Reconstruction Plate Fracture: Mechanism and Recent Advances

Reconstruction plates with or without bone grafts are used to restore mandibular continuity, form and function following segmental resection of mandible. Fracture of reconstruction plate is observed in 2.9 % to 10% of cases reported in the literature excluding other complications. In this case, we report the fracture of stainless steel reconstruction plate used without bone graft and its management using locking reconstruction plate with non vascularised iliac crest graft following removal of the fractured plate. Review of literature describing incidence, pattern and causes of reconstruction plate fracture and its management is discussed.

Application of preoperative localization coupled with CT three-dimensional reconstruction in pulmonary nodule-centered uniportal thoracoscopic combined subsegmental/segmental resection / 中国胸心血管外科临床杂志

@#Objective     To assess the clinical value of preoperative localization coupled with computed tomography (CT) three-dimensional reconstruction in pulmonary nodule-centered uniportal thoracoscopic combined subsegmental/segmental resection. Methods     The clinical data of 30 patients of combined subsegmental/segmental resection in our hospital from December 2019 to October 2021 were retrospectively collected. There were 19 males and 11 females with the mean age of 56.4 (32.0-71.0) years. The pulmonary nodules were located by CT-guided injection of glue before operation. The three-dimensional reconstruction image and operation planning were carried out by Mimics 21.0 software. Results    The operations were all successfully performed, and there was no conversion to open thoracotomy or lobectomy. The mean tumor diameter was 11.6±3.5 mm, the mean distance between the nodule and the visceral pleura was 13.6±5.6 mm, the mean width of the actual cutting edge was 25.0±6.5 mm, the mean operation time was 110.2±23.8 min, the mean number of lymph node dissection stations was 6.5±2.4, the mean amount of intraoperative bleeding was 50.8±20.3 mL, the mean retention time of thoracic catheter was 3.2±1.1 d, and the mean postoperative hospital stay was 4.5± 1.7 d. There was 1 patient of subcutaneous emphysema, 1 patient of atrial fibrillation and 1 patient of blood in sputum. Conclusion     Preoperative CT-guided injection of medical glue combined with CT three-dimensional reconstruction of pulmonary bronchus and blood vessels is safe and feasible in pulmonary nodule-centered uniportal thoracoscopic  combined subsegmental/segmental resection, which ensures the surgical margin and reserves lung tissues.

A comparison between different management surgical approaches in the treatment of splenic flexure colon cancer

Background: There are many surgical approaches which described extent of resection of the colon for adequate surgicalmanagement of splenic flexure cancer, but up till now there is no established surgical procedure, this is because the presence of double lymphatic drainage of themesenteric vessels. Segmental resection of the colon for the management of splenic flexure cancer was a recently accepted surgical procedure. Objective: In the present study, we aimed to compare three surgical management techniques to clarify the best management approach of Egyptian patients with splenic flexure cancer regarding operative, clinical, and oncological outcomes: segmental resection, and extended left or right hemicolectomy,. Materials and Methods In the present study, we included 90 patients with splenic flexure cancer. Cases were divided into 3 groups. Each group included 30 patients in order to compare three surgical techniques: segmental resection, extended left hemicolectomy, and extended right hemicolectomy. Results: We have found no statistically significant differences between the three included groups regarding operative findings, postoperative complications, local recurrence, distant recurrence, disease progression, recurrence-free survival rate, progression-free survival rate, and overall survival rate. The operative time was longer, and the number of lymph nodes was higher in the extended right hemicolectomy group (p<0.001). Conclusion: We have shown that segmental resection of the splenic flexure is surgically and clinically suitable for the adequate management of operable cases of carcinoma of the splenic flexure. (AU)

Preliminary Study of CT Three-dimensional Reconstruction Combined with Ground Glass Nodules of Natural Lung Collapse in Thoracoscopic Pulmonary Segmental Resection / 中国肺癌杂志

BACKGROUND@#Computed tomography (CT) three-dimensional reconstruction technology is increasingly used in preoperative planning of patients with ground glass nodule (GGN), but how to accurately locate the nodule and ensure the safe resection edge is still a difficult problem for clinicians. The purpose of this study was to investigate the accuracy, convenience and safety of CT three-dimensional reconstruction combined with intraoperative natural collapse localization in total thoracoscopic segmental pneumonectomy.@*METHODS@#A total of 45 patients with radiographic findings of pulmonary GGN admitted from July 2019 to December 2019 were selected as the study group. All patients received thin-slice CT scan and underwent preoperative three-dimensional reconstruction. After anesthesia, the small thoracic operation opening and the airway of the patients were quickly opened, and the lung was rapidly and naturally collapsed by pressure difference. GGN were positioned according to the natural marker line, and marked with 3-0 prolene line. After specimen removal, the distance between the GGN and the suture mark, the distance between the GGN and the incision margin were measured, and the incision margin was routinely examined. The general clinical data, pathological data and postoperative complications were counted and compared with 45 consecutive patients who were located with hookwire positioning needle in the same period.@*RESULTS@#The average localization time of non-invasive GGN with natural lung collapse during operation was 6.9 min, and the localization accuracy was 90.6%. There were 2 cases of extensive pleural adhesion and 1 case of emphysema. Postoperative pathology was confirmed as lung adenocarcinoma, and the examination of incision margin was negative. No GGNs were scanned again after surgery, and the precise resection rate of lung segment was 100.0%.@*CONCLUSIONS@#CT three-dimensional reconstruction combined with GGN localization of natural lung collapse during operation can shorten the time of searching for GGN during operation and guarantee the safety of the incision margin. It is a more economical and convenient localization method and makes pulmonary segment resection more accurate.

Jejunal Diverticula Causing a Life-Threatening Lower Gastrointestinal Bleeding: A Case Report

A jejunal diverticulum is a rare and usually asymptomatic disease. More commonly it is usually seen as incidental findings on radiological studies or during surgery. Complications such as bleeding, perforation, abscess formation, obstruction, malabsorption, blind loop syndrome, volvulus, and intussusception may warrant surgical intervention. Herein, we report a case of a 62-year old woman presenting with massive lower gastrointestinal bleeding, she was pale, clammy and hemodynamically unstable, she was initially resuscitated with IV fluids and whole blood, urgent upper endoscopy was normal, colonoscopy revealed sigmoid colon ulcerative lesion with histopathological evidence of adenocarcinoma, there was bleeding coming from upwards. After staging of the tumor, the decision was then made to proceed to exploratory laparotomy with a pre-operative plan of segmental colectomy. Intra-operatively segmental sigmoid colectomy was performed with end to end anastomosis, during formal laparotomy we found 2 giant diverticula in the proximal jejunum, small bowel resection and end to end anastomosis was done with the good postoperative outcome. The aim of this study was to draw attention to jejunal diverticula and their serious complications such as bleeding.

The regularity and clinical significance of intrapulmonary lobar and segmental lymph nodes metastasis in patients with cT1N0M0 stage lung adenocarcinoma / 中华胸心血管外科杂志

Objective To investigate the regularity of intrapulnonary lobar and segmental lymph nodes metastasis in patients with cT1N0M0 stage lung adenocarcinoma.To provide a basis for more accurate determination of N stage and indication for pulmonary segmental resection.Methods A prospective study was performed from March 2014 to December 2015.103 cases of cT1 N0M0 stage lung adenocarcinoma received lobectomy and mediastinal lymph node dissection in the thoracic surgery department of China-Japan Friendship Hospital.Intrapulmonary lobar and segmental lymph nodes were dissected and sorted carefully then sent to the pathological department with the corresponding lung specimen and other lymph nodes.Statistical analysis was carried out considering size of the lesion,imaging features,serum CEA levels,pathological subtypes and so on.Results In total 103 cases,pN0 was confirmed in 82 cases,pN1 in 15 cases,pN1 + N2 in 5 cases,and skipping-pN2 in 1 case.14 cases(93.3％) in pN1 group were detected with station 12-14 lymph node metastasis,while only 5 cases (33.3％) were detected with station 12-14 LSNs metastasis.4 cases(66.7％) in pN2 group were detected with station 12-14 lymph node metastasis,while only 1 case(16.7％) with station 13 and station 7 lymph node metastasis.If LSNs were not detected,the false negative rate of N staging could be as high as 6.1％ (5/82),The rate of missed diagnosis of lymph node metastasis might be 30％ (6/20) to N1 stations alone.41.2％ (7/17)cases with metastasis to the adjacent LSNs had been proved with metastasis to the isolated LSNs.The metastasis rate of the isolated LSNs was significantly lower(P =0.049) in pure GGNs compared with those part-solid/solid nodules.Invasive adenocarcinoma had higher metastasis rate of isolated LSNs,compared with preinvasive lesions or minimally invasive adenocarcinomas,with no statistical difference between groups (P =0.055).No significant difference in isolated LSNs metastasis rate was found between groups with different serum CEA levels(P =0.251) or tumor size(P =0.197).Conclusion Dissection of intrapulmonary lobar and segmental lymph nodes might facilitate a more accurate N stage,reduce the false negative rate of lymph node metastasis,and provide basis for more accurate assessment of prognosis and postoperative adjuvant treatment.The sampling area of lymph nodes during segmental resection should include the adjacent LSNs of the target segment.The isolated LSNs metastasis rate of cT1N0M0 stage lung adenocarcinoma with pureGGN as imaging feature is relative low,which might be suitable for segmentectomy when meeting other criteria.

Therapeutic effect of the combined treatment of multiple segmental resection and choledochoscope lithotomy on complex intrahepatic biliary calculi / 中国基层医药

Objective To learn therapeutic effect of the combined treatment of multiple segmental resection and choledochoscope lithotomy on complex intrahepatic biliary calculi.To provide effective and reliable operation method for the treatment of disease.Methods 213 cases with complex intrahepatic biliary were randomly divided into observation group(117 cases)and control group(96 cases)by random number table method.The control group was treated with multiple segmental resection,the observation group was treated with multiple segmental resection com-bined choledochoscope lithotomy.The postoperative complications of the two groups were observed,and the patients of the two groups were followed up,and the effect of surgical treatment was evaluated.Results The hospitalization time of the observation group was (10.1 ±3.4)d,which was significantly shorter than (13.7 ±4.6)d of the control group (t =6.560,P <0.05).Postoperative 3 -6 weeks residual stone rate of the observation group was 7.69%(9 /117), which was lower than that of the control group,the difference was statistically significant (χ2 =4.099,P <0.05).In both two groups,the average duration of follow -up was (11.2 ±3.9)months.In the observation group,the excellent and good rate of surgery 89.74%(105 /117)was higher than the control group (χ2 =9.154,P <0.05).The postop-erative complication rate of the observation group 18.80%(22 /117)was lower than that of the control group,the difference was statistically significant (χ2 =14.467,P <0.05).Conclusion In the treatment of complex intrahepat-ic biliary calculi,the combined treatment of multiple segmental resection and choledochoscope lithotomy has better curative effect and low postoperative complication rate,with good clinical application value.

Resección segmentaria duodenal por tumor estromal en la tercera porción / Duodenal segmental resection for third portion stromal tumor

Los GIST son tratados preferentemente de manera quirúrgica. La localización duodenal de los mismos corresponde al 4,5% de los casos pero el tratamiento de los tumores en esta localización no está estrictamente definido. Se reporta el caso de una mujer de 59 años con antecedentes de cólicos biliares y melena. El estudio ecográfico demostró litiasis vesicular y una lesión redondeada de 4 cm diámetro de localización retroperitoneal. La tomografía abdominal ubicó a la masa en la tercera porción duodenal (confirmada por la duodenoscopía) con aspecto sugerente de tumor estromal. Fue sometida a laparotomía, donde se realizó colecistectomía y resección segmentaria de la tercera y cuarta porción duodenal con anastomosis duodeno-yeyunal. Durante la internación presentó ictericia pasajera y fuga anastomótica de bajo débito que cerró espontáneamente. El alta se realizó al 16° día postoperatorio. El estudio anatomopatológico reveló un tumor de bajo grado con células características del estroma intestinal. La inmunohistoquímica confirmó la estirpe estromal intestinal del tumor (CD117+).

GISTs are preferably treated surgically, duodenal location corresponding to 4.5 % of cases but the treatment of the tumors in this location is not strictly defined. We report the case of a 59 year old woman with a history of biliary pain, and an episode of melena. Ultrasound examination showed gallstones and a retroperitoneal lesion of almost 4 cm diameter. The TAC placed the mass in the third portion of the duodenum (confirmed by duodenoscopy) with characteristical aspect of a stromal tumor. At the laparotomy was performed segmental resection of the third and fourth portion of the duodenum with duodenal- jejunal anastomosis. During hospitalization the patient presented temporary jaundice and low flow anastomotic leak that closed spontaneously and she went home on the 16th postoperative day. The pathological study revealed low-grade tumor with intestinal stromal cell characteristics. The immunohistochemistry confirmed the intestinal stromal tumor lineage (CD117 +). The duodenum - pancreatectomy is not always necessary for the treatment of tumors of the duodenum.

Anatomy of retrohepatic segment of inferior vena cava and termination of hepatic veins.

Background Information on anatomy of intrahepatic inferior vena cava (IVC) and hepatic vein openings in it is limited. Methods We studied the retrohepatic segment of IVC and hepatic vein openings in it in 69 livers obtained from cadavers. The retrohepatic portion of the IVC was opened posteriorly by a vertical cut, the exposed surface was divided into 12 quadrants and the position, size, and septation of ostia of hepatic veins and any accessory openings were charted; measurements were made using Vernier calipers. Results The median length of the intrahepatic IVC was 5.7 (range 3.3–8.2) cm and its median diameter was 2.3 (range 1.5–3.0) cm. The superior (major) set of hepatic veins comprised of two veins (right and left-middle) in 45 (65%) cases, three veins (right, middle, and left) in 23 (33%) and four veins in one (2%) case. Median diameter of the right hepatic vein was 1.5 (range 0.8–2.7) cm and that of left hepatic vein was 1.2 (0.7–2.6) cm. Middle hepatic vein, when separate, had a median diameter of 1.1 (range 0.5–1.5) cm. The inferior (minor) set of hepatic veins had two to 16 (median 7) veins. Conclusions Our data provide information on number, size, position, and septation of hepatic vein openings into the IVC. This information may be useful to hepatologists, hepatic surgeons while planning segmental resection of the liver, and to radiologists planning diagnostic and interventional procedures on hepatic venous system.

Comparision Pathohistologic T3 with T4 in Clinical T4 Gastric Cancer which was Treated with Radical Gastrectomy Combined Colon Segmental Resection

PURPOSE: If a mesocolon or colon invasion of gastric cancer was clinically suspected during an operation, a colon resection combined with a gastrectomy is generally recommended. However, sometimes no pathologic invasion of cancer cells is experienced. Therefore, the aim of this study was to compare post operative pathohistologic T3 and T4 in cases of clinical proven T4 when treated by a radical gastrectomy combined a colon segmental resection. METHODS: Thirty-eight patients were treated by a radical gastrectomy (D2 lymph node dissection) combined with a colon segmental resection at the Department of Surgery, Gospel Hospital, Kosin University, between Jan. 1990 and Dec. 2001. The accuracy of the preoperative clinical T-stage was analyzed, along with a retrospective analysis of age, gender, tumor site and size, type of gastrectomy, histology, lymph node metastasis, Borrmann type, tumor marker (CEA), and the rates of complications, mortality and survival between pathohistologic T3 and T4. The survival rate was analyzed by the Kaplan-Meier method using the SPSS statistical program; other statistical analyses were performed using the chi-squared test. RESULTS: Stomach cancer, suspected of mesocolon mesentery or colon invasion in the operation field, was treated with an extended radical gastrectomy with colon segmental resection (122 cases). Of the 122 cases 84, which had incurable factors, such as peritoneal metastasis, liver metastasis and follow up loss, were excluded. The remaining 38 cases were curatively treated with an extended radical gastrectomy combined colon segmental resection and D2 lymph node dissection. The accuracy of the clinical T-stage from preoperative CT scans were clinical and pathological T4 in 23 (60.5%) and 17 (44.8%) of the 38 cases, respectively. The 5 year survival rates of pathohistologic T3 and T4 were 21.2 and 13.5%, respectively. CONCLUSION: There was no significant difference between the pathohistologic T3 or T4 stages with respect to the survival rate and other clinical features. For these reasons, a radical gastrectomy combined a colon segmental resection is suggested with stomach cancer when mesocolon mesentery or colon invasion is suspected.

Surgical Treatment of Malignant and Aggressive Bone Tumors Around the Knee by Segmental Resection and Rotationplasty

In patients having malignant or aggressive bone tumors around the knee joint and requiring amputation, segmental resection and rotationplasty was performed and the clinical results were analyzed. Twenty-six patients underwent segmental resection and rotationplasty between February 1988 and June 1994. The mean follow-up period was 57 (6 - 120) months and the average age of patients was 21.4 (5 - 37) years. Out of 26 patients, there were 18 osteosarcomas (> or = stage IIB), 2 synovial sarcomas, and 6 giant cell tumors. Clinical results were evaluated by the Shriner's rating system. Four patients were excluded due to death or amputation and the remaining twenty-two patients were included for assessment. Eighteen patients had excellent results, 3 good, and 1 fair. Range of motion of the ankle joint was -11 (dorsiflexion) - 80 (plantarflexion) degrees and daily walking activity was possible. Local recurrence developed in 2 patients and distant metastasis in 10. Early complications include 3 thromboses and 1 sepsis, and late complications were 6 nonunion, 2 malrotation and 1 stiffness of the ankle joint. Rotationplasty, which is functionally excellent, may serve as an effective partial limb salvage procedure, especially in patients younger than 10 years old who are expected to have leg length discrepancy or loosening of the tumor prosthesis due to the growth of the medullary cavity or when amputation is inevitable for a wide resection margin.

Central Segmental Resection of Pancreas for Cystic Neoplasms in Head and Neck of Pancreas

PURPOSE: Pancreatic cystic neoplasm is a rare disease. It should be resected regardless of the presence of symptoms due to the possibility of malignancy. Standard pancreatic resection such as PPPD or distal pancreatectomy accompanies the loss of a significant amount of normal pancreatic parenchyma and may cause an impairment of normal pancreatic functions. On the contrary, pancreatic enucleation is known to have risks of pancreactic fistula or abscess. The aim of this study is to elucidate whether segmental resection of the pancreas is a safe and effective treatment in cystic neoplasms in the head and neck of the pancreas. METHODS: We reviewed the medical records of seven patients treated with central segmental resection of the pancreas for cystadenoma at Ewha Womans University Mokdong Hospital from December 2000 to April 2001. All lesions were located at the head and neck of the pancreas. A cephalic stump was sutured for closure of minute pancreatic ductal leakage and hemostasis, and the distal stump was anastomosed with a Roux-en-Y jejunal loop. Postoperative pancreatic functions, complications, and follow up results were analysed. RESULTS: The mean age of the patients was 48.14 (+/-9.55) years old. The pathological diagnoses were 4 cases of serous cystadenoma and 3 cases of mucinous cystadenoma. The mean size was 2.03 (+/-0.7) cm. The average operating time was 299.3 (+/-44.2) minutes. There were two cases of minor complications that were mild pancreatic fistulas without symptoms. There was no operative mortality, impairment of pancreatic function, or recurrence. The mean postoperative hospital stay was 23.6 days. CONCLUSION: Segmental resection of the pancreas can be a rational therapeutic option for cystic neoplasms in the head and neck of the pancreas in terms of the potential benefit of preserving pancreatic function.

Segmental Resection for Extrahepatic Bile Duct Cancer (excluding GB cancer)

PURPOSE: It is difficult to preoperatively determine the extent of surgery for extrahepatic cholangiocarcinoma due to its proximity to vital structures. Recently the tendency of combined resection of liver and pancreas for the treatment of this appears to be increasing, although, in spite of the expected survival benefit, this radical surgery cannot be applied to all extrahepatic cholangiocarconoma because of the high rate of operative complications. We reviewed patients who had undergone segmental resection of the bile duct vice radical surgery for extrahepatic cholangiocarconoma in order to study their clinical features and to analyze the prognostic factors for survival. METHODS: Thirty-four patients who underwent segmental resection for extrahepatic cholangiocarcinoma, excepting GB cancer, at our center between 1994 to 2000 were included in this study and their medical records were reviewed retrospectively. RESULTS: The mean age of the patients was 63 years and they underwent segmental resection of bile duct and skeletalization of the hepatoduodenal ligament with hepatico-jejunostomy. The mean length of hospital stay after operation was 17.2 days (8~44) and no operative mortality was encountered. Postoperative complications including 5 wound dehiscences, 1 intraperitoneal abscess, 1 pyloric obstruction and 1 case of gastric ulcer bleeding were all improved following conservative management. The mean size of tumors was 2.6 cm and 11 tumors (32%) involved the resection margin. The estimated 2 and 4 year survival rates of the 34 patients following resection was 64% and 22% respectively and the only significant predictive factor for survival following resection was the tumor involvement of resection margin (P=0.045). The 2-year survival rate of the positive margin group was 34%, although that of the free margin group was 74%. CONCLUSION: Segmental resection for extrahepatic cholangiocarconoma may be a reasonable option offering relatively low morbidity and mortality if the resection margin is tumor- free. Additionally, segmental resection may be more beneficial to patients with high operative risk in particular.

Segmental Resection and Reimplantation with an Autoclaved Bone for Treatment of Malignant Disease / 대한정형외과학회잡지

Wide resection is an acceptable alternative to amputation for the management of primary sarcomas of the long bones or pelvis. The resected bone can be debrided of gross tumor tissue, autoclaved, and than replaced to reconstruct the limb anatomically. The procedure can be combined with prosthetic reconstruction of adjacent joints with sufficient strength to allow early unprotected weight-bearing. We had an experience of a large segmental defect in the shaft of the humerus after wide resection due to.a low grade malignant chondrosarcoma without extension to the surrounding soft tissues and this case had been managed by reimplantation after autoclaving the locally resected segment and autogenous iliac bone graft with a sound union and the favorable functional outcomes. So we are reporting this case with bibliographic reviews as a possible method of reconstruction for the management of the segmental defect which was produced by a local resection for a low grade malignancy.