Treatment of large incisional abdominal wall hernias, using a modified preperitoneal prosthetic mesh repair.

Very large and complex incisional hernias, especially those with loss of abdominal wall, can be a very interesting and perplexing problem, which present a particular challenge to the surgeon. The reported technique was developed and refined by one of our surgeons, between 1998 and 1999 for the repair of incisional hernias in a selected group of patients with large defects, often with a major loss of abdominal wall, overweight and previous attempts for incisional hernia repair. The technique involves a modified preperitoneal approach and was used on 43 eligible patients between 1999 and 2002. There were 30 females and 13 males at a mean age of 61 years. The median ASA score of the group was 2, with a mean BMI of 30.4 and a mean hernia surface area of 162 cm(2). One-third of the patients had one or more previous incisional hernia repair. Mean operating time was 190 min with an average hospital stay of 5.7 days. Postoperative complications occurred in 28% of the patients, most of which were minor and did not necessitate admission to the intensive care unit. None of the patients died. Wound infections occurred in 9.3%, was associated with an increased risk for cutaneous sinus formation, but not for mesh removal or hernia recurrence. A recurrence rate of 12.5% was found after a mean follow-up period of 46 months. We advocate this procedure for the repair of large, complex incisional hernias with loss of abdominal domain in patients with significant risk factors for recurrence.

The role of the gastrocnemius muscle flap in limb-sparing surgery for bone sarcomas of the distal femur: a proposed classification of muscle transfers.

Limb-sparing surgery for bone and soft-tissue sarcomas involves three phases: (1) resection of the tumor with free margins, (2) reconstruction of the bone and joint defect, and (3) reconstruction of the soft tissues. This presentation focuses on the third phase. Between January of 1988 and January of 1994 we performed 33 distal femoral resections, 32 for malignant and 1 for benign tumors. There were 19 men and 14 women aged from 6 to 78 years (mean age 28 years). Twenty-seven patients had gastrocnemius muscle flap transfers, 24 having "primary" transfers and 3 having "secondary" transfers. The lateral gastrocnemius muscle was used in 18 patients, the medial in 8 patients, and both in 1 patient. We propose a classification of the transfers based on the size of the soft-tissue defect above the prosthesis needing coverage and the length of the neurovascular bundle of the muscle. Twenty-six of the 27 muscles survived; one patient had necrosis of the skin and muscle. Two patients had persistent sinuses at the scar that were managed successfully (one of them was before a secondary muscle transfer). Six patients did not have gastrocnemius muscle flap transfers. Two of them had persistent sinuses for years, and one patient had titanium "synovitis" and needed repeated operations including removal of the prosthesis and revision. The particular vascularization of the gastrocnemius muscle (one pedicle at the level of the knee joint) situated close to its origin, the size of the muscle belly, and the fact that it is situated in the dissection field and its transfer does not affect the function of the spared limb make it particularly suitable for the coverage of wide areas of skin and muscle loss at the knee region. In the classification that we propose, type I is reserved for coverage of small areas, while types II and III are used for coverage of larger areas. Flap transfer should be performed primarily at the time of the resection in order to avoid complications of wound healing and to reduce delays in chemotherapy protocols.

[Chylothorax: a rare complication of transaxillary thoracic sympathectomy]. / Le chylothorax: une complication rare de la sympathectomie thoracique trans-axillaire.

Transaxillary upper thoracic sympathectomy is a safe surgical procedure for the treatment of palmar hyperhidrosis. Although thoracic complications such as hemothorax and pneumothorax occasionally occur following this procedure chylothorax is an extremely rare complication. From 1978 to 1991, 215 consecutive patients underwent upper thoracic sympathectomy for the treatment of palmar hyperhidrosis in our institution. We report the surgical management of one patient who developed an intractable chylous fistula which did not respond to non-surgical treatment. Attempts at non-surgical management of the disease, with aspiration therapy, tube thoracostomy and the administration of medium chain triglyceride diet, should be tried first. If, however, this is not successful within two weeks, one should not wait for further metabolic and nutritional impairment before instituting surgical treatment. We believe that proximal thoracic duct ligation is a relatively simple and effective means of controlling chylothorax.

[Upper thoracic sympathectomy by thoracoscopic approach. A method of choice for the treatment of palmar hyperhidrosis]. / La sympathectomie thoracique haute par voie thoracoscopique. Une méthode de choix pour le traitement de l'hyperhidrose palmaire.

Palmar hyperhidrosis is excessive sweating beyond physiological needs in the palm without recognized etiology. Although a benign disease, it is annoying to most patients. Currently the best treatment for this condition is upper thoracic sympathectomy via many different approaches. The video-thoracoscopic approach has been recommended a a minimally invasive procedure. We report our 1-year experience with transaxillary endoscopic sympathectomy in 99 patients with palmar hyperhidrosis. Standard video-laparoscopy was used via a transaxillary approach to perform sympathectomy. The mean operating time of this operation was 12 minutes and mean hospital stay was 32 hours. The results in terms of warm and dry hands were excellent. Only one case of transitory Horner syndrome was noted. Transaxillary thoracoscopic sympathectomy for palmar hyperhidrosis is a relatively simple and effective procedure which can be performed with standard laparoscopic instruments. The advantages are, short recovery time and hospital stay along with excellent functional and cosmetic results. We are convinced that thoracoscopic sympathectomy is the procedure of choice for the treatment of palmar hyperhidrosis.

[Acute ischemia of the lesser gastric curvature--a rare marker of sclerotic disease].

The rich blood supply of the stomach protects it from ischemia and necrosis. Acute gastric ischemia, an emergency with high mortality, is rare. Atherosclerosis is the leading cause of acute ischemia, and the lesser curvature of the stomach is more vulnerable due to its relatively lesser blood supply. Reduction in gastric blood supply usually presents as chronic disease characterized by gastritis, gastric ulcer, or gastroparesis. Gastroscopy can identify lesions of the gastric mucosa, and angiography demonstrates occluded vessels. Treatment of acute gastric ischemia is surgical, with total gastrectomy preferred over partial resection.

Complete recovery after spontaneous drainage of pancreatic abscess into the stomach.

Pancreatic abscess is a dreaded complication of acute pancreatitis, with a high death rate even with aggressive surgical treatment. We report two cases in which recovery followed spontaneous drainage into the stomach. A 75-year-old woman with biliary pancreatitis and a 63-year-old man with ethanol-induced pancreatitis both developed pancreatic abscess, diagnosed by computed tomography scans and ultrasound. The spontaneous gastric fistula was heralded by a large emesis of purulent and necrotic material in one case and copious nasogastric tube secretions of a similar material in the other. Defervescence was immediate, and both patients went on to complete recovery without any further interventions. Contrast studies showed the fistulae. It is concluded that in the event that a pancreatic pseudocyst spontaneously drains into the stomach a 'wait and see' policy should be adopted, and a favorable outcome can be expected.

Gastric outlet obstruction by gallstone: Bouveret syndrome.

Gallstone has rarely been described as a cause of gastrointestinal obstruction. However, the relative incidence of gallstone ileus increases significantly with age. The gastric outlet is very seldom the location of obstruction by a gallstone. The diagnosis of this condition is not difficult. Nevertheless, if treatment is delayed, high morbidity and mortality rates result. Comprehensive treatment aims to relieve the obstruction, to close the biliodigestive fistula and to prevent further gallbladder complications. The surgeon who deals with this type of illness should tailor the treatment plan according to the age, general condition, and intraoperative findings of the individual patient. This paper presents a case report of an 88-year-old woman with gastric outlet obstruction caused by a gallstone.

Five-year survival following hepatic resection after neoadjuvant therapy for nonresectable colorectal.

BACKGROUND: Surgical resection is the most effective treatment for colorectal liver metastases but only a minority of patients are candidates for a potentially curative resection. Our experience with neoadjuvant chemotherapy followed by resection and five years survival analysis of the patients treated is presented. METHODS: Between February of 1988 and September of 1996, 701 patients with unresectable colorectal liver metastases were treated with neoadjuvant chemotherapy. Four categories of nonresectable disease were defined: large size, ill location, multinodularity, and extrahepatic disease. Liver resection was performed in those patients whose disease became resectable. After resection, the patients were followed up every 3 months. A 5-year survival analysis by the different categories described was performed. RESULTS: Ninety-five patients (13.5%) were found to be resectable on reevaluation and underwent a potentially curative resection. There was no perioperative mortality, and the complication rate was 23%. As of December of 1999, 87 patients have completed 5 years of follow-up. The overall 5-year survival is 35% from the time of resection and 39% from the onset of chemotherapy. Respective 5-year survival rates are 60% for large tumors, 49% for ill-located lesions, 34% for multinodular disease, and 18% for liver metastases with extrahepatic disease. In this latter category, however, a 35% 5-year survival was found when all the patients with extrahepatic disease were analyzed rather than only those for whom extrahepatic disease was the main cause of nonresectability. CONCLUSIONS: Neoadjuvant chemotherapy enables liver resection in some patients with initially unresectable colorectal metastases. Long-term survival is similar to that reported for a priori surgical candidates.

Influence of preoperative transarterial lipiodol chemoembolization on resection and transplantation for hepatocellular carcinoma in patients with cirrhosis.

OBJECTIVE: To investigate the impact of preoperative transarterial lipiodol chemoembolization (TACE) in the management of patients undergoing liver resection or liver transplantation for hepatocellular carcinoma. PATIENTS AND METHODS: TACE was performed before surgery in 49 of 76 patients undergoing resection and in 54 of 111 patients undergoing liver transplantation. Results were retrospectively analyzed with regard to the response to treatment, the type of procedure performed, the incidence of complications, the incidence and pattern of recurrence, and survival. RESULTS: In liver resection, downstaging of the tumor by TACE (21 of 49 patients [42%]) and total necrosis (24 of 49 patients [50%]) were associated with a better disease-free survival than either no response to TACE or no TACE (downstaging, 29% vs. 10% and 11 % at 5 years, p = 0.08 and 0.10; necrosis, 22% vs. 13% and 11% at 5 years, p = 0.1 and 0.3). Five patients (10%) with previously unresectable tumors could be resected after downstaging. In liver transplantation, downstaging of tumors >3 cm (19 of 35 patients [54%]) and total necrosis (15 of 54 patients [28%]) were associated with better disease-free survival than either incomplete response to TACE or no TACE (downstaging, 71 % vs. 29% and 49% at 5 years, p = 0.01 and 0.09; necrosis, 87% vs. 47% and 60% at 5 years, p = 0.03 and 0.14). Multivariate analysis of the factors associated with response to TACE showed that downstaging occurred more frequently for tumors >5 cm. CONCLUSIONS: Downstaging or total necrosis of the tumor induced by TACE occurred in 62% of the cases and was associated with improved disease-free survival both after liver resection and transplantation. In liver resection, TACE was also useful to improve the resectability of primarily unresectable tumors. In liver transplantation, downstaging in patients with tumors >3 cm was associated with survival similar to that in patients with less extensive disease.