Anatomical basis of antropyloric transposition for fecal incontinence in humans: the infrapyloric approach.
OBJECTIVE
Antropylorus transposition in the perineum for end-stage anal incontinence has shown to be feasible in humans. Vascular anatomy of the antro-pyloro-duodenal area is critical in preventing complications and increasing pyloric graft survival. This study was undertaken to examine the vascular anatomy of antro-pyloro-duodenal area in an attempt to safeguard the graft blood supply and improve its survival.


METHODS
After obtaining preoperative CT angiography to delineate the infrapyloric artery (IP a.), bench dissection of resected pancreaticoduodenectomy specimens was performed in 12 patients. Ex vivo angiography of these specimens were also performed. Subsequent to the information obtained from these dissections, the method of antropylorus mobilization during transposition was modified in terms of the site of division of the right gastroepiploic a. (Rt GEA). Perioperative outcomes (graft related complications, fecal incontinence scores, Doppler flow studies, and manometry studies of the graft) were compared between the two groups.


RESULTS
IP a. originated only from the Rt GEA in 8 cases (66 %) and from both the gastroduodenal a. and the Rt GEA in the rest. However, its origin solely from the gastroduodenal a. was not observed. The pyloric graft survival, pyloric valve pressures and Doppler flow velocities were significantly (p < 0.05) better when the infrapyloric a. was preserved following this refinement. However, no immediate significant difference in incontinence scores was observed.


CONCLUSIONS
Careful preservation of the pyloric valve vascularity by preserving the IP a. by dividing the Rt GEA at its origin increases vascularity, survival and contractility of the pyloric graft in perineum.
Department of Surgical Gastroenterology, King George Medical University, Lucknow, 226007, UP, India. abhijitchandra@hotmail.com
Abhijit
A
Chandra
Vishal
V
Gupta
Manoj
M
Kumar
Anit
A
Parihar
Ashok
A
Kumar
Ramendra
R
Jauhari
Devendra
D
Singh
P K
PK
Shrivastav
Pankaj
P
Kumar
D000328:Adult; D000368:Aged; D000792:Angiography / Q000379:methods; D005242:Fecal Incontinence / Q000503:physiopathology / Q000601:surgery*; D005260:Female; D024405:Gastroepiploic Artery / Q000000981:diagnostic imaging*; D006084:Graft Rejection; D006085:Graft Survival; D006801:Humans; D008297:Male; D008875:Middle Aged; D016577:Pancreaticoduodenectomy / Q000379:methods; D010502:Perineum / Q000601:surgery*; D011708:Pylorus / Q000098:blood supply / Q000000981:diagnostic imaging / Q000637:transplantation*; D019651:Plastic Surgery Procedures / Q000379:methods; D014057:Tomography, X-Ray Computed / Q000379:methods; D016896:Treatment Outcome