Total anorectal reconstruction with a double dynamic graciloplasty after abdominoperineal reconstruction for low rectal cancer.

Department of Surgery, University Hospital Maastricht, The Netherlands. PURPOSE: Total anorectal reconstruction with a double dynamic graciloplasty was performed after abdominoperineal reconstruction (APR) for low rectal cancer. In four patients an additional pouch was constructed to improve neorectal motility and capacity. The aim of this study was to evaluate the results in the first 20 patients and to report on the preliminary results of patients with an additional pouch. METHODS: Twenty patients with a mean age of 52 (range, 25-71) years and a rectal tumor at a mean of 3 (range, 0-5) cm from the anal verge were treated. In 14 patients the Miles resection, colon pull-through, and construction of a neosphincter were performed in one session. Six patients had the double graciloplasty at an average of 4.1 (range, 1.1-8.8) years after APR. In four patients a pouch was constructed with an isolated segment of distal ileum. RESULTS: After a mean follow-up of 24 (range, 1-60) months after APR, none of the patients developed local recurrence, whereas four patients developed distant metastasis. Fifteen of 20 patients were available for evaluation, and 5 patients were still in training. Of these 15 patients, 8 patients were continent (53 percent), 2 patients were incontinent, and in 5 patients the perineal stoma was converted to an abdominal stoma. Failures were attributable to necrosis of the colon stump (n = 2) and incontinence (n = 3). At 26 weeks mean resting pressure was 44 (standard deviation (SD), 28) mmHg, and mean pressure during stimulation was 90 (SD, 46) mmHg at a mean of 3.5 (SD, 1.2) volts at 52 weeks. Mean defecation frequency was three times per day (range, 1-5). Of the eight patients who were continent, six used daily enemas. Mean time to postpone defecation was 11 (range, 0-30) minutes. CONCLUSION: In experienced hands, the double dynamic graciloplasty is an oncologically safe procedure that can have an acceptable functional outcome in a well-selected group of patients. However, to improve the outcome, further modifications will be necessary. So far, the addition of a pouch has not resulted in improved outcome

The remote handling compatibility analysis of the ITER generic upper port plug structure

The ITER diagnostics generic upper port plug (GUPP) is developed as a standardized design for all diagnostic upper port plugs, in which a variety of payloads can be mounted. Here, the remote handling compatibility analysis (RHCA) of the GUPP design is presented that was performed for the GUPP final design review. The analysis focuses mainly on the insertion and extraction procedure of the diagnostic shield module (DSM), a removable cassette that contains the diagnostic in-vessel components. It is foreseen that the DSM is a replaceable component – the procedure of which is to be performed inside the ITER hot cell facility (HCF), where the GUPP can be oriented in a vertical position. The DSM removal procedure in the HCF consists of removing locking pins, an M30 sized shoulder bolt and two electrical straps through the use of a dexterous manipulator, after which the DSM is lifted out of the GUPP by an overhead crane. For optimum access to its internals, the DSM is mounted in a handling device. The insertion of a new or refurbished DSM follows the reverse procedure. The RHCA shows that the GUPP design requires a moderate amount of changes to become fully compatible with RH maintenance requirements

Support structure concept for integration of ITER diagnostics in the port cell

Development of the diagnostics for ITER tokamak, which is presently under construction by several international partners at Cadarache in France, is a major challenge because of severe environment, strict engineering requirements, and the need for high reliability in the measurements. The diagnostic systems in the upper, equatorial and lower port cells on ITER are designed to be integrated within the interspace and port cell support structures. These structures are interfacing with remote handling rail system for the cask operations, thus facilitating the removal and installation of the diagnostics in the port and hence minimizing time for working close to the tokamak. In this paper, the challenges associated with the integration of the diagnostics in the port interspace and port cell, as well as their solutions will be addressed and presented. The interspace and the port cell support structures, as well as their interfaces with the biological shield, will be discussed