Occlusive dressing for large soft tissue defects following soft tissue tumor excision

Background  Reconstructive surgery using pedicles or free muscle-skin flaps and skin grafting reduces wound complications and promotes favorable limb function; however, the sacrifice of normal tissue remains problematic and complicated. Occlusive dressings are widely employed for management of injuries, burns, and surgical wounds. However, their effectiveness for treating soft tissue defects following a soft tissue tumor excision has not been fully elucidated. The purpose of this study was to evaluate the effectiveness and safety of an occlusive dressing treatment method for soft tissue defects following soft tissue tumor excisions. Methods  We retrospectively reviewed eight patients (three men, five women) whose wounds were treated with polyurethane foam occlusive dressings to allow reconstruction of the soft tissue defect following soft tissue tumor excision. Their mean age was 64.5 years (range 23–83 years), and the mean size of the defect was 60.1 cm² (range 20–144 cm²). The wound was covered with a hydrophilic polyurethane dressing material. The treatment periods, incidence of complications, and ultimate outcomes were evaluated. Results  Seven defects were completely healed by secondary intention without the requirement of any additional surgery. Mean treatment periods were 21.6 weeks (range 13.5–44.0 weeks). Mean follow-up periods were 33.1 months (range 15.8–48.6 months). One patient with a recurrent malignant fibrous histiocytoma (MFH) who had a history of radiotherapy required a posterior thigh flap 44 weeks after the surgery. Recurrence due to a positive surgical margin was observed in only one patient with recurrent MFH. None of the patients exhibited clinical evidence of superficial or deep infection. Conclusions  This treatment method is simple, safe, and reliable. We concluded that the highly favorable indications of this treatment are ideal for patients who wish to avoid sacrificing their normal tissue, have no history of radiotherapy before surgery, and do not require chemotherapy or radiotherapy after the operation.     

Posterior approach for retroperitoneal laparoscopic bilateral nephrectomy in a child

We report on a unique posterior approach for bilateral nephrectomy by retroperitoneoscopy that was conducted in a 13-year-old boy with end-stage renal disease managed by peritoneal dialysis. A posterior approach for bilateral nephrectomy by retroperitoneal laparoscopy provided adequate visualization and created enough working space for the manipulation. The procedure was performed during a short period, and the patient did not need to be repositioned. Retroperitoneal laparoscopic bilateral nephrectomy is a useful option in school-aged children with poorly functioning kidneys, particularly those children also undergoing peritoneal dialysis.     

Magnetic resonance imaging of soft tissue masses

Twenty-nine soft tissue masses were studied with magnetic resonance imaging (MRI) which proved to be useful in the preoperative evaluation of these lesions. Other imaging modalities employed had significant limitations. Plain films were of little value because of the intrinsically low contrast of soft tissues. Angiography was not necessary unless MRI suggested a vascular lesion or proximity to major blood vessels. Computed tomography (CT) and MRI both readily identified fatty lesions and their relationship to adjacent structures. Some soft tissue tumors could not be delineated from normal muscle with CT, but were easily seen with MRI. MRI is ideally suited for the study of suspected soft tissue tumors because of its excellent soft tissue contrast and its ability to image directly in any plane. Optimum evaluation required imaging in at least two planes with spin echo sequences chosen to bring out both T1 and T2 features.     

Endoscopic excision of benign forehead masses: a novel approach for pediatric general surgeons

Purpose

Benign tumors of the brow and forehead are commonly managed by pediatric general surgeons by excision through an overlying incision. Cosmetic results in children can be suboptimal. Plastic surgeons have used endoscopic brow-lift techniques for the removal of these lesions. We review our experience after adopting this endoscopic technique in a pediatric general surgery practice.

Methods

We conducted a retrospective chart review of 9 consecutive outpatient procedures (5 girls and 4 boys; age range, 5 months to 12 years) between March and October 2005. Seven patients had lesions located on the lateral brow (left, n = 4; right, n = 3), 1 patient had a lesion on the left mid forehead, and 1 patient had a nasoglabellar cyst. All procedures were performed using endoscopic brow-lift equipment through a single small scalp incision 2 cm posterior to the hairline. Outcome measures included need for conversion, operative time, cosmetic outcome, and complications.

Results

All lesions (6 dermoid cysts and 3 pilomatrixomas) were successfully excised endoscopically. The mean operative time was 56 minutes (range, 22-90 minutes). There was no intraoperative or postoperative complication. All families were pleased with the cosmetic outcomes.

Conclusion

This case report shows that endoscopic excision of forehead masses is a safe and efficacious procedure in the hands of pediatric general surgeons.     

Intraoperative ultrasound assistance for excision of impalpable musculoskeletal soft tissue tumors

Intraoperative ultrasonography is a useful tool for the detection and extirpation of liver metastases, breast masses, and melanoma. However, the efficacy of this technology in intraoperative localization and resection of small soft tissue tumors has not been addressed. The purpose of this study is to report on the efficacy of intraoperative ultrasound assistance in excising impalpable musculoskeletal soft tissue tumors. Twenty-two soft tissue tumors <3 cm (range, 0.7-3 cm) were resected with intraoperative ultrasound assistance. All tumors were localized in the deep panniculus, fascia, or muscle. Surgical time and length of incisions was recorded in all the cases. Intra- and postoperative reregistration was made to confirm the tumor resection. Ultrasound assistance was successful in obtaining an accurate localization in all treated cases. Mean surgical time was 30 minutes (range, 13-87 minutes). Average incision length was 5.7 cm (range, 2.5-10.6 cm). Reregistration allowed intraoperative confirmation of the adequacy of the excision. The procedure allowed recognized and excised additional nodules not previously diagnosed in 3 cases. Postoperative echography done in all patients confirmed complete extirpation of the tumors, and histopathology confirmed adequate margins obtained. Intraoperative ultrasound can be used as an efficient tool to localize and treat impalpable small soft tissue tumors.     

Metachronous bilateral soft tissue sarcoma of the extremities

Background and aims Synchronous and heterochronous multiple soft tissue sarcoma of the extremities is very rare. Out of 1,201 of our patients, 4 patients presented with symmetrical bilateral soft tissue sarcoma of the extremities. The aim of this study was to identify possible reasons for this unusual manifestation of sarcomas. Materials and methods The patients’ data was acquired by review of the patients’ charts and follow-up information was gathered by phone calls to the patients or their relatives and their general practitioners. Results All tumours were located at the extremities and were diagnosed as leiomyosarcoma in two patients, malignant fibrous histiocytoma and clear cell sarcoma in one patient each. No other individual or family history of cumulation of neoplasms was known in the patients. The median interval between the diagnoses was 3 1/2 years (range: 4 months to 9 1/2 years). In two patients a second primary sarcoma of the same entity was considered the most likely diagnosis, whereas in one patient a contralateral lymph node metastasis and in one other patient an atypical soft tissue metastasis had to be taken into account. A positive family history with a father with malignant fibrous histiocytoma may indicate a hereditary predisposition in one patient. Aside from irradiation effects, exposition to other carcinogenic agents or genetic predisposition, the reasons for the clustering of soft tissue sarcoma in one same patient remain still unclear. Only one patient, although suffering from disseminated metastatic disease was living at follow-up time, the other three patients had already died. Conclusion The interpretation of the bilateral manifestation of soft tissue sarcoma remains open, but predicts an unfavourable outcome.     

带神经血管蒂足底内侧皮瓣修复足跟皮肤软组织缺损

目的探讨带神经血管带足底内侧皮瓣修复足跟皮肤软组织缺损的疗效。方法1995年7月～2005年9月采用带神经血管蒂足底内侧皮瓣修复足跟部皮肤软组织缺损28例,其中外伤21例,跟骨骨髓炎6例,冻伤1例。缺损面积为3cm×3cm～7cm×6cm。结果所有患者随访3～15个月,平均12个月,皮瓣全部成活,外观满意,行走功能良好,皮瓣成活后有感觉存在,未见磨损溃疡发生。结论足底非负重区组织修复足底负重区皮肤软组织缺损不仅功能良好、外形美观,而且感觉良好,是修复足跟部皮肤软组织缺损的理想方法。     

Treatment of necrotizing soft tissue infections. The need for a new approach

Necrotizing soft tissue infections are classified by the type of infecting organism, the presenting clinical picture, and the treatment required. However, reliance on this schema is impractical since it often leads to an inordinate delay in appropriate surgical therapy with an unwarranted loss of a limb or life. Since 1958, 21 patients were treated at the UCLA Medical Center with necrotizing soft tissue infections. Unifocal ulcerations and nonspreading infections were excluded. Of the 21 patients, the initial classification of the infections included necrotizing fasciitis in 38 percent, clostridial gangrene in 38 percent, bacterial synergistic gangrene in 19 percent, and streptococcal hemolytic gangrene in 5 percent. Diabetes or evidence of immunosuppression was found in 71 percent of the patients. The course could be traced to either a perforated viscus in 43 percent or a traumatic injury in 43 percent. No single clinical sign, including tissue gas, was diagnostic for a specific type of necrotizing soft tissue infection. Culture revealed a polymicrobial flora in 76 percent. Overall mortality was 52 percent and the amputation rate was 36 percent. Mean time to appropriate surgical therapy was 1.9 days. Operations performed more than 24 hours after recognition of infection resulted in a 70 percent mortality versus a 36 percent mortality when operations were performed less than 24 hours after recognition. A lesser operation to conserve tissue resulted in a 71 percent mortality versus a 43 percent mortality with initial radical surgery which encompassed all devitalized tissue. Based on these data, we conclude that classification of necrotizing soft tissue infections should be simplified to clostridial and nonclostridial infections. Radical operative debridement, regardless of tissue loss, should be carried out immediately after fluid resuscitation, and antibiotic coverage must be broad spectrum from the time of onset due to the polymicrobial nature of these infections.     

Consider the diagnosis of splenosis for soft tissue masses long after any splenic injury

Splenosis represents the autotransplantation of splenic tissue after splenic trauma or surgery. Disruption of the splenic capsule causes fragments of splenic tissue to be seeded mainly throughout the peritoneal cavity, where they are characterized by diffusely scattered bluish implants. Extraperitoneal locations are very rare and mainly include the thoracic cavity after thoracoabdominal trauma with simultaneous splenic rupture and diaphragmatic laceration. We retrospectively identified all patients in the pathology registry with the diagnosis of splenosis between December 1974 and July 2003 at our urban teaching hospital. Data collected included presenting signs and symptoms, history, imaging studies, treatment, pathology, and outcome. Five cases of splenosis were identified and described. Location of the splenosis was intraperitoneal in two and intrahepatic, intrathoracic, and subcutaneous in one each. In these cases, there was an average interval of 29 years between splenic injury and diagnosis, and most were found incidentally. One of the cases was managed entirely laparoscopically and another thoracoscopically.     

Laparoscopic excision of a gastric diverticulum in a child

Gastric diverticulum is a rare entity; the patient usually presents with vague abdominal pain, nausea, vomiting, and weight loss. Diverticulectomy is required for patients with intractable symptoms or complications. We report the laparoscopic excision of a gastric diverticulum in a 15-year-old girl who had been symptomatic for 5 years. A five-port technique and a linear cutting and stapling device were used.     

Reconstruction after excision of soft tissue sarcomas of the limbs and trunk

From a retrospective analysis of 180 surgical interventions for soft tissue sarcoma of the limbs and trunk, it was concluded that complete excision of the tumour can usually be achieved without sacrifice of major artery, vein, nerve or bone. In this series five major arteries were resected but only one required reconstruction. None of six resected major veins or seven resected nerves were reconstructed. Bone resection in the limb required plating in only two of eleven patients who had limb-sparing resection (there were nine amputations). Both in the limbs and the thorax, resection of bone often involved such a wide excision of the superficial soft tissues as to require a flap repair: four were used in the limbs and three in five chest wall resections. In the majority of operations (140/180) primary wound closure was possible. After 15 procedures for tumour predominantly involving the superficial tissues, split skin grafts were used. These were generally successful (13/15), even occasionally when high-dose radiotherapy had been given. In 16 cases earlier radiotherapy influenced the decision to use a flap repair. A total of 18 flap repairs were performed. In various situations Mersiline mesh (Ethicon, Ltd., UK), Silastic implants and omental swings were used. Wound breakdown in heavily irradiated tissues presented a major challenge for reconstruction. Although major reconstruction was required in only 27 operations (15 per cent), a thorough knowledge of the available methods of reconstruction and repair is essential to allow uninhibited resection with an optimal aesthetic and functional result.     

Symptomatic bilateral renal angiomyolipomas in a child

We report a case of bilateral renal angiomyolipomas in a child with Bourneville's tuberous sclerosis. The case is unusual because of the early age of the patient at which symptoms occurred. The presentation and treatment are discussed, and the literature is reviewed. Renal disease can occur in young patients with tuberous sclerosis and it is of clinical importance to document renal involvement in these children.