477 Surgical Solutions and Problems in An Adult Patient with VACTERL Association

Background We report an adult patient with features of VACTERL - oesophageal and anal atresia, with cardiac malformation. In infancy he underwent colonic interposition for oesophageal atresia using the transverse colon as a conduit. As a teenager he underwent formation of a Koch continent ileostomy after previous stoma formation for anal atresia. Eventual failure of the Koch pouch nipple valve necessitated a laparotomy for attempted refashioning. Unfortunately, this operation was beset by life-threatening complications and a protracted post-operative course. He presented to our hospital with a laparostomy, high output enterocutaneous fistulae (ECF) necessitating home total parenteral nutrition (TPN), severe cachexia and deconditioning. Method Conservative therapy was utilised to improve the nutritional and physiological status of the patient. Simultaneously, attempts were made to define the anatomy of his abdomen in relation to previous surgery. However, operation notes for the original procedures (oesophageal reconstruction and Koch pouch formation) were lost due to closure of the hospital which he attended at the time. A laparotomy was subsequently performed to manage the ECFs. Most of the small intestine was unsalvageable due to multiple fistulae and adhesions, leaving 35cm of small bowel terminating in an end ileostomy. A cholecystectomy was performed to mitigate gallstone formation. Conclusions Efficient communication is imperative in the management of complex patients. The loss of original operation notes made interpretation of subsequent imaging and planning of surgery troublesome. In contrast, efficient communication between teams involved in his peri-operative care, particularly the respiratory and intensive care teams facilitated a smooth post-operative course and successful discharge from hospital.

Cutaneous continent urinary diversion: History, patient selection and preparation

– History. The first supravesical urinary diversion was carried out in 1908. The results of a large number of cutaneous tubularised continent pouches were published in the fifties. The poor results urged urologists to try to improve the continence mechanisms, but it was not until the eighties that these urinary diversions became a stable part of their armamentarium, thanks to the popularisation of the Koch pouch incorporating the principles of detubularisation, reconfiguration and disruption of the peristaltic integrity. After that there was an explosion of interest in continent pouches and new techniques. Nowadays the Indiana, Koch and Mainz pouches and those associated with the Benchekroun valve and the Mitrofanoff principle are the most popular. Patient selection. Nowadays heterotopic continent urinary diversions are performed after a total cystectomy when the urethra is impracticable. The primary goal of cutaneous pouches is to improve the quality of life; a reasonable life expectancy is therefore the first criterion. Patients must be capable of performing self catheterisation and their motivation and intellective compliance must be considered when suggesting these operations. Dementia, renal failure, bowel diseases, malabsorption and previous intestinal demolition are absolute contraindications. Relative contraindications are radiotherapy and cardio-respiratory diseases. Unlike other authors, we believe that a dry continent stoma is the best choice for obese patients. Patient preparation. The ideal patient preparation should be effective, fast, cheap and not create stress or weakness. Dehydration has to be avoided. The mechanical intestinal wash-out could be done either by total irrigation of the bowel with saline solution or by polyethylene glycol electrolyte lavage solution. Antibiotic prophylaxis against aerobic and anaerobic germs reduces the complication rate of intestinal surgery and has to be recommended. Major urological surgery has a high rate of thromboembolism. It is routine practice for us treat with sub-cutaneous calcium heparine in order to reduce post-operative deep venous thrombosis and fatal pulmonary embolisms.