascending colon is divided proximal to the right colic artery. The paracolic arcade is divided, and the mesocolon is incised down to the base of the mesentery parallel to the ileocolic vessels. The isolated segment is irrigated with saline in an antegrade and retrograde fashion. (The ileocecal valve was tested by retrograde high pressure irrigations through the colonic opening and was found to be incompetent in all the patients studied. ) A no. 30 French whistle-tip catheter is introduced into the proximal end of the ileal portion through the ileocecal valve emerging through the colonic stoma. The antirefiux mechanism is obtained by plicating the cecum around the terminal ileum in a collar-like fashion similar to the Nissen fundoplication esophagogastric junction procedure. The catheter is used as an obturator across the ileocecal junction during the plication to avoid too much narrowing of the distal ileum. The ileum is then intussuscepted into the cecum for 2 cm. with three seromuscular sutures of 3-0 Tevdek (Fig. 2A). The anterior and posterior wall of the cecum is wrapped like a collar around the terminal 4 cm. of ileum in a 200 encircling fashion with four appropriately placed seromuscular nonabsorbable sutures incorporating ileum and cecum on either side of the mesentery (Fig. 2B and C). A complete plication of the cecum around the ileum is not possible because of the presence of the mesenteric attachment to the ileocecal area. 0
Figure 2. A, The ileum is intussuscepted into the cecum for 2 cm with three seromuscular sutures of 3-0 Tevdek. B and C, The anterior and posterior wall of the cecum is wrapped like a collar around the terminal 4 cm of ileum in a 200' encircling fashion with four appropriately placed seromuscular nonabsorbable sutures incorporating ileum and cecum on either side of the mesentery. D, The conjoint ureteroureterostomy is sutured to the open proximal ileal portion of the conduit.
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The left ureter is then isolated and brought behind the sigmoid mesocolon in the usual fashion coming out through the parietal peritoneal opening on the right side. A conjoint ureteroureterostomy is constructed by incising the ureters on their anterior surface for 1.5 inches. Their medial walls are then approximated with interrupted sutures of 5-0 chromic catgut, and the conjoint single opening is sutured to the open proximal ileal portion ofthe conduit. This is accomplished with interrupted 4-0 chromic catgut sutures. The anastomoses are splinted with No.8 feeding tubes (Fig. 3). The stoma has been constructed by excising a circle of skin 3 to 4 cm. from the previously designated site in the right lower quadrant. A wide cruciate incision is made in the rectus fascia, the muscle is separated and displaced, and the peritoneum is incised comfortably to allow the transfer of the distal colonic opening through the abdominal wall. Five appropriately placed 2-0 chromic catgut sutures are placed first at the peritoneal level of the opening and sutured to the serosal portion of the cecum as the first layer in the construction of the stoma, and an everting nipple-like stoma is fashioned. The ileocecal segment with its vascular pedicle has sufficient length and mobility to allow the distal end of the colonic portion to be brought through the right lower quadrant without tension (Fig. 4). A
A
Figure 3. A, The ureters are incised for 3 em on their medial sides avoiding significant vessels. B, The medial edges are approxi· mated with interrupted 5-0 chromic catgut sutures. C, The proximal anterior wall is approximated with three interrupted sutures before the ureters are anastomosed to the intestine. D, The conjoint ureteroureterostomy is sutured in watertight fashion to the open end of the ile al portion of the conduit.
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Figure 4. The colonic portion is brought out to the right lower quadrant and the bowel is reconstituted with a two-layer ileo-ascending bowel anastomosis.
restorative two-layer end-to-end anastomosis between the spatulated end of the ileum and the ascending colon is a simple procedure, resulting in a wide lumen with well-vascularized ends. The bowel contents of the right side of the colon are liquid, and there are fewer complications with this anastomosis than with the anastomosis of the sigmoid colon.
RESULTS From 1969 to June 1975,32 patients have undergone this procedure. Most of the diversions were performed for Jewett stage C carcinoma of the bladder. The remainder underwent operation for benign lesions, six of which were potentially reversible forms of urinary diversion. Two patients have undergone undiversion from cecal loops to augmentation cecocystoplasty one and two years after diversion (Table 1). Two patients who previously underwent diversion for benign disease with an ileal loop procedure had serious intractable stomal stenosis with short loops and have undergone conversion to cecal colonic stomas by the addition of ileoileocecostomy. Retrograde conduitography revealed no reflux through the valve in the entire group studied. In one patient a bilateral ureteroileal stricture developed when the Bricker anastomosis was performed. In one patient an upper left postoperative extrinsic ureteral stricture developed. Both of these strictures have been revised with satisfactory results on pyelography (Table 2), No
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Table 1. Indications for Ileocecal Conduit Diversion in 32 Patients, 1969-1975 NUMBER
Malignant Cancer of bladder Cancer of prostate Benign Neuropathic bladder Interstitial cystitis Tuberculosis of bladder Vesicovaginal fistula Bladder outlet (congeintal)
15
9 4
strictures have developed in the 25 patients who have undergone diversion using the Wallace conjoint anastomosis, and no stomal problems have been noted in the entire group. In one patient who had small bowel obstruction, stomal prolapse developed three days after the onset of bowel obstruction, and exploratory laparotomy was required for reduction and release of small bowel adhesions. No urinary leaks and no episodes of nonobstructive pyelonephritis have been noted. Patients have been monitored every 6 to 12 months with interval excretory urography and creatinine clearances (Table 3). Two patients who had ureteral strictures now have normal upper urinary tracts. The status of one patient with severe preoperative bilateral hydronephrosis has not changed. Three patients with azotemia have normal serum creatinine levels, and no electrolyte disturbances have been observed in any of the patients studied, including the two patients who had reversal augmentation cecocystoplasty. The two patients who underwent conversion to cecal colonic stomas by ileoileocecostomy had improvement in upper urinary tract dilatation.
Table 2. Complications in 32 Ileocecal Conduits NUMBER
Ureteroileal stricture Left upper ureteral stricture Small bowel obstruction Wound infection Pelvic abscess Stomal prolapse Stomal bleeding Bilateral ureteral bleeding with clot obstruction
4
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THE ILEOCECAL SEGMENT
Table 3. Pyelographic Status of63 Renal Units in 32 Patients with Ileocecal Antireftuxing Conduit, 1969-1975 PREOPERATIVE
POSTOPERATIVE INTRAVENOUS
INTRAVENOUS
PYELOGRAM
PYELOGRAM
Same Normal Mild dilat ation Severe dilatation Total
Better
22
Worse 2
1
2 5
23
7
2
CONCLUSION In the unclear perspective of the short follow-up experience with colonic loop conduit urinary diversion the incidence of stomal problems appears to be decreasing in the period available for review. The ileocecal loop is a viable alternative to the suspect ileal loop with consistently successful antirefiux qualities, but we are not completely convinced that it will necessarily protect the upper urinary tract. It will take another two decades before the various antirefiuxing intestinal conduits can thoroughly and judiciously be appraised.
REFERENCES 1. Bennett, A. H.: Exstrophy of bladder treated by ureterosigmoidostomies. Long term evaluation. Urology, 2:165-168 (Aug.) 1973. 2. Campbell, J. E., Oliver, J. A., McKay, D. E.: Dynamics of ileal conduits. Radiology, 85 :338-342 (Aug.) 1965. 3. Cohen, S., Harris, L. D., Levitan, R.: Manometric characteristics of the human ileocecal junctional zone. Gastroenterology, 54:72-75 (Jan.) 1968. 4. Cook, R. C., Lister, J., Zachery, R. B.: Operative management of the neurogenic bladder in children: diversion through intestinal conduits. Surgery, 63:825-831 (May) 1968. 5. Gilchrist, R. K., Merriks, J. W., Hamlin, H. H., et al : Construction of a substitute bladder and urethra. Surg. Gyneco!. Obstet., 90:752-760 (June) 1950. 6. Gil Vernet, J. M.: Technique for construction of a functioning artificial bladder. J. Uro!., 83:39-50 (Jan.) 1960. 7. Harbach, L. B., Hall, R. L., Cockett, A. T., et al: Ileal loop cutaneous urinary diversion: a critical review. J. Uro!., 105:511-514 (April) 1971. 8. Kafetsioulis, A., Swinney, J.: A study of the function of ileal conduits. Br. J. Uro!.,42:33-36 (Feb.) 1970. 9. Kelalis, P.: Urinary diversion in children by the sigmoid conduits: Its advantages and limitations. J. Uro!., 112:666-672 (Nov.) 1974. 10. Minton, J. P., Kiser, W. S., Ketcham, A. S.: A study of the functional dynamics of ileal conduit urinary diversion with relationship to urinary infection. Surg. Gyneco!. Obstet., 119:541-550 (Sept.) 1964. 11. Mogg, R. A. : The treatment of neurogenic urinary incontinence using the colonic conduit. Br. J. Uro!., 37:681-686 (Dec.) 1965. . 12. Morales, P., Golimbu, M.: Colonic urinary diversion: 10 years of experience. J. Uro!., 113 :302-307 (March) 1975. 13. Mount, B. M., Susset, J. G., Campbell,J., etal: Ureteral implantation into ileal conduits. J. Uro!., 100:605-609 (Nov.) 1968.
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14. Murphy, J. J., Schoenberg, H. W.: Survey oflong-tenn results of total urinary diversion. Br. J. Urol., 39:700-703 (Dec.) 1967. 15. Nissen, R: Eine einfache Operation zur Beinflussung der Refiuxoesophagitis. Schweiz. Med. Wochenschr., 86:590-592 (May 18) 1956. 16. Richie, J. P.: Intestinal loop urinary diversion in children. J. Urol., 111 :687-689 (May) 1974. 17. Richie, J. P., Skinner, D. G.: Urinary diversion: The physiological rationale for nonrefiuxing colonic conduits. Br. J. Urol., 47:269-275 (June) 1975. 18. Schmidt, J. D., Hawtrey, C. E., Buschsbaum, H. J.: Transverse colon conduit: A preferred method of urinary diversion for radiation-treated pelvic malignancies. J. Urol., 113 :308-313 (March) 1975. 19. Schmidt, S. D., Hawtrey, C. E., Flocks, R H., etal: Complications, results, and problems of ileal conduit diversion. J. Urol., 109:210-216 (Feb.) 1973. 20. Schwarz, G. R, Jeffs, R D.: Ileal conduit urinary diversion in children: Computer analysis offollowup from 2 to 16 years. J. Urol., 114 :285-288 (Aug.) 1975. 21. Shapiro, S. R., Lebowitz, R., Colodny, A. H.: Fate of 90 children with ileal conduit urinary diversion a decade later: Analysis of complications, pyelography, renal function, and bacteriology. J. Urol., 114:289-295 (Aug.) 1975. 22. Symmonds, R E., Gibbs, C. P.: Urinary diversion by way of sigmoid conduit. Surg. Gynecol. Obstet., 131 :687-693 (Oct.) 1970. 23. Turner-Warwick, R I., Ashkin, M. H.: The functional results of partial, subtotal and total cytoplasty with special reference to ureterocaecocystoplasty, selective sphincterotomy and cecocystoplasty. Br. J. Urol., 39:3-12 (Feb.) 1967. 24. Ubelhor, R.: Die Dannblase. Arch. KIin. Chir., 271 :202-210, 1952. 25. Wallace, D. M.: Ureteric diversion using a conduit: a simplified technique. Br. J. Urol., 38:522-527 (Oct.) 1966. 26. Zinman, L., Libertino, J. A.: Ileocecal conduit for temporary and penn anent urinary diversion. J. Urol., 113:317-323 (March) 1975. Lahey Clinic Foundation 605 Commonwealth Avenue Boston, Massachusetts 02215