Laparoscopic longitudinal pancreaticojejunostomy for chronic pancreatitis: Systematic review of the literature.

BACKGROUND: Longitudinal pancreaticojejunostomy, also known as modified Puestow or Partington-Rochelle procedure, is a technique for the treatment of chronic pancreatitis. It is usually performed by laparotomy, but in a very small number of cases it has been performed using a laparoscopic or robot-assisted approach. We carried out a systematic literature review to clarify the current status of laparoscopic longitudinal pancreatojejunostomy (LLPJ). METHODS: Adhering to the PRISMA guidelines, a systematic search for LLPJ was performed in PubMed, Embase, and Cochrane Library, for articles published up to 31 December 2017. RESULTS: 357 articles were evaluated for eligibility and 17 were included for critical appraisal: eight case reports, eight retrospective case series, and one series of cases and controls without randomization. All of them had a grade of recommendation C and a level of evidence 4 according to the CEBM. Patients were relatively young (mean age 37 years), with a slight preponderance of males (ratio 1.3: 1). All had long-standing disease, ERCP prior to surgery and a dilated pancreatic duct (mean 11 mm). The surgery was usually performed laparoscopically using four trocars; the conversion rate was low (5%), bleeding was minimal, the morbidity rate was 11% and no mortality was reported. Mean hospital stay was 5.6 days. The follow-up period varied but was usually short (less than two years). The results for pain control were very good since 90% of patients reported no pain, although visual analog scales were rarely used. CONCLUSIONS: In conclusion, LLPJ seems to be a safe, feasible and effective technique in patients with chronic pancreatitis. However, the number of descriptions published to date is very small, and there are no studies with high scientific evidence comparing LLPJ with open surgery or with endoscopic treatment that would allow us to draw firmer conclusions at the present time.

Is radical surgery feasible in liver hydatid cysts in contact with the inferior vena cava?

BACKGROUND: Cysts in contact with the inferior vena cava (IVC) represent a challenge for hepato-pancreatico-biliary surgeons. Although the literature on the topic is scarce, the most widely accepted approach is conservative surgery. Partial cyst resection is recommended, because radical resection is considered a high-risk procedure. STUDY DESIGN: This was a retrospective study over the period January 2007-December 2012. We operated on 103 patients with liver hydatidosis. A total of 32 patients (31 %) had a liver cyst in contact with the IVC. We proposed a cyst classification based on location of the cyst and length of contact and degrees of involvement of the IVC. RESULTS: Median size of the contacting cyst measured by computed tomography (CT) was 12 cm. On CT, median length of contact with the IVC was 37 mm. The median degree of involvement was 90°. Radical surgery was performed in 20 patients (62.5 %). No IVC resection was done. Morbidity rate was 28 %, and mortality was 3 %. In follow-up (median 27 months), no relapses or problems related to IVC flow were detected. Postoperative stay and transfusion rate were higher in the conservative surgery group, but these patients presented fewer complications. There was no relationship between circumferential grades and length of contact with the IVC and the type of surgery performed. CONCLUSIONS: Liver hydatid cysts in contact with the IVC are large cysts usually located in the right liver. They do not normally cause clinical symptoms related to IVC contact. Radical surgery is feasible, and was performed in 60 % of our series, but it is technically demanding. We propose a classification of cysts in contact with the IVC.

Cysto-biliary communication in liver hydatidosis.

BACKGROUND: Liver hydatidosis is a severe health problem in endemic areas. Due to migration from these countries to other zones, now it is a worldwide problem. Liver hydatidosis can provoke many complications (abscess, fistula to adjacent organs, migration, etc.), but the most frequent and one of the most severe complication is the communication between the cyst and the biliary tree. AIM: The aim of this study is to perform a review on the epidemiology, clinical features, diagnostic methods, and therapeutic options to treat the communication between the cyst and the biliary tree. RESULTS: Due to the lack of randomized clinical trial or meta-analysis on this topic, we performed a classical review and included our personal algorithm. CONCLUSIONS: The communication between the cyst and the biliary tree varies from a small communication to a frank intrabiliary rupture. The percentage of patients with the communication between the cyst and the biliary tree is not well known because there is no accepted definition. The therapeutic options are multiple and related to the size of the communication, the location of the cyst, and the experience of the hepatobiliary surgeon. ERCP is now an important tool for the treatment of the communication between the cyst and the biliary tree.

Systematic review of the mesopancreas: concept and clinical implications.

BACKGROUND: In 2007, Gockel et al. coined the term mesopancreas (MP). In the next 10 years, a limited number of publications about MP have been published, but little is known about the oncological benefit of MP resection. We performed a systematic review of the literature on MP. METHODS: An electronic search was performed in PubMed, EMBASE, Cochrane, Latindex, Scielo, and Koreamed databases until 15 June 2017 to identify all published articles dealing with the subject of MP. Some language restriction was done (Chinese and Rumanian). RESULTS: The search yielded 51 articles; 28 articles were selected as relevant. All were retrospective studies focused more on describing technical variants, feasibility and safety than on the cancer results. The R0 rate in patients with MP resection ranged between 57 and 96.7%. In all the articles with a control group, the R0 rate was higher in the MP excision group. Survival data were explicitly stated only in five series. CONCLUSION: MP is a difficult-to-excise retropancreatic area. In theory, it is agreed that MP excision raises the rate of R0 resections, which in turn reflected in an improvement in the oncological results; however, at present there are no randomized studies to prove this. Achieving a worldwide consensus on its concept, landmarks, excision technique and oncological results is essential.

[Liposuction in children: clinical utility]. / Liposucción en niños: utilidad clínica.

Liposuction has become one of the most frequent aesthetic procedures. The "typical" patient is a young female with fat deposits in the trochanteric region. Gradually the safety of the technique together with the high satisfaction rate of the patients have contributed to the widening of its indications to other pathologies of the adipose tissue in different age populations. However, there is scarce literature regarding liposuction in childhood. The authors present their experience with liposuction as the treatment of congenital as well as acquired lipodystrophies in the paediatric age. Some particular details of the technique are described and the advantages of liposuction versus open surgery in these cases are analyzed.

A new technique for the treatment of palpebral bags.

A new technique for the treatment of palpebral bags is presented. The technique consists of returning fat to the orbital cavity and retaining it by means of a continuous suture (with nonabsorbable filament) of the capsulopalpebral fascia to the periosteum of the lower orbital rim. The anatomic basis for the technique, after examination of the relevant literature and dissection on fresh cadavers, is analyzed. The procedure followed and results obtained are described in detail. Evaluation of the results suggests to the authors that this might be the method to be applied in the majority of patients.

Two cases of nevoid basal cell carcinoma syndrome.

Motivated by the diagnosis and treatment of two cases of nevoid or Goltz-Gorlin syndrome, we have taken a brief look at the literature and present these two cases, which display the four principal features defining this syndrome: multiple basal cell carcinomas, maxillary cysts, skeletal anomalies, and ectopic calcifications. Certain aspects are emphasized, including the association in one of them of basal cell carcinomas with a cystic adenoma or Brooke's tumor, which, although described by other authors, is infrequent.

Lifting of the upper two-thirds of the face: supraperiosteal-subSMAS versus subperiosteal approach. The quest for physiologic surgery.

The supraperiosteal-subSMAS lifting technique, which has been performed since 1985, for the rejuvenation of the upper two-thirds of the face is described, and the results obtained in a series of 128 cases treated, emphasizing the attainment of an effective rejuvenation together with a minimum of complications and undesired effects is presented. A discussion on the two dissection planes (supraperiosteal-subSMAS versus subperiosteal) used most commonly in the lifting of the upper two-thirds of the face is presented. From an anatomohistophysiologic basis, the tissue manipulations that the two techniques mandate are discussed and evaluated. Based on these facts, the supraperiosteal-subSMAS technique is the most logical physiologically, because it produces less tissue trauma, which leads to fewer complications and a more rapid recovery to a normal social life.

Stromal tumors of the stomach. Review of our experience and reclassification of a series of patients.

OBJECTIVE: To retrospectively review a series of 12 patients operated on in our department for stromal tumor of the stomach. Clinical and morphological data, and the patients' postoperative course, were analyzed. METHODS: Medical records for 12 patients (mean age 63.3 years) were retrospectively reviewed to obtain data on clinical presentation, diagnosis and treatment. Surgical morbidity and mortality were analyzed. A pathologist reviewed the resected specimens to determine the morphological factors of prognostic value. The biological nature of the tumor was reclassified based exclusively on mitotic index, and all tumors were staged according to the TGM system. Recurrence and survival rates were also calculated. RESULTS: The most frequent clinical presentation was abdominal pain and gastrointestinal bleeding. The most sensitive diagnostic methods were computerized tomography and echographic endoscopy. Operability and resectability rates were 100% and 91.6% respectively. Local resection was done in 5 patients, partial gastrectomy in 5, and extended total gastrectomy in 1. Histologically, 6 cases were muscular tumors (2 leiomyomas, 3 low-grade leiomyosarcomas and 1 high-grade leiomyosarcoma), 2 were gastrointestinal autonomic nerve (GAN) tumors, and 4 were pure stomal tumors. The morbidity rate was 33.3% and the mortality rate was 8.3% (1 patient). All patients were followed up: 1 patient each died after 9 months and 4 years, 1 developed liver metastases after a disease-free interval of 14 months, and the other 9 patients were still alive and free of disease after intervals ranging from 4 months to 7 years. CONCLUSIONS: Stromal tumors include a group of tumors which may present muscular differentiation (the most frequent type), neural differentiation (GAN tumors) or no differentiation at all (pure stromal tumors). The mitotic index is the most valid parameter to determine biological nature, considering that classification as a benign tumor requires the total absence of mitoses. Treatment was mostly surgical, and local resection with adequate safety margins was effective. Prognosis was relatively good, but long-term follow-up is needed to assess the malignant potential of these tumors.

The sliding fat pad technique with use of the transconjunctival approach.

BACKGROUND: The different possibilities for management of excessive or pseudoherniated fatty tissues in the lower eyelid are a subject of lively discussion in the field of aesthetic surgery. OBJECTIVE: We present a technique that uses the transconjunctival approach for the simultaneous treatment of excessive or pseudoherniated fat and marked periorbital sulci, which is based on the sliding fat pad technique first described by Loeb. METHOD: Incision of the conjunctiva, inferior tarsal muscle, and capsulopalpebral fascia is performed about 3 mm above the fornix. Dissection is performed following the preseptal-suborbicularis dissection plane, freeing the arcus marginalis, traversing the malar septum, and passing below the palpebromalar and nasojugal sulci. Retraction is performed with a specially designed transconjunctival retractor and lower-lid retractor. The orbital septum is opened and blunt dissection of the inner and central fat bags is performed. The fat flap is secured with transcutaneous stitches tied over small pieces of silicone. A transcutaneous-transconjunctival suture is performed to reduce postoperative discomfort and promote scarring of the transected planes. RESULTS: We have achieved aesthetically satisfactory results with no major complications. CONCLUSIONS: The sliding fat pad technique by the transconjunctival approach is a new technique that allows a natural and effective simultaneous correction of the lower eyelid, periorbital sulci, and mild cutaneous excesses with no disruption of the muscular and cutaneous planes, prompt recuperation, and a very low incidence of adverse effects when performed by surgeons experienced in transconjunctival procedures. (Aesthetic Surg J 2001;21:487-492.).

Walled-off pancreatic necrosis.

Acute severe pancreatitits may be complicated by the development of 'walled-off pancreatic necrosis' (WOPN), which is characterised by a mixture of solid components and fluids on imaging studies as a consequence of organised pancreatic tissue necrosis. We present here an overview of the definition, clinical features, and diagnostic and therapeutic management of this clinical condition, which is mostly based on consensus as adequate clinical trials are lacking.

Three trocars laparoscopic resection of angiomyolipoma of the liver.

Angiomyolipoma of the liver (AML) is an infrequent neoplasm composed of three tissues (adipose, muscle and vessels). In spite of advances in radiology, preoperative correct diagnosis is difficult. Clasically, a conservative management strategy was adopted in patients with asymptomatic tumors less than 5 cm with undoubtful diagnosis. But after publishing some few cases of malignant angiomyolipoma a more radical has been advocated. Laparoscopic resection of liver tumors is becoming a excellent approach for operating on benign liver tumors. Usually is performed using five trocars but in some cases a less invasive technique with three trocars could be used. We present a laparoscopic resection of liver angiomyolipoma in a 65 year-old male using only three trocars and also discuss the optimal management of AML and technical tips of three-trocar technique.

Postmastectomy reconstruction by a contralateral abdominomammary flap.

A new technique for breast reconstruction following mastectomy is suggested. It is based on three principles: (1) use of excess abdominal skin that is stretched upward; (2) use of skin from the healthy breast, when breast reduction or corrective ptosis is necessary; and (3) transposition of skin and excess subcutaneous tissue from the abdomen and the healthy breast, as a contralateral flap (abdominomammary flap), but with a homolateral and a heterolateral pedicle. The abdominomammary flap, adequately deepithelialized, provides material for subclavicular and axillary contouring, as well as a first, partial, or total covering of the prosthesis, while the cutaneous covering is obtained by stretching upward the thoracoabdominal skin of the affected side.

Supraperiosteal lifting of the upper two-thirds of the face.

This paper presents an alternative to subperiosteal lifting (mask-lift), consisting in making the dissection following the natural plane of the sub-SMAS in the upper and middle thirds of the face. It constitutes what we have called supraperiosteal lifting of the upper two-thirds of the face, or suspension of the fronto-temporo-periorbito-malar SMAS. In our experience, this technique offers certain advantages and has fewer complications than subperiosteal lifting, allowing natural and harmonious rejuvenation of the upper two-thirds of the face, leaving no sequelae other than the coronal scar which is concealed in the scalp. The article describes the surgical procedure and the results obtained, as well as its frequent association with other procedures such as blepharoplasty, modification of the orbital bone rim, malar augmentation, rhinoplasty, cervicofacial lifting etc.

The rationalization of liposuction: toward a safer and more accurate technique.

Liposuction, like all surgical procedures, is subject to complications and unfavorable results. Since it is a closed procedure and departs from the usual concept of surgery, its practice is, to a large extent, based on subjective intraoperative estimation. Therefore, it is liable to errors that might have serious local and systemic consequences. In an attempt to improve the technique, the authors have designed new instruments: the "tunnel tracer" and the "guided cannulae." They provide the basis for systematizing the procedure and applying it in a more rational manner. With these instruments and the methodology described in this article, over the last three years we have obtained very satisfactory results and notable reduced morbidity. The advantages are less trauma, less risk, less hemorrhage, less effort for the surgeon, and greater precision.