Pulmonary Infarction with Pleural Effusion - Pathologic Surprise in the Oncological Patient.

We present the case of a 49 years-old female treated 10 years ago for a breast cancer (mastectomy followed by radio- and chemotherapy), referred to our unit for a recurrent pleural effusion with no response to medical treatment (pleural liquid - total proteins 4,1 g%, glucose 100 mg%, LDH 493 U/l, abundant cellularity with 30% eosinophils but no obvious neoplastic cells). The CT examination showed a loculated pleural effusion and a thickened irregular pleura, raising the suspicion of malignancy. Intraoperatively we found a loculated effusion - Fraser Gourd decortication and 7 subpleural pulmonary tumors with a diameter between 0,5 and 5 cm which we considered to be pulmonary metastases and performed non-anatomical resections with pulmonary reconstruction. The postoperative course was favourable, with discharge on postoperative day 16.The pathologic examination showed an inflammatory infiltrated pleura with no atypia and pulmonary infarction in all the 7 pulmonary resection specimens. Standard coagulation tests were normal but a detailed analysis of the coagulation status was not available, while postoperative cardiac and peripheric venous ultrasound did not show any abnormality explaining the pulmonary infarction. After the definitive diagnosis, the patient was treated with antiaggregants and dicumarinic oral anticoagulation, the later being abandoned due to poor compliance. At the 26 months follow-up the patient showed no signs of recurrence but she died at 32 months after surgery due to a stroke. The case is interesting due to the illustration of the diagnostic difficulties encountered in the oncological patients with pleural effusions; considering this case as "inoperable" would have resulted in anuseless chemotherapy and progression towards a more severe pleuro-pulmonary suppuration.

Laparoscopic Mobilization of an Omental Flap for a Chronic Scarpa Triangle Suppuration after Vascular Graft Infection.

We report a case of laparoscopic mobilization of an omental flap (left epiploic vessels) which was used to solve a Scarpa triangle chronic suppuration after a vascular prosthesis infection (coverage of bovine pericardium patch angioplasty for closure of the defect resulting after the excision of the vascular graft). The procedure lasted 90 minutes and was performed using 3 trocars and standard laparoscopy instruments. The immediate postoperative course was favourable, with regain of transit after 12 hours and healing of the wound; the patient died 9 months later due to some complications that occurred on the contralateral leg. In cases with a favourable anatomy, the laparoscopic mobilization of the omentum is extremely easy, being associated with a quick recovery and a reduction of the morbidity.

Anatomo-clinical analysis of 14 consecutive cases of primary cystic mesenterico-epiploic tumors.

BACKGROUND: The aim of this study is an anatomo-clinical evaluation of the primary cystic mesenterico-epiploic tumors,based on a single-center's 15 year experience. MATERIAL AND METHOD: We performed a retrospective study of a series of 14 primary cystic mesenterico-epiploic tumors that were operated in the Surgical Department 4 UMPh Targu-Mures, Romania, between 01.01.1997 and 01.01.2012. Data about the clinical complaints, imagistic aspects, associated lesions, surgical approach, hospitalization, pathology, and immediate and late postoperative course were recorded and analysed using the Microsoft Excel software. RESULTS: In all cases we performed a complete and intact surgical excision, using an open approach in 13 cases and laparoscopy in 1 case, with no mortality and no significant surgical-related morbidity; we have encountered a single recurrence at 1.5 years after surgery. We had no preoperative pathological diagnosis; the exact preoperative anatomic location of the tumor was possible only in one case. Pathologic examination showed the following types: inclusion cysts - 4 cases, enteral duplication cysts - 2 cases, simple mesothelialcysts - 6 cases, cystic lymphangioma - 1 case and simple lymphatic cyst - 1 case. We have systematized 3 clinicoimagistic patterns according to the dimension of the tumor,with no relationship to the histologic origin of the tumor. CONCLUSIONS: Primary cystic mesenterico-epiploic tumors aredifficult to diagnose preoperatively. Complete excision is usually possible, even for large tumors. These relatively rare tumors must be considered in the differential diagnosis of cystic abdominal masses.

Extraperitoneal mobilization of the omentum--analysis of a personal series of 12 patients.

OBJECTIVE: The aim of the paper is to evaluate the results achieved after mobilization of the omentum outside the peritoneal cavity. MATERIAL AND METHOD: Between 01.01.2006-01.01.2012, the main author has performed an extraperitoneal mobilization of the omentum in 12 patients. The indications for the use of this flap were: prophylactic filling of the remnant space after the Miles procedure - 4 cases, solving of some pelvisubperitoneal and perineal complications after rectal surgery - 3 cases, covering of vascular prosthesis - 3 cases (2 of them with active infection) and closure of a post-pneumonectomy bronchial fistula - 1 case. The mobilization of the flap was performed by laparotomy - 10 cases, by laparoscopy - 1 case and transdiaphragmatic (thoracotomy) - 1 case; all the procedures were performed by the same team, with no assistance on behalf of a plastic surgeon. RESULTS: We have encountered one immediate postoperative death through myocardial infarction on postoperative day 12 (vascular prosthesis infection in a 75 years old patient). Based on the clinical and imagistic evaluation, we have encountered no necrosis of the omental flap. At late follow-up (1-5 years) we have encountered no significant complications related to the use of this flap. CONCLUSIONS: The omentum is a solution for a great variety of defects located outside the peritoneal cavity; it's mobilization is relatively simple and does not involve a major morbidity. Knowledge of the omentum's anatomy and techniques of mobilization are mandatory in digestive, thoracic and vascular surgery.