Angel Uchikov

Small Bowel Obstruction by the Silicone Tube of the Gastric Band

A wide range of operations are used today for morbid obesity. Adjustable gastric banding (AGB) is one of the most widespread. Numerous complications after AGB are known, namely gastric perforation, band slippage, penetration of the band into stomach, port disconnection, port-site infection, etc. The authors present a case of small bowel obstruction caused by the intra-abdominal silicone tube of the gastric band in a woman with AGB performed 9 years before, with a very good result and considerable weight loss. She was operated as an emergency, and part of the terminal ileum was found incarcerated around and between the silicone tube and the anterior abdominal wall. Bowel resection for intestinal necrosis, with terminal ileostomy, was performed, followed 1 month later by an end-to-end ileo-ileal anastomosis. The patient recovered without sequelae.

Madelung Disease: On the Morphologic Criteria for Diagnosis and Treatment

To the Editor: We read with great interest the article by Ramos et al, which presents their series of 47 patients (the largest series from a single institution presented in the literature to our knowledge) and a thorough review on the benign symmetric lipomatosis (Madelung disease). As mentioned by Ramos et al, Madelung disease is more common in the Mediterranean population, which can explain the higher incidence of this condition in their series. However, in our clinical practice, we do not see it so commonly, as reported by Ramos et al. Although, benign fat tissue tumors are among the most common tumefactions in the human body, we feel that Madelung disease is not so common. In the National Organization for Rare Disorders (NORD) guide to rare diseases, the Madelung disease is included as a rare disorder and only in the list of differential diagnosis in cases with multiple lipomatosis. Guilemany et al cited an incidence of 1 to 25,000 males. Our impression from the clinical practice is that Madelung disease can be both under or over diagnosed. One of the possible reasons is probably the fact that there are no strict inclusion criteria as to the localization and dimensions in Madelung disease because reports are scarce in the literature. The typical discretion consists of massive lipomatous deposits around the neck, which gave rise to the classic descriptions of lipoma anulare colli, “buffalo hump” and “horse collar.” According to Enzi, Madelung disease is characterized by diffuse, symmetric, painless, nonencapsulated, and irreversible growth of lipomatosis, which has a tendency to recur after surgical treatment. Smith et al also defined the condition as massive fatty deposits, arranged symmetrically around the neck, shoulders, and arms. However, Guilemany et al extended the definition and concluded that the primary manifestation of Madelung disease is a painless, symmetrical adipose deposit situated on the face, neck, shoulders, upper trunk, arms, abdomen, and legs. In the report of Guilemany et al, the legs were also included in the definition. Ramos et al presented a patient (not clear for us whether male or female) with abdominal localization of the lipomatosis without any neck and shoulder manifestations (unless previously operated on). In this sense, should this patient be included in the category of Madelung disease? If we follow the “classic” definition, the answer should be “no,” because there was no upper torso and neck and shoulder localization. On the other hand, should we reserve the term “Madelung disease” only to cases corresponding to the “classic” definition? The answer should be probably negative because the Madelung disease is also called “benign symmetric lipomatosis.” In this latter definition, the localization of the fat deposits is not taken into consideration, which means that abdominal and leg localizations should be included in this group. Sometimes large encapsulated lipomas are called Madelung disease just because they are in the neck region or around the shoulder, as we have seen in our practice. In other cases, large diffuse, nonencapsulated fibromatous deposits are diagnosed as giant lipomas, although they are probably a presentation of Madelung disease. In a recent report, Silistreli et al presented a male patient with abdominal localization of a large nonencapsulated lipomatous mass, which was diagnosed as a giant lipoma. Similar case is reported by Ramos et al, which was diagnosed as Madelung disease. All this illustrates that the question whether a huge lipomatous mass is a Madelung disease and whether to include only patients with neck and upper torso lipomatosis in the category of Madelung disease remains open. May be one of the most significant criteria remains the absence of a capsule in Madelung disease along with its localization, dimensions, accompanying metabolic or endocrine disorders, alcohol abuse, human immunodeficiency virus (HIV), respiratory malignancies. Most of the patients presenting with Madelung disease demand treatment only when the “tumor” is large enough to cause functional disorders (restricted movements, dysphagia, and dyspnea) or leads to aesthetic disturbances. Dermolipectomy and suction-assisted lipectomy (SAL) represent the mainstay of surgical treatment in Madelung disease, which remains the only effective therapeutic option, as underlined by Ramos et al. We consider that both methods have their role if properly used. However, SAL yields less satisfactory results in our hands because of 2 reasons. First, the amount of the fat deposit to be aspirated is commonly too large. Second, the resultant skin redundancy can hardly adapt to the new volume and usually requires skin excision. That is why we also recommend dermolipectomy, with the SAL reserved for cases of smaller volumes and less skin redundancy. As mentioned by Ramos et al, SAL should be considered as well in cases of diffuse deposits where lipectomy would be difficult to perform. We also agree with Ramos et al that the dermolipectomy offers improved exposure, major debulking with better control of noble structures, and better cosmetic result. In our practice, the combination of SAL, followed by dermolipectomy has also yielded satisfactory results. The preliminary SAL reduces the fat volume and renders the dissection and consecutive skin resection easier. Finally, both resected specimens and aspirate from SAL should be subjected to pathologic evaluation to exclude any underlying liposarcoma. We thank Ramos et al for this nice and exhaustive report, which will add further clarification to Madelung disease.

Pectoralis Major and Pectoralis Minor Muscle Flap for Postpneumonectomy Empyema

The article by Nomori et al. has profoundly impressed us. Plastic and thoracic surgeons often collaborate because the vascularized muscle fl aps are needed for the treatment of empyema. We have observed in our practice cases in which the latissimus dorsi muscle (LDM) was sectioned not only after posterolateral thoracotomy but after lateral thoracotomy as well. It is possible that the sectioning of the LDM not only at posterolateral thoracotomy might be much more frequent than is believed. Since the thoracodorsal vascular pedicle and its hilus lies close to the lateral border of the LDM it can be easily sectioned when performing thoracotomy, the vascularization and, thus, the use of the LDM as a fl ap becoming uncertain. The importance of this fact was pointed out also by Malczewski et al. In treating empyema we have successfully used the LDM, even when sectioned, as a muscle fl ap on its lumbar and intercostal perforants for obliteration of the basal part of the empyema cavity. As mentioned by Nomori et al., the obliteration of the thoracic apex is quite diffi cult. In these cases the pectoral muscles are the closest source for vascularized tissue. Our anatomic studies showed that the vascular pedicle of the pectoral minor muscle (PMi) can be a branch either of the thoracoacromial artery, or a separate branch of the axillary artery or the lateral thoracic artery. In either case this branch lies very close to the primary pedicle of the pectoralis major muscle (the thoracoacromial artery), thus allowing the inclusion of the two muscles in one fl ap. Based on this anatomical study, in January 2000 we used the pectoral major (PMa) and PMi muscles as a single fl ap in a case of postpneumonectomy empyema without bronchopleural fi stula. The patient had undergone pneumonectomy for lung cancer. We performed intrathoracic transposition of the PMa and PMi muscles with simultaneous thoracoplasty. Excellent obliteration of the thoracic apex and the residual pleural cavity to the level of the third rib was achieved. The patient was dismissed on the 21st day without complications. He was free of empyema for 8 months when he presented with renal metastasis from his lung carcinoma. We consider the PMa and PMi muscle fl ap proposed by Nomori et al. as excellent for obliteration of the thoracic apex in empyema patients, with minimal functional and aesthetic donor site deformity.

A primary ovarian hydatid cyst

Hydatid disease (human echinococcosis, hydatidosis) is a parasitosis caused by Echinococcus granulosus and is endemic in the Mediterranean, Eastern Europe, Middle East, South America, Australia and New Zealand. Echinococcus cysts are most commonly found in the liver (60%) and the lungs (15%), but can be located in any part of the body. Pelvic echinococcosis is rare (incidence between 0.2% and 0.9%) and most of the cases represent secondary hydatidosis due to accidental rupture of a liver cyst. Herein, we report on a case of primary ovarian hydatid cyst.

Size of tumour as a risk factor for malignancy in patients with peripheral pulmonary nodules

ABSTRACT Peripheral pulmonary tumours are often quite difficult to diagnose and treat. Their detection brings immediately the problem of whether clinicians should just wait and observe or operate the patients. The AIM of this study was to determine if there is a direct correlation between tumour size and the risk for malignancy and whether the tumor size should be considered a risk factor for malignancy. PATIENTS AND METHODS: Between 1997 and 2009, 145 patients with peripheral pulmonary tumours of less than 3 cm in diameter underwent video-assisted thoracoscopic (VATS) resection for the purpose of histologic examination of the tumor. RESULTS: The mean age of the patients was 62.60 ± 0.95 years. The youngest patient was 17 years old and the oldest - 82. The study sample included 61 women and 84 men; the men were statistically signifi cantly more than the women (57.3% and 42.07%, respectively) (t = 2.74 , P < 0.01). The total number of patients we operated were 145 with 198 resected tumours. The diameter of the lesions ranged between 0.30 cm and 3 cm (mean 1.41 ± 0.06 cm). We found that 108 (54.55%) of the tumours were malignant, and 90 (45.45%) were benign, the difference between them failing to reach statistical signifi cance (t = 1.82, P > 0.05). The mean size of malignant lesions was statistically signifi cantly greater than that of benign tumours (1.62 ± 0.08 cm vs 1.15 ± 0.06 cm). CONCLUSION: The results of this study suggest that the bigger the diameter of the nodule, the greater the percentage share of malignant tumours, which means that the size of the tumour is an important risk factor for malignancy.

The endoscopic latissimus dorsi flap harvest: advantages and technical drawbacks.

We read with great interest the article of Guven et al. 1 on presenting their series of endoscopic harvesting of latissimus dorsi (LD) flap with the electrothermal bipolar vessel sealer (EBVS; Ligasure). After its introduction in the 1990s, the endoscopic harvesting of LD muscle flap was used in orthopedic surgery, postoncologic breast reconstruction, breast reconstruction in Poland anomaly, free flap reconstruction with LD flap, and pediatric surgery. Surgeons were inspired by the potential advantages of the endoscopic technique, which include improved visualization of deep structures, shortened hospital stay, decreased postoperative pain, and limited incisions. Although postoperative pain was suggested to be less important after endoscopic harvest compared with the classic open technique, Vasconez stated that postoperative pain was comparable in both traditional and endocopic LD harvests. The smaller scar in endoscopic harvest, which lead to decreased scar formation and a better cosmetic outcome, represents a clear advantage, especially in young women, but that was again put into question. In this sense and after the initial enthusiasm, the endoscopic LD harvesting could not gain enough popularity and be established as the preferred approach because of several drawbacks. These are essentially technical difficulties independent from the indications and the type of surgery. First, it is difficult to create an adequate optical cavity because of the lack of sufficient elasticity of the skin and soft tissues. In our hands this was the most important problem to solve. Several methods were used for this—external traction of the skin and soft tissues by traction sutures, internal retraction by light retractors and/or saline-filled balloon retractors, the combination of external and internal retraction, insuflation of CO2. 3 Neither of these seems to create conveniently a comfortable optic space for LD flap harvesting. The second point was the difficulty with hemostasis and sectioning of the muscle in its most distal and medial parts. Using the classic bipolar and monopolar cauterization, the percentage of revision due to bleeding was reported as high as 4% in certain series. As shown by Guven et al., the use of EBVS will probably improve the technical aspect of hemostasis and muscle division. We have used the ultrasound endoscopic scalpel with the impression that it facilitates hemostasis and muscle sectioning in comparison to classic bipolar and monopolar cauterization. The other point is that EBVS probably decreases the amount of seroma formation. This is important, because some reports underline that there is no difference in seroma formation between the classic and endoscopic techniques. Personally, we feel that the large undermining created in LD harvesting is more important for seroma formation than the technique used for hemostasis. Moreover, in both open and endoscopic techniques the undermined surface remains virtually the same. Finally, the mentioned technical difficulties imply a steep learning curve with longer operative times in the beginning; this discouraged a lot of surgeons, who returned to the classic open approach. However, today the operating time for an endoscopic approach is not much different form that of the open technique in the hands of surgeons experienced with the former. In the field of breast reconstruction, with the broadening of the indications of skin-sparing mastectomy, the endoscopic LD flap technique will probably gain increasing importance. In conclusion, the endoscopic harvesting of the LD muscle presents advantages consisting of improved visualization of deep structures, shortened hospital stay, decreased postoperative pain, and limited incisions. However, despite the progress of surgical techniques over the years, the technical difficulties in dissecting the LD flap are not entirely resolved. In this sense, we thank Dr. Guven et al. for their important contribution and efforts in improving the endoscopic harvest of LD flap.

Indications for Free-Tissue Transfer in Cleft Palate Reconstruction

To the Editors: We read with great interest the article of Ozkan et al on the reconstruction of palatal defects with the anterolateral thigh (ALT) free flap. Their interesting study has raised several questions that we would like to comment on. Ozkan et al reported on 8 cases of reconstruction of palatal defects of various etiology with the ALT free flap. However, in 5 of these cases, palatal defects were cleft palate-related defects: primary cleft in 1 case, a secondary cleft palate-defect in 1 case, and palatal fistulae in 3 cases. Although free-tissue transfer has been increasingly used for reconstruction of oncologic maxillary and palatal defects, it is rarely used in patients with cleft palate defects. In our experience, we have not encountered a primary cleft palate defect that could not be reconstructed with one of the well-established techniques for palatoplasty. However, Ozkan et al report a case of primary cleft palate that needed free-flap reconstruction. Free-tissue transfer remains a technique that is generally needed in recalcitrant palatal fistulae and oronasal communications. Such secondary cleft palate defects can be a difficult-to-solve problem, especially in multioperated cases (multiple failures of cleft palate and palatal fistulae repairs). Multiple failed attempts of closure lead to scarring and fibrosis of the palatal tissue, which in turn increase the size of the defect due to scar contraction. After several surgical attempts, local tissues may become rigid, poorly vascularized, and unusable. In such cases, well-vascularized pliable tissue can be borrowed from the neighboring tongue, buccal surface, or extraorally. In our practice, we favor the local and/or regional options with special emphasis on the posteriorly based buccinator musculomucosal flap (BMMF). We opt for this flap because it is reliable, well-vascularized, and brings similar tissue to the defect. The procedure is one-staged just as the free-tissue transfer; however, it is simpler, faster, and does not require special equipment and training for microsurgery. The BMMF can reach even the most anterior palatal regions. In cases where this is not possible, the anteriorly based BMMF can be used having in mind that it is a 2-staged procedure and requires interdental space for passage. It is true that a single BMMF may be insufficient to cover large defects. But in these cases, bilateral BMMF either pedicle or as islanded can be used and can cover virtually the entire palate. In this sense, we believe that freetissue transfer should be reserved for the cases where all simpler solutions are exhausted or rendered unusable. We feel that the indication of free-flap reconstruction in primary cleft palate is rather overestimated if ever existent, and it should be reserved for the most recalcitrant cases. Which free flap should be used? Undoubtedly, this should be a thin and pliable flap with long vascular pedicle. In this sense, the ALT flap does not seem to be the most suitable choice. We believe that this flap is quite thick for isolated palatal fistula repair (in any case it is thicker than the radial forearm flap in the same individual and probably even thicker than the first dorsal metatarsal artery flap) and this was also underlined by Ozkan et al. Furthermore, it is quite unsuitable especially in male patients because of the intraoral hair growth. Actually, Ozkac et al were forced to perform a “deepithelialization for hair removal” in one of their patients. In this sense, if ALT flap is still quite suitable in cases of oncologic palatal and/or maxillary reconstruction, we believe that it is less suitable for cleft palate defects reconstruction, which was also underlined by Schwabegger et al. Finally, Ozkan et al have defined the indications for free-tissue transfer as follows: previous failures, heavily scarred and poorly vascularized tissue around the defect, defects unsuitable for local and regional tissues, and use of osseous flap only when the residual cleft requires bone graft. Actually, this was well summarized by Schwabegger et al who stated that the primary indication for freeflap reconstruction in patients with cleft palate defect is the repeated failure of local and regional flaps. In conclusion, we would like to thank Ozkan et al for their interesting series which will bring further clarity to the difficult problem of palate reconstruction, in particular in cleft palate-related secondary reconstruction.