Subtotal Thigh Flap for Large Abdominal Wall Defect Reconstruction in Patient With Recurrent Dermatofibrosarcoma Protuberans: A Case Report and Literature Review.

BACKGROUND: Harvesting an adequate-sized flap is challenging for reconstructing large defects on the abdominal wall. A subtotal thigh flap would be one of the choices as it provides a well-vascularized large flap with muscle components. Moreover, dermatofibrosarcoma protuberans (DFSP) is a low-grade dermal neoplasm with a high recurrence rate. There is still no consensus on the extent of resection to prevent a recurrence. OBJECTIVES: We present a case of a patient who underwent the reconstruction of a large abdominal wall defect with a subtotal thigh flap after the resection of recurrent DFSP. MATERIALS AND METHODS: A 59-year-old man killed from a recurrent huge mass in the lower abdomen with an invasion of the small intestine. His baseline characteristics and records of operations, medications, and outcomes were reviewed. RESULT: After tumor excision, a 28 × 30-cm subtotal thigh flap was harvested from his left thigh to reconstruct the abdominal defect. A microvascular anastomosis with left deep inferior epigastric vessels was made eventually. The flap was in good condition, and the donor site was covered with a split-thickness skin graft. CONCLUSIONS: Subtotal thigh flap may be considered for large abdominal wall defect reconstruction as it allows good perfusion of relatively large skin paddles compared with other free flaps. Also, patients with DFSP need definite margin-free resection and close follow-up to prevent a recurrence.

Heterotopic pancreas involved muscularis propria mimicking mesenchymal tumor in stomach.

Heterotopic pancreas is defined as pancreatic tissue found outside the usual anatomic location of the pancreas. It is often an incidental finding and can be found at various sites in the gastrointestinal tract. It is usually asymptomatic, however, symptoms such as abdominal pain, nausea, vomiting or even gastrointestinal bleeding could be possible. In this report, a 38-year-old woman with epigastric fullness and endoscopic impression of the gastric submucosal tumor is described. Preoperative surveys including endoscopic ultrasound and computed tomography suggested gastric mesenchymal tumor such as leiomyoma. A surgical operation was arranged with a diagnosis of the heterotopic pancreas as confirmed by pathological assessment.

Acute cholecystitis after minimally invasive coronary artery bypass grafting: a report 2 cases.

Acute cholecystitis following coronary artery bypass grafting (CABG), although rare, is a potentially life-threatening consequence of prolonged cardiopulmonary bypass (CPB)procedures. Minimally invasive direct coronary artery bypass (MIDCAB), performed without sternotomy and without CPB, is perhaps the least traumatic type of CABG procedure.Nevertheless, we present 2 cases of acute cholecystitis following MIDCAB, demonstrating that a MIDCAB does not eliminate the risk of gastrointestinal complications. Our experience with these cases points to the benefits of early and aggressive management in the treatment of acute cholecystitis after MIDCAB.

Laparoscopic common bile duct exploration with T-tube choledochotomy for the management of choledocholithiasis.

Although laparoscopic cholecystectomy (LC) has become the gold standard for the management of gallstone disease, the application of laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis has been slower. The aim of this study is to determine the feasibility and effectiveness of LCBDE. A retrospective cohort study was conducted to compare LCBDE (n = 82) with conventional common bile duct exploration (CCBDE) (n = 75) and endoscopic sphincterotomy (EST) (n = 80) in the management of choledocholithiasis. All our LCBDEs were performed through choledochotomy with T-tube placement. The mean operative time of the LCBDE group (124 +/- 48 minutes) was not significantly longer then the CCBDE group (118 +/- 35 minutes), while the postoperative hospitalization was shorter in both the LCBDE (8 +/- 5 days) and EST (9 +/- 4 days) groups than in the CCBDE (13 +/- 6 days) group. In the LCBDE group, 14 patients (17.1%) required postoperative choledochoscopy to clear residual stones through the T-tube tract. The only mortality occurred in the CCBDE group. The morbidity rate was 3.7% (3/82) in the LCBDE group, including bile leakage in 1 case and bile peritonitis in 2 cases; 6.7% (5/75) in the CCBDE group, including atlectasis in 2 cases, sepsis in 1, and wound infection in 2. There were 2 cases of postoperative pancreatitis (2.5%; 2/80) in the EST group. The difference in the average number of sessions needed for complete clearance of choledocholithiasis in each group was statistically significant (EST, 1.46 +/- 0.67; LCBDE, 1.23 +/- 0.42; and CCBDE, 1.09 +/- 0.28; P < 0.0001). Our results suggested that EST and LCBDE tended to require more therapeutic sessions then CCBDE, although these sessions were less invasive. The benefits of LCBDE include minimal invasiveness, concurrent treatment of gallbladder stone and CBD stones in a single session, and a shorter postoperative hospital stay. However a longer learning curve is needed. Selection of the most suitable therapeutic option for individual patients by an experienced surgeon gives the most benefits to patients.

Management of bile leakage after laparoscopic cholecystectomy based on etiological classification.

PURPOSE: To analyze and classify bile leakage after laparoscopic cholecystectomy (LC) according to its etiology. This classification will help to determine the most appropriate management strategy, whereby unnecessary intervention can be avoided. METHODS: We examined the medical records of 16 patients in whom bile leakage occurred as a complication of LC. RESULTS: Bile leakage was classified according to its cause into the following groups: insecure closure of the cystic duct stump (n = 3); retention of a common bile duct (CBD) stone (n = 1); CBD injury (n = 10); unsuspected accessory bile ducts (n = 1); and unknown origin (n = 1). The management strategies included observation (n = 3), laparoscopic intervention with drainage (n = 4), laparotomy with drainage (n = 3), and laparotomy with Roux-en-Y choledochojejunostomy for CBD transection (n = 6). All 16 patients recovered uneventfully with similar hospitalization. CONCLUSIONS: Bile leakage is not always caused by bile duct injury, and it would be inappropriate to attribute leakage to bile duct injury if there is a retained CBD stone, an unsuspected accessory duct, or an unsecured cystic duct stump. Thus, the management of each condition should vary accordingly. Reviewing a videotape of the surgery and early cholangiogram can help to establish the etiological diagnosis and select the most appropriate course of action.

Mesenteric lymphangioma causing bowel obstruction: report of one case.

A 6-year-old female was sent to our ER due to nausea, vomiting and abdominal distension for 2 days. This child had a history of constipation and failed intermittent medical treatment for 2 years. Her plain abdominal X-ray showed multiple intestinal loops and under the impression of acute abdomen with mechanical intestinal obstruction, an exploratory laparotomy was performed. A huge mesenteric tumor was discovered to be the cause of the intestinal obstruction; the involved bowel and the mesenteric lymphangioma were resected and primary anastomosis was done. Mesenteric cystic lymphangioma is a rare cause of bowel obstruction; preoperative diagnosis is difficult due to silent clinical course and lack of awareness of the clinical and morphological features of this disease. The case is presented along with a review of literature with the conclusion that a high index of suspicion is recommended. An abdominal ultrasonography may be recommended to evaluate a long-term constipated child to ascertain that any cystic lesion will not be missed.