Reconstruction of the chest wall and the diaphragm using the inverted Y Marlex methylmethacrylate sandwich flap.

OBJECTIVE: Chest wall resection and reconstruction is a demanding operation involving a dedicated team. It can be performed with minimal mortality with excellent cosmetic and functional results using various substitutes. However, reconstructing the lower costal margin with diaphragmatic resection is a challenging prospect needing special techniques. METHODS: We describe a technique of reconstructing the chest wall defect involving the lower costal margin and diaphragm with an Inverted Y Marlex Methylmethacrylate Sandwich Flap. RESULTS: There were no intra operative or postoperative complications and immediate extubation was possible in all six patients without the need for postoperative ventilation. There was a good functional and cosmetic result in all the patients. CONCLUSIONS: This is an easy and safe technique resulting in a stable and satisfactory reconstruction after large antero-lateral full-thickness chest wall resections involving the diaphragm.     

Reconstruction of the thoracic wall

The resection of the thoracic wall for cancer, traumas or results of radiotherapy could require a reconstruction of the same wall with prosthetic material of different nature to the purpose of protect the important intrathoracic structures, avoid the flail chest and maintain a ventilation adjusted with aesthetically acceptable results. Numerous and varied they have been and they are the materials used to such aim, but the more numerous experiences concern the reconstructions of the wall with the employment of nets of Marlex or the patch of Gore-Tex. In the complete two years eight patients have arrived at our observation in which a prosthetic reconstruction has been performed with heterologous material. In three of them has been used the net of Marlex, in five the patch of Gore-Tex of two millimeters of thickness. The prostheses have stayed well you bear and in all the patients the authors have gotten a good stabilization of the thoracic wall.     

Complicated torsion of the gallbladder. Presentation of a clinical case

A case of gallbladder torsion complicated by sigmoid volvulus and sub-torsion of the ileus is reported because of the difficulty of diagnosis, conditioned by polymorphic symptomatology, the expression of a variety of causes and contributing causes that play an important role in the greater or less onset of dramatic symptomatology, and because of the rarity of the pathology.     

Cystic lymphangioma of the liver. Presentation of a clinical case

The cystic lymphangioma of the liver is an extremely rare benign tumor that usually belongs to a systemic lymphangiomatosis. A case of an adult woman presenting a cystic lymphangioma as single hepatic lesion with no other viscera affected is described. Ultrasonography and computed tomography did not allow a differential diagnosis of the lesion from the more common hydatid cyst. Definitive diagnosis and treatment were reached only by exploratory laparotomy.     

Myxoid liposarcoma of the retroperitoneum. Presentation of a clinical case

Of all the soft tissue sarcomas, those localised in the retroperitoneum represent a particular challenge to the surgeon. Diagnosis is often late, when the tumour has already reached considerable proportions, creating particular problems for its removal. Liposarcomas are the most common histological form of retroperitoneal tumour. The authors report the case of a patient with retroperitoneal myxoid liposarcoma and use their analysis as the starting point for a review of the literature focused on the diagnosis and treatment of retroperitoneal tumours. They underline that modern imaging techniques (Eco, CT, NMR) are essential during the preoperative stage for a complete and detailed study of the neoplasm, as well as during follow-up. With regard to treatment, surgery is still the most effective approach in cases where this is feasible. The current trend towards aggressive surgery is backed by the improved results in terms of survival. An improved prognosis for patients with retroperitoneal tumours is linked to an early diagnosis and the development of more efficacious complementary therapies.     

Secondary costal myxoid chondrosarcoma. Presentation of a clinical case

A type of malignant neoplasm of not frequent observation is reported and the difficulties concerning the distinction from the benign counterpart are underlined, for which a detailed instrumental study is made necessary, integrated with pre and, above all, postoperative histologic analysis. A white male patient of 83, affected by plurirecidivant chondromyxoma of the rib, was admitted for local recurrence. The lesion objectively appeared not dissimilar from the preceding ones, as an ovalar mass fixed on the underlying plains. Radiologic and ultrasonographic examinations seemed to confirm the admission diagnosis; at the end the patient underwent a new intervention. Histologic examination of the lesion yielded a diagnosis of chondromyxosarcoma. The clinical case is made even more interesting by the finding, through the TC technique, preoperatively performed, of a metastatic repetition on the opposite side. The authors examine the problem of the early recognition of a malignant neoplasm developing, in a patient with a clinical history of recidival chondromyxoma. Physical examination and laboratory analysis are not useful in the assessment of the occurring transformation. At molecular level chondromyxosarcoma is characterized by several genomic rearrangements and mutations. Though primitive chondromyxosarcoma often involves the ribs, chondromyxoma's transformation into its malignant counterpart is not a common event. The development of distant metastasis characterizes long term cases. Given the lack of encouraging results about chemo and radio-therapy efficacy in influencing the natural course of the disease, a systematic approach will be made necessary in patient management.     

Post-traumatic intrathoracic gastric volvulus. Presentation of a clinical case

The paper describes a case of traumatic hernia of the diaphragm, complicated by mixed gastric volvulus, with a rapid onset and severe clinical symptoms. The etiopathogenesis, diagnosis and therapeutic methods inherent in this rare affliction are discussed.     

Reconstruction of the abdominal wall using a tensor fasciae latae musculocutaneous island flap. A case report

A case is reported which provides further evidence of the reliability of a unilateral tensor fasciae latae myocutaneous island flap in the repair of a large full-thickness defect in the lower abdominal wall.     

Diverticulitis of the right colon. Presentation of a clinical case]

The recent observation of one case of diverticulitis of the right colon led to an evaluation of clinical diagnostic and therapeutic aspects of this comparatively rare condition, on the basis of reported data. Preoperative diagnosis is very difficult because it clinically resembles acute appendicitis in many ways, or because of the objective observation of a mass in the right iliac fossa. Instrumental examinations require preparation times that are often incompatible with the degree of surgical urgency. In the reported case, the inflammatory process was modest and treatment was straightforward, there being no diagnostic doubts. This confirms the fact that in so-called "usual" cases, the idea surgical approach must be as conservative as possible. In so-called "hidden" cases, on the other hand, the doubt as to the nature of the pathology often leads to extensive surgery, such as right hemicolectomy.     

Marlex mesh for repair of abdominal wall defects.

The best synthetic material available for repair of abdominal wall defects associated with an insufficiency of tissue is Marlex mesh. Among 14 patients with large hernias and 3 who underwent tumour resection only 2 manifested recurrence of the defect. In three of these patients infection developed, but its control made it unnecessary to remove the Marlex. In another three with gross infection of the abdominal wall, Marlex was used successfully to provide abdominal wall closure.     

Reconstruction of complex and unusual defects of the thoracic wall

Summary From 1981 to. 1989, a total of 13 procedures were performed on 12 patients requiring complex reconstructions of the thoracic wall. The most common cause of these defects was cancer. Muscle flaps remain the treatment of choice for thoracic wall reconstruction and have been used in 10 cases. Microsurgical tissue transfer opens even larger therapeutic perspectives. A team approach is recommended.