Rescue strategy for advanced liver malignancy with retrohepatic inferior vena cava thrombi: experience to promote surgical oncological benefit.

BACKGROUND: The prognosis of advanced liver malignancy with inferior vena cava (IVC) thrombi is poor. Many therapeutic policies are challenging for long-term prognosis. We performed the modified effective technique of transdiaphragmatic intrapericardial IVC isolation for curative resection of IVC tumors and prolonged survival time. METHODS: Between 2003 and 2015, 10 patients, sustained liver malignancy with IVC thrombi, underwent surgical intervention. Liver resection with thrombectomy under total hepatic vascular exclusion via the transdiaphragmatic intrapericardial IVC isolation method was performed for these 10 patients. The first 4 patients underwent retrohepatic IVC resection in order to complete resection, and the other 6 patients preserved the retrohepatic IVC. The last 3 patients received preoperative locoregional therapies, and all 10 patients received postoperative adjuvant chemotherapies immediately. RESULTS: All 10 patients underwent gross en bloc tumor resections with thrombectomy with R0 resection. There was no surgical mortality. Shortening of operation time and reduction of both intraoperative blood loss and hospital stay were demonstrated in the last 6 patients with preserving the retrohepatic IVC. However, similar time to recurrence and survival time were noted in the first 7 patients. The last 3 patients, who had received preoperative locoregional therapies, have better disease-free survival time. CONCLUSION: Simplified surgical procedure combined with preoperative locoregional therapies and rapid postoperative adjuvant treatment may provide a greater advantage for these patients.

Oncological safety and outcomes of nipple-sparing mastectomy with breast reconstruction: a single-centered experience in Taiwan.

INTRODUCTION: Nipple-sparing mastectomy has become a contemporary surgical treatment that achieves improved cosmetic outcomes for patients with breast cancer in Western countries. We examined oncological and cosmetic outcomes in Asian women who underwent nipple-sparing mastectomy in Taiwan. METHODS: Between 2006 and 2011, 42 patients with breast cancer who underwent 44 nipple-sparing mastectomy operations with immediate reconstruction at the Tri-Service General Hospital were reviewed. The cancer type, tumor stage, reconstruction method, presence of local recurrence, presence of distant metastasis, mortality, and complications were assessed and documented. Questionnaires were used to assess and rate patients' satisfaction with regard to appearance, sensation, symmetry, color, arousal, and texture. RESULTS: The mean follow-up period was 40.9 months (median, 45.5 months; range, 13-72 months). Among the 42 cases, only one case (2.4%) of local recurrence was observed and treated by nipple-areola complex resection. The overall complication rate was 25%, with nipple necrosis comprising 13.6%. CONCLUSION: Nipple-sparing mastectomy is a safe procedure in properly selected patients with breast cancer. This procedure yields similar oncological safety and cosmetic outcomes among Asians and women from Western countries.

Diabetic foot ulcers combination with lower limb lymphedema treated by staged charles procedure: case report and literature review.

Primary or secondary, lymphedema is lymphatic dysfunction which results in protein-rich interstitial fluid accumulated in the skin and subcutaneous tissue. In developed countries, surgical resection of regional lymph nodes or chronic inflammation process is the most common etiology of lymphedema instead of parasite infection seen in developing countries. Patients with lymphedema sustain either cosmetic or functional problems, and several studies have indicated the potential risk, though not high, transforming lymphedema to lymphangiosarcoma. Here we introduce a simple idea with staged Charles procedure by a case report to decrease the size of wound healing in each procedure and decreasing the rate of surgical complication.

Transumbilical Silicone Implants Breast Augmentation (TUSBA).

Transumbilical breast augmentation with pre-filled silicone implants has been performed previously, but technical challenges remain to accommodate more implant options and dissection planes. We aimed to demonstrate the feasibility of transumbilical breast augmentation using various types of pre-filled silicone implants (TUSBA), and its applicability for subglandular, subfascial, dual-plane implantation. In the early stage, TUSBA was primarily performed using endoscope-assisted blunt dissection, and later converted to full endoscopy dissection to achieve better results. Endoscope was used to confirm the pocket and check bleeding for both groups. For endoscope-assisted group, surgical techniques were modified from conventional TUBA. In full endoscopy TUSBA, the entire dissection process was performed under endoscopic monitoring. Preliminary data of patients undergoing TUSBA from June 2016 to April 2021 were retrospectively reviewed. Breast implants with smooth, textured or nanotextured surface properties and round or anatomical shapes were used, with sizes up to 500 mL. Seventy-four patients with mean age 36.4 years (range: 21-55 years) were enrolled in this study. Follow-up ranged from 1 month to 4 years and 6 months (mean: 15.6 months). No excessive postoperative pain in breast or abdomen was reported. Surgery outcomes were aesthetically pleasing in both groups. In the endoscope-assisted group, 3 (4.6%) required major revisional procedures. No revision was required in the full endoscopy group. TUSBA with various types of silicone implants is feasible, and accommodable to all dissection planes. Full endoscopy technique is helpful in reducing the higher complication rate.

Reconstruction of the complete loss of upper and lower lips with a chimeric anterolateral thigh flap: a case report.

It is difficult to totally reconstruct the lips and achieve good functional and aesthetic results, such as oral sphincter function, sensation, appearance, color, and movement. There have been few reports of reconstructing complete lip defects. We present a case of completely reconstructing the lip defects of a 55-year-old patient who had verrucous carcinoma of the buccal mucosa and lips. Extensive ablation was performed by wide bilateral excision of the buccal mucosa and marginal resection of the anterior mandible and both lips. The tongue, partial tongue base mucosa, and retromolar trigone were preserved. To reconstruct and resurface the intraoral and lip defects nearly totally, we applied a free anterolateral thigh (ALT) flap in chimeric style with two independent sets of perforators and skin islands. To achieve better oral function and cosmetics, revisions of the ALT flap, full-thickness scrotal skin grafting, autologous fat grafting, and skin tattooing were done in stages. Postoperative oral sphincter function was obtained without drooling; the general appearance of the lips was also acceptable.

Use of a totally implantable access port through the external jugular vein when the cephalic vein approach is not feasible.

BACKGROUND: We report our experience of using a totally implantable access port (TIAP) through the external jugular vein (EJV) when the cephalic vein (CV) approach is not feasible. METHODS: We reviewed 197 cases involving TIAP implantation through the EJV in a single medical center between January 1995 and January 2009. All the ports were implanted after the CV approach was found unfeasible. Patient characteristics, operating time, and early and late complications were recorded. RESULTS: The mean patient age was 50 years (range: 33-75). The mean operating time was 54.5 ± 7.5 minutes. Early complications within the first 30 postoperative days included port hematoma (2%) and catheter migration (2%). The late postoperative complications included catheter occlusion (2.5%), venous thrombosis (2%), and port infection (1.5%). There were no complications associated with TIAP disconnection. CONCLUSIONS: The EJV approach is an easy and safe alternative method for TIAP implantation when the CV approach is not feasible. This method can avoid conversion to percutaneous puncture of the subclavian vein, which could result in life-threatening complications such as pneumothorax and hemothorax. In patients with breast cancer or those who are contraindicated for TIAP implantation on the opposite side, the EJV cutdown approach provides an alternative route with comfortable and satisfactory results as complications with this approach are rare.

Retransplant as Rescue Treatment for ABO-Compatible Living-Donor Liver Transplant Related Antibody-Mediated Rejection: A Case Report.

Antibody-mediated rejection after liver transplant, especially when the donor is not a direct relative; it is associated with additional inconvenience for patients. We encountered a case in which antibody-mediated rejection because of de novo donor specific antibodies against donor human leukocyte antigen developed 6 months after ABO-compatible living-donor liver transplant and was treated with retransplant. A 38-year-old man with hepatitis B virus-related hepatocellular carcinoma underwent living-donor liver transplant with a graft from his wife. Six months later, he experienced fatigue and jaundice. Liver biopsy revealed C4d deposits, and histologic examination showed an antibody-mediated rejection pattern. We re-evaluated recipient-donor human leukocyte antigen matching and tested the patient's blood for antihuman leukocyte antigen donor-specific antibodies against donor human leukocyte antigen. De novo auto-antibodies against human leukocyte antigen-DQ6 were identified by Luminex single antigen beads.Because exhausting all treatment options, a rescue second living-donor liver transplant was planned with the patient's stepdaughter as the donor. Pretransplant human leukocyte antigen matching was performed, and the patient was discharged without event. Two months later, hyperbilirubinemia was noted, and a residual common bile duct from the first donor with chronic fibrosis and stricture was strongly suspected. Redo hepaticojejunostomy was successfully performed, with no problems during 1-years' follow-up. Thus, liver retransplant could be a rescue treatment for antibody-mediated rejection complicated with hepatic failure.

Clinical applications of the pedicled anterolateral thigh flap in reconstruction.

BACKGROUND: Reconstruction of extensive defects of the lower abdomen, penoscrotum, trochanter, groin and knee without using complex microsurgery is a reconstructive challenge. Pedicled anterolateral thigh (ALT) flaps offer many advantages over other regional flaps for this purpose, such as the large skin area and soft-tissue availability, a remarkable pedicle length, and possessing multiple components and reliability. We present our experience of using pedicled ALT flaps for repairing various defects. METHODS: From September 2006 to December 2013, 42 pedicled ALT flaps were used in 41 patients for defects of the lower abdomen (three patients), trochanter (26 patients), penoscrotum (10 patients), groin (one patient) and knee (one patient). Twenty-eight were men and 13 were women, and their mean age was 70.5 years (range, 22-103 years). The characteristics of the patients' age, sex, cause, flap size, flap component, follow-up and donor sites were recorded. RESULTS: The flap size ranged from 8 × 5 cm (40 cm2 ) to 11 × 18 cm (198 cm2 ). The length of the pedicle ranged from 9 to 16 cm, which was enough to reach the defect without tension. No surgery-related mortality occurred. In 34 flaps, donor sites were closed primarily and eight underwent split-skin grafting. Satisfactory coverage was achieved in all patients. CONCLUSION: Our experience has shown the wide arc of rotation, large skin replacement potential, multiple components and reliability of pedicled ALT flaps. They are technically simple to apply as myocutaneous/fasciocutaneous flaps with minimal donor site morbidity.

Inferior Gluteal Artery Perforator Flap for Sacral Pressure Ulcer Reconstruction: A Retrospective Case Study of 11 Patients.

Despite advances in reconstruction techniques, sacral pressure ulcers continue to present a challenge to the plastic surgeon. The flap from the gluteal crease derives blood supply from the inferior gluteal artery perforator (IGAP) and reliably preserves the entire contralateral side as a donor site. To incorporate the IGAP in the reconstruction of sacral pressure ulcers, a skin paddle over the gluteal crease was created and implemented by the authors. Data from 11 patients (8 men, 3 women; mean age 67 [range 44-85] years old) whose sacral ulcers were closed with an IGAP flap between June 2006 and May 2012 were retrieved and reviewed. All patients were bedridden; 1 patient in a vegetative state with a diagnosis of carbon monoxide intoxication was referred from a local clinic, 2 patients had Parkinson's disease, and 8 patients had a history of stroke. The average defect size was 120 cm(2) (range 88-144 cm(2)). The average flap size was 85.8 cm(2) (range 56-121 cm(2)). Only 1 flap failure occurred during surgery and was converted into V-Y advancement flap; 10 of the 11 flaps survived. After surgery, the patients' position was changed every 2 hours; patients remained prone or on their side for approximately 2 weeks until the flap was healed. After healing was confirmed, patients were discharged. Complications were relatively minor and included 1 donor site wound dehiscence that required wound reapproximation. No surgery-related mortality was noted; the longest follow-up period was 24 months. In this case series, flaps from the gluteal crease were successfully used for surgical closure of sacral pressure ulcers. This flap design should be used with caution in patients with hip contractures. Studies with larger sample sizes are needed to ascertain which type of flap is best suited to surgically manage extensive pressure ulcers in a variety of patient populations.

Asymptomatic pulmonary nodules in a patient with early-stage breast cancer: Cryptococcus infection.

In breast cancer patients, pulmonary nodules are frequently considered a metastatic disease or primary lung tumor. We report the case of a 53-year-old woman with early-stage breast cancer (T1micN0M0) presenting with asymptomatic pulmonary nodules in the left upper lobe at follow-up 6 years after she underwent a mastectomy. A presumptive diagnosis of pulmonary metastasis was made, and the patient underwent a video-assisted thoracoscopic lung biopsy. Pathology showed granulomatous inflammation with Cryptococcus infection. Subsequently, antifungal therapy was prescribed, and full recovery followed. We demonstrate the importance of differentiating between pulmonary Cryptococcus infection and metastasis in breast cancer patients for correct management. The relationship between pulmonary Cryptococcus infection and breast cancer is also discussed.