Total omentectomy in gastric cancer surgery: is it always necessary? / Omentectomia total na cirurgia do câncer gástrico: é ela sempre necessária?

ABSTRACT Background: Traditionally, total omentectomy is performed along with gastric resection and extended lymphadenectomy in gastric cancer (GC) surgery. However, solid evidences regarding its oncologic benefit is still scarce. Aim: To evaluate the incidence of metastatic omental lymph nodes (LN) in patients undergoing curative gastrectomy for GC, as well as its risk factors and patients' outcomes. Methods: All consecutive patients submitted to D2/modified D2 gastrectomy due to gastric adenocarcinoma from March 2009 to April 2016 were retrospectively reviewed from a prospective collected database. Results: Of 284 patients included, five (1.8%) patients had metastatic omental LN (one: pT3N3bM0; two: pT4aN3bM0; one: pT4aN2M0 and one pT4bN3bM0). Four of them deceased and one was under palliative chemotherapy due relapse. LN metastases in the greater omentum significantly correlated with tumor's size (p=0.018), N stage (p<0.001), clinical stage (p=0.022), venous invasion growth (p=0.003), recurrence (p=0.006), site of recurrence (peritoneum: p=0.008; liver: p=0.023; ovary: p=0.035) and death (p=0.008). Conclusion: The incidence of metastatic omental LN of patients undergoing radical gastrectomy due to GC is extremely low. Total omentectomy may be avoided in tumors smaller than 5.25 cm and T1/T2 tumors. However, the presence of lymph node metastases in the greater omentum is associated with recurrence in the peritoneum, liver, ovary and death.

RESUMO Racional: Tradicionalmente a omentectomia total é realizada juntamente com a ressecção gástrica associada à linfadenectomia na cirurgia do câncer gástrico. No entanto, evidências sólidas em relação ao seu benefício oncológico são escassas . Objetivo: Avaliar a incidência de metástases em linfonodos do omento maior em pacientes submetidos à gastrectomia potencialmente curativa por câncer gástrico, assim como, avaliar os fatores de risco para a ocorrência e a evolução dos pacientes. Métodos: Pacientes consecutivos submetidos à gastrectomia D2/D2 modificada devido ao adenocarcinoma gástrico foram analisados retrospectivamente a partir de um banco de dados. Resultados: Dos 284 pacientes, cinco (1,8%) tinham linfonodos metastáticos no omento maior (um pT3N3bM0; dois pT4aN3bM0; um pT4aN2M0 e um pT4bN3bM0). Quatro faleceram e um estava em tratamento paliativo com quimioterapia devido à recidiva da doença. Os linfonodos metastáticos no omento maior tiveram correlação significativa com o tamanho do tumor (p=0,018), estádio N (p<0,001), estádio clínico (p=0,022), invasão venosa (p=0,003), recorrência (p=0,006), local de recorrência (peritônio p=0,008; fígado p=0,023; ovário p=0,035) e óbito (p=0,008). Conclusão: A incidência de linfonodos metastático no omento maior de pacientes submetidos à gastrectomia radical por câncer gástrico é baixa. A omentectomia total pode ser evitada em tumores menores que 5,25 cm e estádios T1/T2. Entretanto, a presença de metástases linfonodais no omento maior está associada à recidiva no peritônio, fígado, ovário e óbito.

Retalho de omento maior no tratamento da mediastinite pós-operatória do lactente / Greater omentum flap in the treatment of infant postoperative mediastinitis

INTRODUÇÃO: A mediastinite pós-operatória é uma condição grave, com altas taxas de mortalidade. O retalho de omento maior é usado com êxito no tratamento de mediastinites pós-operatórias decorrentes de cirurgia cardíaca. O uso dessa abordagem não foi relatado em lactentes, provavelmente porque nessa idade o omento maior é membranáceo, pouco volumoso e possui tecido adiposo escasso. MÉTODOS: Entre julho de 2010 e agosto de 2014, foram tratados quatro lactentes com mediastinite pós-operatória decorrentes de cirurgia cardíaca, realizada por esternotomia. O tratamento cirúrgico consistiu em remoção dos fios de aço da osteossíntese esternal, desbridamento e lavagem do mediastino, seguidos da transposição de todo o omento maior para a cavidade mediastinal. O tratamento cirúrgico foi feito em um só tempo. Não foi feita nova síntese do esterno com fios de aço. RESULTADOS: Os quatro pacientes sobreviveram ao tratamento e obtiveram alta da unidade de tratamento intensivo sem infecção. CONCLUSÕES: Embora membranáceo e apresentando pequeno volume, o retalho de omento maior se mostrou um excelente método de abordagem da mediastinite pós-operatória do lactente.

INTRODUCTION: Postoperative mediastinitis is a serious condition that presents high mortality rates. The greater omentum flap has been used with good results in postoperative mediastinitis after cardiac surgery. The use of this approach has not been reported in infants probably because at this age, the greater omentum is membranous, not bulky, and has little amount of fatty tissue. METHOD: Between July 2010 and August 2014, four infants who presented with mediastinitis after a cardiac surgery via sternotomy were treated. The surgical treatment consisted of steel wire removal, debridement, and wound washing, followed by transposition of the entire greater omentum to the mediastinal cavity. Surgical treatment was performed in a single step. No rewiring of the sternum was performed. RESULTS: All four patients survived the treatment and were discharged from the intensive care unit without infection. CONCLUSIONS: Although membranous and not bulky, the use of a greater omentum flap proved to be an excellent approach in infant postoperative mediastinitis.

Study of the clinical and histopathological repercussions of the "omental band" in dogs' stomach

PURPOSE: To evaluate the efficacy of the "omental band" as a bariatric surgical technique. METHODS: A sample of 35 dogs was studied. The Test Group was composed by 20 dogs. Of these, six were observed by 10 days, six were observed by 20 days and eight were observed by 30 days of post-operatory. The Control Group was composed by 15 dogs. Of these, five were observed by 10 days, five were observed by 20 days and five were observed by 30 days of post-operatory. The weight loose was the variable utilized to the evaluation of the efficacy of the surgical technique described in this study, once all of the dogs were weighted in precision balance before the surgical act and at the end of the post-operatory observation period. RESULTS: At the end of the study it was observed that the weight loose of the dogs submitted to the "omental band's" surgical technique was meaningfully higher in comparison with the dogs of the Control Group at the end of the post-operatory observation period. CONCLUSION: The surgical technique of the "omental band" showed effective in dogs, once has proposed a meaningfully weight loose. .

Tumoración pélvica en una paciente con síndrome de li fraumeni / Pelvic tumor in a patient with li-fraumeni syndrome

El síndrome de Li Fraumeni (SLF) es una rara enfermedad hereditaria asociada con un riesgo incrementado de padecer ciertos tumores malignos. Presentamos el caso de una paciente con diagnóstico de SLF con antecedentes de sarcoma de glúteo con metástasis pulmonares y cáncer de mama bilateral metacrónico. Acudió al Servicio de Urgencias por distensión y dolor abdominal. Se objetivó una masa pélvica y se pensó en un probable origen ovárico de la misma. La paciente fue intervenida en el Servicio de Ginecología, y durante la intervención se descartó dicho origen ya que la tumoración dependía del epiplón. El diagnóstico final fue metástasis de sarcoma.

Li-Fraumeni syndrome (LFS) is a rare, inherited syndrome associated with increased risk of various malignant tumors. We present the case of a patient diagnosed LSF with a history of gluteal sarcoma with lung metastases and metachronous bilateral breast cáncer. She came to the emergency department for abdominal bloating and pain. She had a pelvic mass and we had thought probable ovarian dependence. The patient was operated on at the Department of Gynecology, and during the intervention we realized that the tumor depended on the omentum. The final diagnosis was a metastatic of sarcoma.

Torsión secundaiia del omento mayor: una causa poco frecuente de dolor en herniia inguinal complicada / Secondary torsion of the greater omentum, an unusual cause of complicated inguinal hernia

Introducción: La torsión del omento mayor en el interior de un orificio herniario es una entidad muy infrecuente como complicación de una hernia. Caso clínico: Presentamos el caso de un paciente varón de 43 años que acude a Urgencias por cuadro de dolor en fosa ilíaca derecha (FID). El estudio mediante tomo-grafía computarizada muestra un patrón "en remolino" en la grasa mesentérica que se introduce en el orificio inguinal derecho, sugerente de hernia complicada secundaria a torsión de omento mayor. Los hallazgos quirúrgicos y anatomopatológicos confirman el diagnóstico. La torsión de omento mayor es una causa poco frecuente de complicación de hernia inguinal.

Background: Secondary torsion of the greater omentum due to a complicated hernia is uncommon. Case report: We report a 43 years old male presented to the emergency room for pain in the right lower quadrant of the abdomen. An abdominal CT scan showed that mesenteric fat was herniating through the right inguinal orifice with a whirling pattern, suggesting a complicated hernia secondary to torsion of the greater omentum. The patient was operated and the preoperative diagnosis was confirmed.

Retalho autólogo de grande omento como estrutura cirúrgica de reparo extraperitoneal. Estudo experimental comparativo, pareado e controlado de suas propriedades adaptativas / The autologous greater omental flap as a structure for extraperitoneal surgical repair: a comparative, paired, and controlled experimental study of its adaptive properties

Introdução: O grande omento vem sendo utilizado como estrutura de reparo desde o século XIX e a partir do século XX tem sido descrito, em meio extraperitoneal, para o tratamento de diversas afecções em várias especialidades cirúrgicas. Apesar de amplamente estudado a partir da década de 1960, não há descrição de estudos comparativos sobre o seu retalho em meio extra peritoneal. O objetivo do presente estudo foi analisar as características adaptativas do grande omento em meio extra peritoneal para identificar a real aplicabilidade cirúrgica desta estrutura. Métodos: Estudo experimental comparativo, pareado e controlado de 20 amostras teciduais de ratos (Rattus norvegicus) fêmeas obesas, irmãs da linhagem Sprague- Dawley. De cada animal foram analisados e comparados, macroscopicamente e microscopicamente, através das técnicas de Hematoxilina-eosina (HE) amostras de: (1) omento sem manipulação, (2) omento manipulado intraperitoneal, (3) omento manipulado extraperitoneal e (4) tecido adiposo subcutâneo. Resultados: omento extraperitoneal, macroscopicamente, apresentou uma coloração amarelado mais intenso, semelhante à gordura subcutânea adjacente, com alto grau de contração se comparado ao omento intraperitoneal de controle. Pela técnica de HE, foi identificado alto grau de fibrose e tamanho médio dos adipócitos semelhante ao omento de controle e inferior ao do subcutâneo (p<0,001). Conclusão: O omento extraperitoneal não se mostra capaz de promover regeneração tecidual, uma vez que não foi observado metaplasia à histologia do retalho translocado. Entretanto, pode servir para a correção de pequenas deformidades, para o tratamento de áreas isquêmicas, como estrutura carreadora para a reconstrução cirúrgica e como plataforma germinadora para o desenvolvimento de novos órgãos.

Introduction: The greater omentum was initially used in the repair of gastrointestinal defects in the 19th century; during the 20th century, it has been used extraperitoneally in the treatment of various disorders, in several surgical specialties. Despite the fact that the greater omentum was studies in detail in the 1960s, there are no reported comparative studies concerning the use of omental flaps extraperitoneally. The present study analyzed the adaptive features of the greater omentum in the extraperitoneal space, with the aim of identifying its surgical applicability. Methods: A paired, controlled comparative study was conducted using 20 tissue samples from 5 obese female Sprague-Dawley rats (Rattus norvegicus). The following specimens from each animal were analyzed and compared, macroscopically and microscopically, using the hematoxylin-eosin (HE) technique: (1) omentum without manipulation; (2) intraperitoneally manipulated omentum; (3) extraperitoneally manipulated omentum; and (4) subcutaneous adipose tissue. Results: Macroscopically, the extraperitoneal omentum exhibited a more intense yellowish color and a higher degree of contraction than the control (intraperitoneal) omentum. The extraperitoneal omentum was similar in color to the adjacent subcutaneous adipose tissue. HE staining revealed a high degree of fibrosis and an average adipocyte size, similar to that in the control omentum, but lower than that in subcutaneous adipose tissue (p< 0.001). Conclusion: The results of this study indicate that the extraperitoneal omentum was not able to promote tissue regeneration, as metaplasia of the translocated flap was not observed in the histological analysis. However, this structure may be used to correct small deformities, in the treatment of ischemic areas, as a carrier structure for surgical reconstruction and as a germination platform for the development of new organs.

Follicular Dendritic Cell Sarcoma of the Omentum: Multidetector Computed Tomography Findings

We report computed tomography (CT) findings for a rare case of follicular dendritic cell sarcoma of the greater omentum from a 47-year-old female patient. The tumor presented ash a palpable mass lesion in the umbilical region for the last two months. Multidetector CT scan of the abdomen showed a 14-cm soft-tissue mass with calcification and necrosis within the greater omentum. As a result, a follicular dendritic cell sarcoma should be considered in the differential diagnosis of a solitary omentum mass, especially one with coarse and chunk-like calcifications.

Extragonadal omental teratoma: a case report

Mature cystic teratomas or dermoid cysts are among the most common ovarian tumors; however teratomas of extragonadal origin are extremely rare. The most common extragonadal site of these teratomas is the omentum. It is generally accepted that teratomas arise from germ cells that originate in the mature gonads. Of the three proposed etiologies of omental teratoma, auto-amputation and subsequent re-implantation of gonadal teratoma is the most likely preceding event. A review of literature reveals that only 31 cases of teratoma of the greater omentum have been published to date and three cases reported wherein omental teratoma and dermoid of the ovary were coexisting. We report a rare case of an omental teratoma in a 26-year woman who underwent ovarian cystectomy for dermoid cyst. This is the fourth case of an omental mature teratoma with coexisting ovarian dermoid cyst

Torsión primaria de epiplón: caso clínico / Primary omental torsion: report of one case

We report a 40 years old female consulting in the emergency room for abdominal pain and a mass in the left lower quadrant. An abdominal CAT sean showed an omental torsion. The patient was operated, excising the involved omentum. The postoperative period was uneventful and the patient was discharged three days after admission.

El objetivo de este trabajo es presentar el caso clínico de una paciente con torsión de epiplón manejado en nuestra institución. Se trata de una paciente de sexo femenino de 40 años de edad, que se presenta al servicio de urgencias por clínica de dolor abdominal de una semana de evolución asociado a masa abdominal en flanco izquierdo, en quien se realiza tomografía que revela cambios compatibles con torsión de epiplón por lo cual es llevada a cirugía realizándose resección de todo el omento.

Omental and pleural milky spots: different reactivity patterns in mice infected with Schistosoma mansoni reveals coelomic compartmentalisation

In vertebrate animals, pleural and peritoneal cavities are repositories of milky spots (MS), which constitute an organised coelom-associated lymphomyeloid tissue that is intensively activated by Schistosoma mansoni infection. This study compared the reactive patterns of peritoneal MS to pleural MS and concluded from histological analysis that they represent independent responsive compartments. Whole omentum, lungs and the entire mediastinum of 54 S. mansoni-infected mice were studied morphologically. The omental MS of infected animals were highly activated, modulating from myeloid-lymphocytic (60 days of infection) to lymphomyeloid (90 days of infection) and lymphocytic or lymphoplasmacytic (160 days of infection) types. The non-lymphoid component predominated in the acute phase of infection and was expressed by monocytopoietic, eosinopoietic and neutropoietic foci, with isolated megakaryocytes and small foci of late normoblasts and mast cells. Nevertheless, pleural or thoracic MS of infected mice were monotonous, consisting of small and medium lymphocytes with few mast and plasma cells and no myeloid component. Our data indicate that compartmentalisation of the MS response is dependent on the lymphatic vascularisation of each coelomic cavity, limiting the effects or consequences of any stimulating or aggressive agents, as is the case with S. mansoni infection.

Inflammatory pseudotumor of the omentum.

Inflammatory pseudotumor is an unusual quasineoplastic lesion, of uncertain natural history and etiopathogenesis, which consists of inflammatory cells and myofibroblastic spindle cells; and is usually found in children and young adults. Clinical manifestations and radiological feature of this rare entity, can be indistinguishable from a malignant sarcomatous or lymphoproliferative disorders. Here, a case of surgically proven inflammatory pseudotumor of the omentum in a child and its review of literature is presented. Conservative surgery is curative in most cases of inflammatory pseudotumors. Awareness of this lesion is essential for clinicians, radiologists and pathologists, as pre-operative recognition may spare the child from unnecessary radical surgery or harmful chemoradiotherapy.

Clinical Aspects of Intraabdominal Cystic Lymphangioma in Korea / 대한소화기학회지

BACKGROUND/AIMS: Cystic lymphangioma is an uncommon disease, and rarely develops in the intraabdomen. The aim of this article was to discuss about clinical characteristics of intraabdominal cystic lymphangioma developed in Korea. METHODS: Age, sex, symptoms, locations and size of the lesions, diagnostic methods, treatments, complications and recurrence were analyzed in 13 pathologically confirmed cases of intraabdominal cystic lymphangioma and 18 cases of literature consideration reported in Korea. RESULTS: Intraabdominal cystic lymphangioma commonly developed in adults compared to the other lymphangioma, and frequently located in the mesentery. Abdominal pain was the most common symptom, but it was a non-specific finding. Tenderness and abdominal mass were not significantly associated. The size of mass was diverse. Abdominal ultrasonography and abdominal CT were diagnostic tools most commonly used, but preoperative diagnosis was possible only in 22.6%. All patients were discharged without any complications, and no recurrence was reported. CONCLUSIONS: Preoperative diagnosis of intraabdominal cystic lymphangioma is difficult and symptoms and signs are not specific. Intra-abdominal cystic lymphangioma should be suspected in patients with non specific abdominal pain and intraabdominal mass and active diagnostic evaluation is mandatory.

Torsión primaria de epiplón en paciente HIV / Primary omental torsion in a patient with HIV infection

Primary or idiopathic torsion of the greater omentum, without preexistent abdominal disease, in an uncommon cause of acute abdomen. On account of its raraness and absence of specific symptomatology, the diagnosis usually is performed at laparoscopy. This condition can be mistaken for appendicitis and in women the alternative diagnosis is usually a twisted ovarian cyst. The twisted omentum may become gangrenous and give rise to peritonitis. We report a patient with an acute abdomen with HIV infection with primary torsion fo the greater omentum. This torsion with primary infarction of the greater omentum is an infrequent cause of acute abdomen as much as in immunocompetent patients the same as in HIV positives. The elective treatment is the surgical removal.

Acquired Omental Cystic Lymphangioma after Subtotal Gastrectomy: A Case Report

We herein describe a case of cystic lymphangioma in the greater omentum of the remnant stomach, which is thought it to be related with subtotal gastrectomy 10 yr ago for early gastric cancer. A 76-yr-old man was admitted to our department with postprandial abdominal discomfort and bowel habit change. Intraabdominal multilocular cystic mass was detected by ultrasonography and computed tomography. We performed a complete En-bloc tumor resection including spleen and distal pancreas, and histological examination confirmed cystic lymphangioma originated from the greater omentum of the remnant stomach. Although the etiology of omental lymphangioma remains largely unclear, these findings suggested strongly that obstruction of the lymphatic vessels after gastric resection for gastric carcinoma might be the most plausible cause. The surgical extirpation with resection of organs involved appears to be a treatment of choice for such unusual case.

Ectopic decidual reaction mimicking peritoneal tubercles: a report of three cases.

Ectopic decidual reaction is commonly seen in the ovary and cervix; however, peritoneal localization is rare. Peritoneal deciduosis is usually an incidental histological finding. It may present a diagnostic dilemma by mimicking grossly peritoneal carcinomatosis or tubercles and deciduoid mesothelioma, microscopically. We report three cases of ectopic decidual reaction discovered incidentally during caesarian sections, as whitish yellow nodules resembling tubercles. Histology revealed extensive decidualisation. To the best of our knowledge, this is the first report of ectopic decidua mimicking peritoneal tubercles.

Omental cyst masquerading as ascites.

Two children presented with massive generalised enlargement of abdomen simulating ascites. Common medical causes being excluded. They were treated with antituberculous drugs without any response until the radiological features suggested and surgical exploration proved the condition to be omental cyst.