Complications arising from a misdiagnosed giant lipoma of the hand and palm: a case report

<p>Abstract</p> <p>Introduction</p> <p>Lipomas are benign tumors which may appear in almost any human organ. Their diagnosis rate in the hand region is not known.</p> <p>Case Presentation</p> <p>We present the case of a 63-year-old Greek Caucasian woman with a giant lipoma of the hand and palm which was not initially diagnosed. After repeated surgical decompression of the carpal tunnel the patient was referred with persisting symptoms of median and ulnar nerve compression and a prominent mass of her left palm and thenar eminence. Clinical examination, magnetic resonance imaging, nerve conduction study and biopsy, revealed a giant lipoma in the deep palmar space (8.0 × 4.0 × 3.75 cm), which was also infiltrating the carpal tunnel. She had already undergone two operations for carpal tunnel syndrome with no relief of her symptoms and she also ended up with a severed flexor pollicis longus tendon. Definitive treatment was performed by marginal resection of the lipoma and restoration of the flexor pollicis longus with an intercalated graft harvested from the palmaris longus. Thirty months after surgery the patient had a fully functional hand without any neurological deficit.</p> <p>Conclusion</p> <p>Not all lipomas of the wrist and hand are diagnosed. Our report tries to emphasize the hidden danger of lipomas in cases with carpal tunnel symptoms. The need for a high index of suspicion in conjunction with good clinical evaluation and the use of appropriate investigative studies is mandatory in order to avoid unnecessary operations and complications. Marginal excision of these tumors is restorative.</p

Laparoscopic Distal Pancreatectomy: Feasibility Study of Radiofrequency-Assisted Transection in a Porcine Model

This is a copy of an article published in the Journal of Laparoendoscopic and Advanced Surgical Techniques © 2012 [copyright Mary Ann Liebert, Inc.]; Journal of Laparoendoscopic and Advanced Surgical Techniques is available online at: http://online.liebertpub.com.Background and Aim: Despite technological improvements in pancreatic surgery, the incidence and morbidity of pancreatic leak after resection of distal pancreas are persistently high in most series. Laparoscopic distal pancreatectomy (LDP) is today the gold standard procedure for benign and certain malignant neoplasms of the pancreatic body and tail in specialized centers. This study evaluated safety and feasibility of a radiofrequency (RF)-assisted transection device in a porcine model of LDP. Materials and Methods: LDP was performed on 10 pigs (median weight, 39.6 kg) using a new device based on an internally cooled RF-assisted electrode (Coolinside (R), Apeiron Medical, Valencia, Spain). The animals were subjected to daily observation and then sacrificed and necropsied at 4 weeks postoperatively. Primary end points were the development of postoperative pancreatic fistula using the Pancreatic Anastomotic Leak Study Group definition and/or the presence of abdominal amylase-rich fluid collections or abscesses during necropsy and pathological study and/or dye extravasation from the pancreatic remnant duct. Secondary end points were intra- or postoperative complications, surgery, and transection duration. Results: No clinically relevant postoperative pancreatic fistulas were observed. In one case a grade A postoperative fistula was diagnosed due to amylase drain concentration of more than 6200 IU/mL on postoperative day 4. Median peritoneal liquid amylase concentration on postoperative day 4 was 2399.0 IU/L (range, 819.2-7122.0 IU/L), similar to the median plasma amylase level of 1520.8 IU/L (range, 1015.3-4056.6 IU/L). Median surgery time was 93.5 minutes (range, 46.0-140.0 minutes), and median transection time was 4.5 minutes (range, 2.0-26.0 minutes). There was one postoperative wound infection. There were no postoperative deaths or major complications. During the histopathological study, the surgical margin of the remaining pancreas showed a common pattern with a central area of necrosis surrounded by granulomatous infiltrate and fibrosis. Ductal obliteration was observed. No purulent inflammatory infiltrate or abscesses were present. Conclusion: Experimental findings suggest that performing pancreatic transection with Coolinside in a animal model of LDP is feasible and safe.This work received financial support from the Spanish "Plan Nacional de I+D+I del Ministerio de Ciencia e Innovacion," grant number TEC2008-01369/TEC, and from the Generalitat Valenciana (Ayudas Complementarias de I+D para Grupos de Calidad ACOMP/2010/008).Dorcaratto, D.; Burdio Pinilla, F.; Fondevila, D.; Andaluz, A.; Poves, I.; Martínez, MÁ.; Quesada, R.... (2012). Laparoscopic Distal Pancreatectomy: Feasibility Study of Radiofrequency-Assisted Transection in a Porcine Model. Journal of Laparoendoscopic and Advanced Surgical Techniques. 22(3):242-248. https://doi.org/10.1089/lap.2011.0417S24224822

Lymphatic, blood vessel and perineural invasion identifies early-stage high-risk radically resected gastric cancer patients

The availability of different treatment options for radically resectable gastric cancer reopened the question of treatment selection and correct definition of high-risk categories. Lymphatic, blood vessel and perineural invasion (LBVI/PNI) seem to possess the necessary potential to provide useful information for the clinical management of this disease. Seven hundred and thirty-four patients with advanced gastric cancer who underwent curative gastrectomy were analysed according to the presence of LBVI/PNI. Patients were divided into two groups: group A for patients with LBVI/PNI (189 patients 26%) and group B for patients without LBVI/PNI (545 patients, 74%). The disease-free survival (DFS) for patients in group A was 32.1 months, whereas it was not reached for patients in group B (P=0.0001); the median overall survival was 45.5 months for patients in group A, whereas it was not reached for patients in group B (P=0.0001). At multivariate analysis, the presence of LBVI/PNI appeared an independent prognostic factor for DFS and OS. Our results were confirmed in subgroup analysis, separately considering stage I and early gastric cancer patients with and without LBVI/PNI. Taken together, our findings suggest the importance of LBVI/PNI in gastric cancer as it may provide additional information for identifying patients at high risk, who may be candidates for further medical treatment after or before surgery

Evolution of laparoscopic left lateral sectionectomy without the Pringle maneuver: through resection of benign and malignant tumors to living liver donation

BACKGROUND: Laparoscopic left lateral sectionectomy (LLS) has gained popularity in its use for benign and malignant tumors. This report describes the evolution of the authors' experience using laparoscopic LLS for different indications including living liver donation. METHODS: Between January 2004 and January 2009, 37 consecutive patients underwent laparoscopic LLS for benign, primary, and metastatic liver diseases, and for one case of living liver donation. Resection of malignant tumors was indicated for 19 (51%) of the 37 patients. RESULTS: All but three patients (deceased due to metastatic cancer disease) are alive and well after a median follow-up period of 20 months (range, 8-46 months). Liver cell adenomas (72%) were the main indication among benign tumors, and colorectal liver metastases (84%) were the first indication of malignancy. One case of live liver donation was performed. Whereas 16 patients (43%) had undergone a previous abdominal surgery, 3 patients (8%) had LLS combined with bowel resection. The median operation time was of 195 min (range, 115-300 min), and the median blood loss was of 50 ml (range, 0-500 ml). Mild to severe steatosis was noted in 7 patients (19%) and aspecific portal inflammation in 11 patients (30%). A median free margin of 5 mm (range, 5-27 mm) was achieved for all cancer patients. The overall recurrence rate for colorectal liver metastases was of 44% (7 patients), but none recurred at the surgical margin. No conversion to laparotomy was recorded, and the overall morbidity rate was 8.1% (1 grade 1 and 2 grade 2 complications). The median hospital stay was 6 days (range, 2-10 days). CONCLUSIONS: Laparoscopic LLS without portal clamping can be performed safely for cases of benign and malignant liver disease with minimal blood loss and overall morbidity, free resection margins, and a favorable outcome. As the ultimate step of the learning curve, laparoscopic LLS could be routinely proposed, potentially increasing the donor pool for living-related liver transplantation

Liver surgery in the presence of cirrhosis or steatosis: Is morbidity increased?

<p>Abstract</p> <p>Background data</p> <p>The prevalence of steatosis and hepatitis-related liver cirrhosis is dramatically increasing together worldwide. Cirrhosis and, more recently, steatosis are recognized as a clinically important feature that influences patient morbidity and mortality after hepatic resection when compared with patients with healthy liver.</p> <p>Objective</p> <p>To review present knowledge regarding how the presence of cirrhosis or steatosis can influence postoperative outcome after liver resection.</p> <p>Methods</p> <p>A critical review of the English literature was performed to provide data concerning postoperative outcome of patients presenting injured livers who required hepatectomy.</p> <p>Results</p> <p>In clinical studies, the presence of steatosis impaired postoperative outcome regardless the severity and quality of the hepatic fat. A great improvement in postoperative outcome has been achieved using modern and multidisciplinary preoperative workup in cirrhotic patients. Due to the lack of a proper classification for morbidity and a clear definition of hepatic failure in the literature, the comparison between different studies is very limited. Although, many surgical strategies have been developed to protect injured liver surgery, no one have gained worldwide acceptance.</p> <p>Conclusion</p> <p>Surgeons should take the presence of underlying injured livers into account when planning the extent and type of hepatic surgery. Preoperative and perioperative interventions should be considered to minimize the additional damage. Further randomized trials should focus on the evaluation of novel preoperative strategies to minimize risk in these patients. Each referral liver center should have the commitment to report all deaths related to postoperative hepatic failure and to use a common classification system for postoperative complications.</p

Total Intermittent Pringle Maneuver during Liver Resection Can Induce Intestinal Epithelial Cell Damage and Endotoxemia

Contains fulltext : 110009.pdf (publisher's version ) (Open Access)OBJECTIVES: The intermittent Pringle maneuver (IPM) is frequently applied to minimize blood loss during liver transection. Clamping the hepatoduodenal ligament blocks the hepatic inflow, which leads to a non circulating (hepato)splanchnic outflow. Also, IPM blocks the mesenteric venous drainage (as well as the splenic drainage) with raising pressure in the microvascular network of the intestinal structures. It is unknown whether the IPM is harmful to the gut. The aim was to investigate intestinal epithelial cell damage reflected by circulating intestinal fatty acid binding protein levels (I-FABP) in patients undergoing liver resection with IPM. METHODS: Patients who underwent liver surgery received total IPM (total-IPM) or selective IPM (sel-IPM). A selective IPM was performed by selectively clamping the right portal pedicle. Patients without IPM served as controls (no-IPM). Arterial blood samples were taken immediately after incision, ischemia and reperfusion of the liver, transection, 8 hours after start of surgery and on the first post-operative day. RESULTS: 24 patients (13 males) were included. 7 patients received cycles of 15 minutes and 5 patients received cycles of 30 minutes of hepatic inflow occlusion. 6 patients received cycles of 15 minutes selective hepatic occlusion and 6 patients underwent surgery without inflow occlusion. Application of total-IPM resulted in a significant increase in I-FABP 8 hours after start of surgery compared to baseline (p<0.005). In the no-IPM group and sel-IPM group no significant increase in I-FABP at any time point compared to baseline was observed. CONCLUSION: Total-IPM in patients undergoing liver resection is associated with a substantial increase in arterial I-FABP, pointing to intestinal epithelial injury during liver surgery. TRIAL REGISTRATION: ClinicalTrials.gov NCT01099475