Successful Surgical Treatment of Intractable Chylous Ascites Using the Lymphatic Cable Flap: A Retrospective Review Study.

OBJECTIVE: For evaluation of a novel surgical procedure for the treatment of chylous ascites. Chylous ascites is a debilitating condition associated with high morbidity and mortality rates. At least one-third of patients are refractory to medical therapy and may warrant further treatment. Traditional methods involving ligation of lymphatic fistulas or small bowel resection do not address the basic pathophysiologic mechanism of the underlying obstruction, and identification of chyloperitoneal fistulas may be challenging. METHODS: A novel flap based on deep inferior epigastric vessels with its surrounding lymphatic fatty tissue was designed in this study and transferred into abdominal cavity, with anastomosis to the fourth jejunal vessels. Three consecutive cases with chylous ascites treated by this vascularized lymphatic cable transfer were retrospectively reviewed. RESULTS: All three patients recovered from chylous ascites after the lymphatic cable transfer and tolerated regular diet well, with follow-up of 3 years at least. CONCLUSIONS: Lymphatic cable flap based on the deep inferior epigastric vessels could be a potential option for treatment of intractable chylous ascites, with safe and successful long-term outcomes in three consecutive patients. The proposed functional mechanism of the flap is bypass of the obstructed intra-abdominal lymphatics to an extraperitoneal route as well as local lymphangiogenesis.

Second-trimester diagnosis of complete trisomy 9 associated with abnormal maternal serum screen results, open sacral spina bifida and congenital diaphragmatic hernia, and review of the literature.

OBJECTIVES: To present the prenatal diagnosis of complete trisomy 9 and to review the literature CASE: A 25-year-old primigravida woman was referred for amniocentesis at 19 weeks' gestation because of abnormal maternal screen results showing an elevated maternal serum alpha-fetoprotein (MSAFP) level and a low maternal serum free beta-human chorionic gonadotrophin (MSfreebeta-hCG) level. RESULTS: Genetic amniocentesis revealed a karyotype of 47,XX,+9 in the amniocytes and an elevated amniotic fluid AFP level. Ultrasonography demonstrated intrauterine growth restriction, left congenital diaphragmatic hernia, fetal ascites, a sacral spina bifida, a horseshoe kidney, and absence of amniotic fluid. Ultrafast magnetic resonance imaging scans further depicted detailed anatomical configurations of the major congenital malformations. The pregnancy was terminated subsequently. The proband postnatally manifested characteristic facial dysmorphism, limb deformities, and an open sacral spina bifida with myelomeningocele. Cytogenetic analysis of the skin fibroblasts revealed a karyotype of 47,XX,+9. Molecular studies of various uncultured fetal tissues using microsatellite markers confirmed a diagnosis of complete trisomy 9 resulting from a meiotic I nondisjunction error of maternal origin. CONCLUSION: Complete trisomy 9 can be identified prenatally with advanced maternal age, sonographically detected fetal structural abnormalities, and abnormal maternal serum screen results. Fetuses with complete trisomy 9 may be associated with congenital diaphragmatic hernia, an open sacral spina bifida, elevated MSAFP, and low MSfreebeta-hCG. We suggest detailed prenatal imaging investigations and genetic analyses of multiple fetal tissues when a prenatal diagnosis of trisomy 9 is made.

Successful triplet pregnancy and delivery after oocyte donation in an infertile female with chromosome mosaicism for monosomy X, partial trisomy X, and terminal Xp deletion.

OBJECTIVE: To present successful triplet pregnancy and delivery after oocyte donation and IVF in a female with chromosome mosaicism for monosomy X, partial trisomy X, and terminal Xp deletion. DESIGN: Descriptive case study. SETTING: Large tertiary care hospital. PATIENT(S): A 23-year-old infertile woman with primary amenorrhea, short stature, and a mosaic karyotype of 45,X[10]/46,X,idic(X)(qter-->p22.3::p22.3-->qter)[40]. Fluorescence in situ hybridization investigation of the isodicentric X chromosome revealed terminal Xp deletion. INTERVENTION(S): Ultrasound and laparoscopic examinations revealed streak ovaries and a hypoplastic uterus. Oocyte donation and IVF resulted in a triplet pregnancy without major maternal complications. MAIN OUTCOME MEASURE(S): Ultrasound and laparoscopy. RESULT(S): A cesarean section was performed at 32 weeks gestation because of preterm labor and malpresentation. Three babies were delivered with birth weights of 1,514 g, 1,686 g, and 1,968 g. All infants survived and were healthy at 3 years of age. CONCLUSION(S): With careful evaluation and counseling, assisted reproductive technology can be safely used in females with mosaic X chromosome abnormalities and gonadal dysgenesis.

Sonographic appearance of the uterus after simple square suturing for rapid control of postpartum hemorrhage and preservation of fertility.

We describe the postoperative sonographic appearance of the uterus after successful use of simple square suturing for rapid control of profuse bleeding during cesarean section in a pregnant woman with uterine atony and placenta accreta. The serial sonograms initially showed decreased echogenicity in the compressed uterine area, but about 1 week after surgery, echogenicity of the compressed area returned to normal and, 2 weeks after surgery, patency of the uterine canal became evident. This report highlights the usefulness of this suturing technique for controlling such hemorrhage and the role of sonography in evaluating uterine status postoperatively.