Life-threatening hemorrhage from a vulvar hemangioma

Capillary hemangioma, the most common tumor of infancy, usually does not require any treatment, but in a minority of cases it may cause morphologic, functional, or life-threatening complications. The authors report a case of a vulvar emangioma complicated by life-threatening hemorrhage not responsive to corticosteroids therapy, which showed no signs of spontaneous involution. The therapeutic approach consisted of 3 steps of selective arterial embolizations followed 5 months later by surgical excision and reconstruction of the vulva. Selective embolization rarely is used in the treatment of hemangiomas but may be required in cases of intractable bleeding, severe heart failure, large and poorly involuting hemangiomas, and as preparation for surgery. The results of the combined approach in this case are reported, and the indications discussed.     

瘤体内结扎加平阳霉素注射治疗血管瘤30例

目的 提供一种简便、安全有治疗海绵状和蔓状血管瘤的方法。方法 先进行纵横交错的瘤体内结扎,使血管瘤分隔成许多互不相连的小区,再分次用平阳霉素对各小区注射。结果 本组共３０例（３５个瘤体）,治愈２４例（２８个瘤体）,占８０％,好转６例（７个瘤体）,占２０％。结论 瘤体内结扎＋平阳霉素注射疗法有较广泛的适应证,对海绵状和蔓状血管瘤尤其是不宜手术或单纯瘤体内注射无效者,均有较高的治愈率和安全性。     

Place of the precocious surgical treatment in facial hemangioma

Infantile cutaneous hemangioma is a benign vascular tumour present at 10% of the infants. It forms part of the group of the vascular tumours in the classification of international society for vascular anomalies (ISSVA). Usual surgical attitude is abstention and surgery is proposed only in order to treat sequelae. But some particular situations require early surgery to avoid functional impairment, deformation or growth delay due to the lesion's development. Using our observations, we recall the epidemiology, the physiopathology, the clinical aspects, the particularities of the facial localizations and their treatments. In these localizations the time intervenes like a fourth dimension that is going to modify, to improve or to aggravate the prognosis. Treatment requires a strategy and precocious surgery. We insist on the fact that the dogma of the therapeutic abstention remained true for a majority of children with small size hemangioma and that a precocious surgery must be proposed for some localizations in the face.     

Operative outcomes of 546 Louisiana State University Health Sciences Center peripheral nerve tumors

The surgical management of benign PNSTs and some other benign tumors can result in successful outcomes. Schwannomas and nonplexiform neurofibromas can be resected with minimal deficit by sparing all but the fascicles entering and exiting the tumor. These fascicles, if not functional by NAP testing, can be resected, and the tumor can be removed. Surgery to remove other benign lesions, such as intraneural ganglion cysts, hemangiomas,and ganglioneuromas, has become more timely. The desmoid tumor, although microscopically benign, is locally and regionally invasive, and chemotherapy and radiation therapy may need to be used as adjunctive therapy. Neurogenic sarcomas and other malignancies have high morbidity and mortality despite aggressive limb ablation or limb-sparing surgery with adjunctive therapy. Thus, surgery involving decompression as well as the most complete resection possible remains the essential initial step in the management of most malignancies.     

Congenital vascular lesions: clinical application of a new classification

Two hundred and ninety-seven patients with 375 pediatric vascular lesions were followed from 1967 to 1981. By history and physical examination, 96% of childhood vascular lesions can be classified as hemangiomas or malformations. Hemangiomas are often not present at birth (40%), but make their appearance during the first month. A proliferative phase, lasting an average of 3 months, is followed by a slow, but eventually complete involution. A "perfect" cosmetic result is more likely when involution is complete before age 6. Malformations are always present at birth, their growth is commensurate with the patient's, and they never involute. Analysis of clinical characteristics fails to identify a subgroup of hemangiomas destined for early involution.     

Hemangiomas of the nose: surgical management using a modified subunit approach

OBJECTIVES: To study a new surgical approach to pediatric nasal hemangiomas and the need for early surgical intervention. Childhood hemangiomas are most common in the head and neck area. They can result in life-altering situations by causing airway obstruction, disfigurement, ulceration, and other adverse effects. DESIGN: A retrospective study of 44 consecutive patients with hemangiomas treated in our clinic during the last 9 years. The clinical characteristics of these hemangiomas are assessed and the outcome after surgery is discussed with respect to different surgical approaches. A new modified subunit approach is introduced. RESULTS: Based on the subunit principle, the incision line was modified to allow better access to all nasal subunits. The results using this technique were superior to the results using conventional incisions with respect to accessibility of the tumor, ability to trim excess skin after tumor removal, and aesthetic outcome. In contrast to reports in the literature, early surgical intervention is advocated as a result of this study. CONCLUSIONS: This modified surgical technique shows superior results to the techniques used in earlier years. We strongly advocate early surgical intervention.     

Major resections of the liver in patients with high surgical risk

Experience with 75 major anatomic resections of the liver in patients with high surgical risk due to low functional reserve of the liver, spontaneous disruption of hepatic tumor, chronic purulent infection in patients with hepatic abscesses, posttraumatic sequestration of the liver with hemobilia, giant hepatic hemangiomas, old age and severe concomitant diseases was analyzed. General postoperative lethality was 14.7% which was determined mainly by unfavorable outcomes in postoperative patients in spontaneous disruption of tumor and massive intraabdominal bleeding, and also by severe postoperative hepatic insufficiency in patients after right-sided hemihepatectomy for hepatocellular carcinoma with postnecrotic cirrhosis of the liver. Immediate results of surgery in patients with obstructive jaundice and biliary hepatic cirrhosis were better that ones of patients with postnecrotic cirrhosis. There were no lethal outcomes in group of patients after surgery for giant hemangiomas, abscesses and posttraumatic sequestration of the liver. Thorough selection of patients based on detailed study of functional hepatic reserves and also volume of removed hepatic parenchyma is necessary for improvement of immediate results of surgical treatment. It is valid to perform portal venous embolization before right-sided hemihepatectomy in patients with postnecrotic, biliary cirrhosis, and also in old patients to decrease the risk of postresection hepatic insufficiency. Roentgenondovascular occlusion of the hepatic artery, Cell-Seiver use for intraoperative blood reinfusion and in some cases--use of methods of complete vascular isolation of the liver are indicated for patients with giant hepatic hemangiomas.     

Vascular neoplasms of the mediastinum

During a period of 42 years the authors had 44 patients with various vascular neoplasms of the mediastinum--angiomas. Experience in the treatment of 6 of them is discussed in B. V. Petrovsky's monograph Surgery of the Mediastinum (1960). The other 38 cases were distributed as follows: hemangiomas 28 (14 mature and 14 immature) and lymphangiomas 10 (all mature). The patients' ages ranged from 11 to 63 years, the duration of the anamnesis from 4 weeks to 40 years. Mediastinal angiomas are mainly encountered in children and young people, with equal frequency among females and males. Their clinico-radiological picture is diverse and unspecific, the diagnosis is established with difficulty. Surgery is the principal method of treatment. Radical removal of the tumor must be attempted. Radiologically-guided endovascular occlusion of the vessel supplying the tumor is possible in some cases. The late results of surgical treatment are good in cases of mature angiomas and depend on the radicalism of the operation in immature forms.     

Body Contouring Following Massive Weight Loss

Background: Obesity and its associated medical morbidities carry substantial health risk. While massive weight loss allows improvement in health status and lifestyle, physical sequelae due to symptomatic skin redundancy still require treatment. Areas affected include the arms, breasts, abdomen, back, and thighs. After open gastric bypass, patients often have poor abdominal support and incisional hernias. To completely address the treatment of patients following massive weight loss, body contouring procedures are performed, often in one stage and tailored to each patient, to rid the functional and esthetic impairment from skin redundancy. Methods: This retrospective study includes 30 patients treated from March 1998 to August 2002 by a single surgeon at an academic hospital. Average weight loss had been 71 kg, and average weight and BMI at the time of contouring surgery were 98.6 kg and 33 kg/m² respectively. Procedures included abdominal panniculectomy, thighlift, backlift, brachioplasty, mastopexy and incisional hernia repair, performed either alone or in combination. Results: Average weight of resected tissue was 5.9 kg. Average length of stay was 3 days. Complications included seroma, wound breakdown, hematoma requiring surgical drainage, and lymphocele after brachioplasty. One patient died of a pulmonary embolus within weeks after surgery. Conclusion: Patients requiring surgical skin excision after massive weight loss for functional and/or esthetic reasons are challenging, and require individualized approaches with intensive follow-up.     

Early surgical treatment of Cyrano-nose haemangiomas with Rethi incision.

Nasal haemangiomas may cause great social distress. Complete involution of these haemangiomas does not usually result in a return to normality. The subcutaneous tumour infiltrates the alar cartilages, resulting in a globular aspect of the nasal tip. In this location, haemangiomas are slow to regress, and contour deformities result from the fibrofatty tissue that remains after total involution and also from definitive deformation of the nasal cartilages. Surgery to remove the affected tissue and preserve the anatomy seems to be the best treatment for these tumours. We report six cases of nasal haemangiomas removed using the Rethi incision and a double rim incision. This procedure allows complete dissection of the tumour, and leaves only a small scar. The alar cartilages are returned to their anatomical position to allow normal growth. Surgery is performed at around 2 years of age; skin excision is not necessary because spontaneous skin retraction occurs. Our patients were evaluated by their parents, the surgeon and members of the dermatology staff not involved in their treatment. Pain, scar and final aspect were evaluated using statistical analysis. The parents and surgeon rated the postoperative results as very satisfactory or satisfactory. The dermatology staff also reported improvement after surgery. The scar is nearly invisible and the procedure allows excision of large nasal haemangiomas.     

Surgical removal of pontomesencephalic cavernous hemangiomas

Cavernous hemangiomas of the brain stem are usually discovered accidentally during evacuation of a hematoma, and successful surgical treatment of these lesions is seldom achieved. With the increasing use of magnetic resonance imaging, the presence of a cavernous hemangioma can be detected before surgery, allowing an elective surgical approach. We successfully removed pontomesencephalic cavernous hemangiomas from 2 patients and pontomedullary hemangiomas from 2 others. Elective surgery was performed with perioperative bimodal monitoring of somatosensory and auditory evoked potentials. Performing surgery soon after the hemorrhage minimizes the risk of additional postoperative neurological deficit, since surgical excision is facilitated when the hematoma is not completely organized. Pontine hemangiomas are approached via the 4th ventricle. Mesencephalic hemangiomas are removed by a midline supracerebellar approach when they are lateralized by using a subtemporal approach. The lesion can be removed through a small incision in the brain stem at the site of the lesion. The favorable results, which include marked improvement of preoperative neurological deficits and documentation of complete removal of the lesion by magnetic resonance imaging, support a more aggressive approach to the treatment of symptomatic cavernous hemangiomas of the brain stem. Further investigation of the natural history of these lesions is mandatory.     

Endoscopic Management of Polypoid Early Colon Cancer

Endoscopic management of polypoid early colonic cancer (malignant polyps and polypoid carcinomas) is no longer controversial. When the endoscopist is satisfied that excision is complete and histology is "favorable" (a resection margin of 2 mm and well or moderately well differentiated tumor), surgery is unnecessary. When histology show "unfavorable" characteristics (which a few histologists still take to include invasion into lymphatics), surgical or laparoscopic resection may be indicated, providing the patient is considered at suitable risk. Surgery kills some patients without finding residual cancer and cannot save others with metastases, so it should be recommended only with due clinical consideration. Sessile or broad-based polyps, especially those in the rectum, are more likely to be "high risk" and merit specialist management if local removal is to be attempted and to allow proper histologic assessment. Endoscopic approaches such as saline injection polypectomy, india-ink tattooing, and use of the argon beam coagulator are applicable in some cases. New approaches that still require trials include ultrasonographic probes, which occasionally clarify the degree of invasion, and prototype stapling devices to allow full-thickness histologic specimens to be obtained.     

Resection of advanced stage malignant retroperitoneal neoplasms with tumor thrombus extending into the right atrium: Report of four cases

Surgery for retroperitoneal neoplasms with a tumor thrombus extension into the right atrium is challenging. This study reviewed four surgical cases of advanced stage malignant neoplasms with the tumor thrombus extending into the right atrium. The malignant neoplasms involved the kidney in two patients, and the liver and adrenal gland in one each. The tumor thrombus was removed through a longitudinal cavotomy and right atriotomy in all cases. The inferior vena cava reconstruction was performed by directly closing it in one patient and by pericardial patch suturing in another. Cardiopulmonary bypass was used for all procedures and a Pringle maneuver was used to reduce bleeding from the liver in three. There was no perioperative or hospital death. Two of the four with renal cell carcinoma were alive 7 and 13 months after the surgery. One with hepatocellular carcinoma died of recurrent malignancy after 4 months, while the patient with an adrenal carcinoma remained disease free after surgery. These cases indicate the safety of the present procedure. Although the long-term results are still unknown, there were favorable early results and a lack of perioperative complications. Surgical challenges in resecting an intracardiac extension of retroperitoneal malignancy require close cooperation among the attending urologist, and both gastrointestinal and cardiovascular surgeons.     

Laparoscopic hepatic wedge resection of hemangioma: report of two cases

INTRODUCTION: Cavernous hemangiomas are the most frequent type of benign liver tumor. A large proportion are discovered unexpectedly. The widespread use of ultrasound (US) and computerized tomography (CT) scanning has made diagnosis more common. Laparoscopic liver surgery has, however, developed more slowly. There have been only a few anecdotal reports of hepatic laparoscopic resections, most of which are limited to wedge resections. Laparoscopic anatomical liver resections are still at an early stage of development. DISCUSSION: This paper describes two cases of hepatic cavernous hemangiomas, both of which were removed laparoscopically. No blood transfusion was necessary. No surgical complications occurred and the patients were discharged on the second postoperative day. We conclude that, depending on the size and location of the tumor, laparoscopic resection of liver hemangiomas can be performed safely.     

Benign liver tumors in adults: Diagnosis and management

Benign tumors of the liver are a heterogeneous group of lesions whose detection has greatly increased because of the widespread use of imaging techniques. Only a few types, such as cavernous hemangiomas, focal nodular hyperplasia (FNH), hepatic adenoma (HA), and cysts, are frequent enough to be of clinical importance. Although often asymptomatic, these tumors are sometimes associated with pain or digestive symptoms. In some of them, hormonal manipulation has a role in both the development and the course. Complications, such as spontaneous rupture or sudden increase in size, have been reported. Only in hepatic adenoma is malignant transformation considered possible. The clinical importance of these tumors lies mainly in making a correct diagnosis of the type of lesion, and in ruling out primary or metastatic tumors. Although most cases can now be identified through imaging techniques, in some, diagnosis remains uncertain even after percutaneous biopsy, making surgical exploration necessary. We here consider 104 patients with benign lesions: 60 underwent resection; the remaining 44 had follow up only. Of the former group, 35 had hemangiomas, 16 “cellular” tumors (either FNH or HA), and 9 cystic lesions. Forty-four were resected due to the presence of symptoms and 16 because of uncertain diagnosis. It is concluded that cavernous hemangioma, FNH, and most of the cysts have a favorable clinical evolution and, when the diagnosis is certain, resection is not indicated. Surgery can be considered for symptomatic or complicated cases and those in which the diagnosis remains uncertain with imaging work-up techniques. HA and cystic adenoma require surgical treatment even in asymptomatic patients.     

Tumor Seeding following Laparoscopy: International Survey

The aim of the study was to determine if tumor seeding during laparoscopic surgery for cancer is a rare event or a typical complication of this procedure. Laparoscopic staging and treatment of intraabdominal tumors is increasing in gastroenterology, gynecology, and general surgery. A total of 1052 questionnaires were mailed to surgical department chairmen, members of the German Society of Surgery, Swiss Association for Laparoscopic and Thoracoscopic Surgery, and Austrian Society of Minimal Invasive Surgery asking them to list their department's experience with tumor seeding after laparoscopy for nonapparent or known malignancy. There were 607 (57.7%) surgeons who reported a total of 117,840 laparoscopic cholecystectomies, 409 incidental gallbladder carcinomas, and 412 laparoscopies on patients with colorectal carcinoma. Altogether 109 patients who developed tumor recurrence in connection with laparoscopic surgery have been reported. Port-site recurrence was identified in 70 of 409 patients (17.1%) with a median of 180 days following laparoscopic cholecystectomy for nonapparent gallbladder carcinoma. In 8 cases (11.5%) a protective plastic bag had been used for gallbladder retrieval. Six patients without port-site metastases were found to have a diffuse peritoneal carcinomatosis a median of 120 days after cholecystectomy. Of 412 laparoscopies for colorectal cancer, 19 cases (4.6%) of tumor seeding have been reported, 16 of which (3.9%) had documented port-site and scar recurrences a median of 196 days after laparoscopy. The tumor specimen was intact, and a plastic bag was used for extraction in seven cases. In 14 patients trocar-site metastases have been reported a median of 70 days after laparoscopy for different nonapparent or known malignancies. The probability of developing abdominal wall metastasis is higher after laparoscopy for cancer than after open surgery. An intact surgical specimen and the use of a plastic retrieval bag do not exclude the risk of port-site recurrences. These facts and the early appearance of peritoneal carcinosis in a few cases of intraabdominal malignancies seem to confirm a specific laparoscopic risk for intraperitoneal tumor cell seeding and implantation.     

Angiomatous lips

After defining vascular malformations and tumors, the authors approach specific problems of these lesions involving the lips. Careful planning and assessment are necessary throughout the clinical course and evolution. Therapeutic management concern the vascular anomaly but the functional, cosmetic and psychological repercussions as well. The rules of surgical treatment are discussed in this labial location. Capillary malformations can be treated by pulsed dye laser for the skin involvement, but sometimes by reconstructive surgery in case of soft tissue and bony overgrowth. Venous malformations require percutaneous sclerotherapy, partial or total removal surgery, reconstructive surgery, with or without previous embolization, according to the size and functional repercussions. Lymphatic malformations involving the lip are based upon conservative and observing treatment or surgery according to impairment and psychological impact. There is a strong tendency for these lymphatic microcystic malformations to invade and to recur after surgery. The new lasers (diode, Nd Yag) have to be assessed in this area. Arterio-venous malformations are the most severe anomaly. When the lesion is cosmetically and functionally acceptable, the authors propose conservative management waiting for therapeutic progress expected from genetics research. Otherwise management require embolization and complete surgical treatment with lip reconstruction. The first-line treatment of hemangiomas is medical and pharmacological (local medical care, corticosteroids, interferon, vincristine) but surgery may be indicated in three situations. In urgent cases with severe complications surgery is performed after failure of medical management. Early surgery is recommended to prevent functional or cosmetic disturbance or serious psychological distress. Ultrasound dissection (Dissectron) an significantly contribute to the surgical outcome. Late surgery retains its classical cosmetic and functional indications and techniques to treat the residual after-effects. Three key-words dominate the rules of therapeutic management of all types of vascular anomalies: multidisciplinary approach, experience and carefulness.     

Endangering cutaneous infantile hemangioma treated with vincristine: a case report

Infantile hemangiomas are the most common tumors of childhood. They have a well-defined self-limiting natural history. In about 10% of patients, the hemangioma threatens or potentially threatens life or function during the proliferative phase. The most common treatments for such endangering hemangiomas are intralesional and/or oral steroids. Although steroids are well known to slow growth and promote involution in hemangiomas, there may be no effect on proliferation in up to 30% of patients. There are several reports of the use of intravenous vincristine being successfully used for steroid-resistant hemangiomas, although most of these have been described as hemangioendotheliomas. The degree of improvement in such cases is somewhat subjective. We describe a patient with a large steroid-resistant cervicofacial infantile hemangioma causing stridor. The use of intravenous vincristine rapidly improved the clinical state so much that immediate tracheostomy was avoided, and adrenaline nebulizers could be stopped within 1 day of starting vincristine. We believe that this is the first report of objective improvement in the symptom associated with an infantile hemangioma as a result of treatment with vincristine.     

Optic pathway tumor in children: Toward a new classification for neurosurgical use

ObjectOptic pathway tumors (OPT) represent a challenge for pediatric neurosurgeons. Role of surgery is debated due to the high risk of iatrogenic damage, and in lasts decades it lost its importance in favor of chemotherapy. However, in some cases surgery is necessary to make biomolecular and histological diagnosis, to manage intracranial hypertension (IH) and to cooperate with medical therapies in controlling tumor relapse. With the aim to standardize selection of surgical OPT cases, we propose a simple, practical and reproducible classification.MethodsWe retrospectively analyzed data of 38 patients with OPT treated at our institution (1990–2018). After careful analysis of MRI images, we describe a new classification system. Group 1: lesion limited to one or both optic nerve(s). Group 2: chiasmatic lesions extending minimally to hypothalamus. Group 3: hypothalamo-chiasmatic exophitic lesions invading the third ventricle; they can be further divided on the base of concomitant hydrocephalus. Group 4: hypothalamo-chiasmatic lesions extending widely in lateral direction, toward the temporal or the frontal lobes. Patients’ data and adopted treatment are reported and analyzed, also depending on this classification.ResultsTwenty children were operated on for treatment of OPT during the study period. Permanent clinical impairment was noted in 5 (25%) of operated patients, while visual improvement was noted in 1 patient. OS rate was 100% at 5 years, with a median follow up of 9 years (ranging from 2 to 23). Prevalence of intracranial hypertension and proportion of first-line surgical treatment decision were significantly higher in groups 3-4 compared to groups 1-2 (P < 0.001 for both tests).ConclusionSurgery can offer a valuable therapeutic complement for OPT without major risk of iatrogenic damage. Surgery is indispensable in cases presenting with IH, as in groups 3 and 4 lesions. Eligibility of patients to surgery can be based on this new classification system.