Gastric Pelvic Flap for Augmentation of Continent Urostomy or Neovagina

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Gastric Pelvic Flap for Augmentation
of Continent Urostomy or Neovagina

Radiation therapy is one of the keystone treatments in gynecologic cancer. A sequela of radiation therapy, however, can be endarteritis with fibrosis and ischemia to the pelvic tissues as well as the rectosigmoid colon and terminal ileum. When a continent urostomy is made out of irradiated bowel, the compliance of this radiated tissue is frequently low; therefore, because it cannot stretch under filling with urine, the pressure in a continent urostomy pouch will be elevated, which may lead to incontinence.

Neovaginas made out of radiated sigmoid colon have the same compliance features as continent urostomies. The compliance is low, secondary to radiation fibrosis, and distensibility is minimal.

A source of highly compliant nonirradiated bowel is frequently needed to allow a reconstructed organ such as a continent urostomy and neovagina to have an excellent blood supply and function as desired.

The stomach is a resource available for both. It has not been irradiated. It has copious blood supply. It secretes hydrochloric acid that reduces urinary tract infections in the continent urostomy and provides an acid secretion for the neovagina.

Physiologic Changes. Removal of a small flap of gastric tissue from the greater curvature of the stomach has few sequelae. The stomach is a highly vascular organ and reanastomosis of the stomach heals very well. Gastrointestinal physiology is not significantly reduced by the use of a small gastric flap. Using the gastric flap as part of a continent urostomy changes the physiology of the urine from alkaline to an acid, compromising the environment for growth bacteria.

The acid secretion of a flap augmenting a sigmoid neovagina makes the secretions more acid and allows greater distensibility through compliance to the sigmoid neovagina.

Points of Caution. The main point of caution is the protection of the gastroepiploic artery and the short gastric arteries that provide the blood supply to the gastric flap.

A second point of caution is the careful removal of all staples in the gastric flap. If present in the suture line in contact with urine, they will be a source of stone formation.

Third, the stainless staples should never be left in a neovagina. If present, they can cause a penile laceration.

Technique

The esophagus, spleen, and stomach with the omentum and the right and left epigastric arteries in place are shown. The right or left gastroepiploic arteries can be ligated. The short gastric arteries proximal or distal to the proposed flap are individually ligated and tied. The flap is marked off with a skin-marking pencil. The reader is referred to the "clam" gastrocystoplasty for the two steps involved in stapling and cutting the flap with the gastrointestinal anastomosis (GIA) linear stapler cutter. As seen in Figure 1 of the clam gastrocystoplasty (Bladder and Ureter), the first GIA stapler is placed over the drawn triangular area across the anterior and posterior stomach wall. It is fired and cut. As seen in Figure 2 of the "clam" gastrocystoplasty, a second GIA stapler is placed on the pencil markings of the stomach. The stapler is fired and cut. This leaves a triangular flap of the anterior and posterior gastric wall approximately 5-6 cm at the base and approximately 5 cm into the stomach.

Figure 3 of the clam gastrocystoplasty shows the missing wedge-shaped flap from the greater curvature of the stomach. Two small gastrostomies are created adjacent to the staple line. These incisions in the stomach next to each staple line edge of resection allow the placement of another GIA stapler for reanastomosis.

The GIA stapler is inserted into the small gastrotomy incisions. In this figure, the GIA stapler is ghosted as it approximates the edges of the previous staple line and, when it is closed and activated, transects the septum created by taking the wedge of gastric flap. In Figure 5 of the clam gastrocystoplasty, the two gastrotomy defects are picked up with Babcock clamps, and a TA-55 stapler is placed across these defects in the stomach wall. Excess tissue is trimmed away. The stomach is now continuous. All incisions have been closed with staples.

A feeding tube gastrostomy is performed as demonstrated in Figures 6-8 of the clam gastrocystoplasty.

The transverse colon is retracted caudad, and a retractor is placed under the reconstructed stomach, revealing the vena cava (VC). The celiac artery and its branches are also shown.

A defect is made in the mesentery of the transverse colon medial to the middle colic vessels. The omentum with the gastric flap attached is passed through the defect in the mesentery of the transverse colon.

The right gastroepiploic artery has been used in this case with the short gastric branches attached. If the left gastroepiploic vessels are used, the omentum and its flap are placed lateral to the left colon.

Shown here is the passage of the omentum with its gastric flap through a defect in the transverse colon mesentery, proceeding to a second defect created in the avascular plane of Treves of the mesentery of the terminal ileum. Shown also are the middle colic vessels in the transverse colon mesentery and the superior mesenteric artery. The right gastroepiploic artery selected in this case and the stomach wedge-shaped flap are passed through the second opening created in the avascular plane of Treves. This step drops the gastric flap deep in the pelvis and makes it available for an augmentation patch for continent urostomies or neovaginas.

Shown here are the right gastroepiploic vessel with its short gastric branches to the stomach and the wedge-shaped gastric flap. Each staple is removed with sharp dissection.

The triangular gastric flap is now opened into a diamond-shaped flap. At the bottom, a Kock pouch continent urostomy has been constructed out of small intestine that may have been irradiated.

Instead of folding the intestine over on itself to make a classic Kock pouch (see Kock Pouch Continent Urostomy), the open diamond-shaped stomach flap can be placed over the intestine of the Kock pouch as shown, and the corresponding edges can be sutured with synthetic absorbable suture.

The colonic ileal pouch (Miami pouch) has been made at the bottom. Also shown are the open right colon and the terminal ileum, below which will become the afferent bowel limb of the Miami pouch. At the far right, the ureters have been implanted into a segment of ileum that has been sutured to the medial opening of the right colon. At the top, the omental flap with the right gastroepiploic vessels can be seen, with the gastric flap sutured to the open colon, giving the resultant pouch more capacity at lower pressure.

A sigmoid neovagina has been created and sutured to the vaginal introitus. The gastric flap can be sutured to the sigmoid neovagina in a fashion that would augment the sigmoid neovagina that has been irradiated. This allows greater distensibility of the vagina with improved blood supply from a nonirradiated source.