Broad Pedicle Research Articles

Polypoid colorectal endometriosis with abundant leiomyoma-like smooth muscle cell proliferation treated by endoscopic resection.

A 55-year-old female patient with abdominal pain was referred for resection of an atypical lesion in the descending colon after office-based colonoscopy. Endoscopic visualization of the estimated 15-mm nodular lesion with a broad pedicle at 11 o´clock appeared not consistent with adenoma, although minor mucosal changes, potentially related to previous biopsies were discernible (Fig. 1A). Corresponding to the endoscopic aspect, no submucosal injection of indigo carmine was achievable, however, endoscopic resection was, nonetheless, pursued to achieve tissue diagnosis (Fig. 1B). Therefore, the lesion was cautiously snare resected in a superficial manner (Fig. 1C), and post-interventional evaluation of the resection defect excluded perforation (Fig. 1D). The further clinical course was uneventful, and, with a view to histopathology, the patient was referred for gynecological care. Indeed, pathology indicated an abundant leiomyoma-like nodular smooth muscle cell proliferation with minor reactive epithelial changes with endometrial glands and stroma in between (Fig. 2A), Closer-up scrutinization of endometrial tissue elements excluded dysplastic changes (Fig. 2B). Dedicated immunohistochemistry for endometrial structures highlighted the localization around the nodular smooth muscle cell proliferation (Fig. 2C) with desmin immunoreactivity (Fig. 2D). Intriguingly, hormonal receptor immunohistochemistries indicated marked positivity in the endometrial tissue plane as well as within the leiomyoma-like nodule (Fig. 2E, F). The latter finding rather suggests a reactive nature over coincident leiomyoma. Fig. 2(A) Abundant leiomyoma-like nodular smooth muscle cell proliferation with minor reactive epithelial changes with endometrial glands and stroma in between. (H&E, x1.6). (B) Closer-up demonstration of endometrial tissue elements without dysplasia. (H&E, x5) (C) Dedicated immunohistochemistry for endometrial structures pinpoints the localization around the nodular smooth muscle cell proliferation (CD10, x1.6), (D) which exhibits strong desmin immunoreactivity. (desmin, x1.6) (E, F) Hormonal receptor immunohistochemistry, in addition, indicated marked positivity in the endometrial tissue plane as well as within the leiomyoma-like nodule, rather suggestive of its reactive nature. (estrogen (ER) and progesterone receptor (PR), x2.5 each). View Large Image Figure Viewer Download Hi-res image

8569 Approach to a Giant Pedunculated Fibroid

<h3>Study Objective</h3> This video reviews the surgical approach to a large pedunculated fibroid including preoperative assessment and intraoperative considerations for performing a laparoscopic myomectomy with contained tissue extraction. <h3>Design</h3> Surgical technique demonstration. <h3>Setting</h3> The patient was seen in an academic medical center. In the outpatient setting, she was consulted by a minimally invasive gynecologic surgeon with expertise in fibroid management. The surgery was performed in the outpatient surgery center. <h3>Patients or Participants</h3> A 37-year-old nulliparous female with a fibroid uterus. Based on preoperative imaging, the predominant fibroid was a posterior, pedunculated fibroid with an estimated weight of 1300 grams. The patient agreed to the use of photos and videos for educational purposes via an informed consent process. <h3>Interventions</h3> Preoperatively, the patient received leuprolide acetate injection in effort to decrease the size and vascularity of the large, broad-stalked, pedunculated fibroid. Eight weeks later she underwent laparoscopic myomectomy with a minilaparotomy for contained tissue extraction. Prior to the start of the surgery, she received misoprostol and tranexamic acid to aid in hemostasis. The video demonstrates the intraoperative use of vasopressin in addition to the surgical approach to the primary myomectomy. Use of the minilaparotomy for surgical assistance, open myomectomy of an additional fibroid, and contained morcellation is portrayed in the video. <h3>Measurements and Main Results</h3> N/A. <h3>Conclusion</h3> This video reviews the surgical approach to a large, pedunculated fibroid via laparoscopic myomectomy with minilaparotomy. The surgery was without complication and the patient was discharged on the same day. Key learning points that lead to a successful case included: preoperative optimization when you expect to encounter high risk of blood loss, retention of a rim of serosa overlying a broad pedicle when performing myomectomy of an exophytic fibroid, and use of minilaparotomy to aid progression of case, not only for tissue extraction.

An Uncommon Mass of the Esophagus: Esophageal Hemangioma

A 73-year-old woman complaining of retrosternal pain and swallow discomfort over the past 1 month was admitted to our hospital. She denied any dysphonia, regurgitation or weight loss. Physical examination was unremarkable. The hematological and biochemical profiles were normal. Barium meal studies revealed a smooth oval-shape mass with broad pedicle in the posterior wall of the upper esophagus (Figur 1). The patient refused to endoscopic investigation because of irregular heart rhythms. Further chest CT scan revealed a soft tissue mass with punctuate calcification and narrowing of the lumen to around 40% of the original size. The lesion showed moderately inhomogeneous enhancement after contrast injection (Figure 2 &amp; 3). There was no lymphatic node adenopathy in the mediastinum. Based on her symptoms and related radiological findings, the patient was firstly suspected with esophageal hemangioma and underwent thoracoscopic enucleating. Intraoperative photography showed deep-red lesion with smooth surface (Figure 4) and the mass was completely resected under the thoracoscopy. Histopathological findings were consistent with esophageal haemangioma (Figure 5). Post-operative course was uneventful and the patient’s symptom of retrosternal chest pain was completely resolved after surgery. She remained asymptomatic at 2-year follow-up.

A rare case of giant multiseptated thoracic myelomeningocele with segmental placode.

A rare case of giant multiseptated thoracic myelomeningocele with segmental placode.

Large and Deep Diabetic Heel Ulcers Need not Lead to Amputation

Management of large and deep heel ulcers (LDHUs) is a challenge in patients with diabetic foot lesions. We assessed outcomes of a treatment protocol to save feet with LDHUs from amputation. We managed LDHUs (larger than 3 cm(2)) in diabetic feet using a multidisciplinary approach consisting of medical and surgical management, including revascularization and amputation, if necessary. For deep heel infection and/or gangrene, we frequently debrided and drained the deep spaces of the heel, as needed. In patients with non-ischemic feet, we made a flap from the heel pad with a broad pedicle. When satisfactory granulation tissue covered the base of the heel and the inner surface of the flap, we sutured the heel flap to its base. We managed 37 feet with LDHUs among 384 patients. Twenty-nine patients (78.4%) had neuropathy, 6 (16.2%) had ischemic diabetic feet, and 2 (5.4%) had both neuropathy and ischemia. Twelve (32.4%) had septic diabetic feet. We performed two femoropopliteal bypasses, 2 infrapopliteal bypasses, and 1 distal bypass (crural) for ischemic heel ulcers. Thirty-three of the 37 feet with heel lesions (89.2%) were salvaged using this multidisciplinary approach. These 33 LDHUs healed after 4 to 7 months (median, 6 months). Transtibial amputation was performed for 4 feet (10.8%; 2 ischemic and 2 neuropathic cases). Diabetic patients with LDHUs can be managed with a multidisciplinary approach to prevent amputation. If necessary, deep spaces of the heel can be debrided by elevating the heel pad like a flap and then performing satisfactory reconstruction. Level IV, retrospective case series.

The Reverse Posterior Interosseous Artery Flap: Technical Considerations in Raising an Easier and More Reliable Flap

Major injuries of the hand with skin loss often require early flap cover, which should be versatile, simple in technique, and safe. The reverse posterior interosseus flap satisfies all of these requirements. Over the years, refinements in the technique of harvesting this flap have evolved to prevent venous congestion and flap necrosis. This study presents adaptations to avoid such complications and raise a successful flap. A total of 21 patients underwent this flap reconstruction between January 2008 and November 2010 for injuries around the wrist and hand. The average follow-up period was 6 months; 19 were male and 2 were female. The average age was 33 years (range, 9-70 y). In 17 patients, the flap reconstructions were done for posttraumatic injuries, in 2 after skin defects following tumor resection, and 1 each after defects resulting from release of first web contracture in multiple congenital contractures and burns. Average size of the flap was 51 cm(2) (range, 90- 30 cm(2)). The donor area was covered by a split skin graft. All flaps survived without major complications. Generally the flap matched the surrounding skin except for palmar defects. No patients reported donor skin graft color mismatch. The reverse posterior interosseous flap is a reliable and safe flap for soft tissue cover to the wrist, palm, dorsum of hand, first web space, and metacarpophalangeal joints. Thorough attention to the technical details, including performing a proximo-distal flap dissection with the deep fascia, avoiding dissection of the anastomotic arc between posterior and anterior interosseous artery, creating a broad pedicle with a cutaneous handle, and avoiding its tunneling for inset, will contribute to survival of the flap.

Gross and histopathologic characteristics of penile fibropapillomas in young bulls

Fibropapilloma of the penis is caused by the bovine papillomavirus. Two 12- and 18-month-old bulls were presented with a history of gradually enlarging mass on the glans of penis. Grossly, the masses were multinodular proliferations, of varied sizes mainly between 0.5 and 5 cm in diameter, well circumscribed, and nonpigmented and were attached to the glans by a relatively broad pedicle. Histopathologically, the masses were papillomatous features with irregular hyperplasia and epidermal rete ridges. The dermis consisted of densely packed irregular collagenous connective tissue with many fibroblasts. In the epidermis, orthokeratotic hyperkeratosis, many koilocytes with variably sized keratohyalin granules, and rare presence of intranuclear inclusion bodies were present. The morphologic patterns were typical of fibropapillomas of papillomavirus etiology. In one case, recurrence of lesion occurred about 2 months after surgical treatment.

Computed tomography study of implantation corridors in canine vertebrae

To define the characteristics of optimum implantation corridors in vertebral bodies C2 to C7 and T10 to S1, using computed tomography examination. Measurements were taken from 207 vertebrae from 35 different adult dogs. Implantation corridors of the cervical vertebrae are narrow. The width preserving the transverse hole is less than 2.5 mm in 68.6 per cent of the 86 vertebrae C2 to C6. Dorsal implantation corridors of the last four thoracic vertebrae are narrow, and major anatomical structures are very close to their emergence point. In 63 per cent of the 40 thoracic vertebrae, the right azygos vein is at a distance less than or equal to 1 mm from the vertebral body. The first six lumbar vertebrae have broader corridors. Furthermore, vascular structures are far from the emergence point. The last lumbar vertebra and the sacrum have a broad pedicle, which provides an alternative site for implant placement. For the vertebrae L1 to S1, the dorsal implantation can be performed. For the cervical vertebrae, the risk of laceration of the vertebral artery is high. For the last four thoracic vertebrae, the dorsal implantation should not be used.

The versatility of genioplasty using a broad pedicle

The biologic and clinical foundation for using a broad soft-tissue pedicle genioplasty technique is described. This technique is versatile and stable and produces more predictable soft-tissue changes than previously reported methods of altering chin contour with alloplastic implants. The broad pedicle genioplasty technique has clear advantages over other techniques for procedures such as secondary genioplasty using local anesthesia, concomitant genioplasty and anterior subapical osteotomy, simultaneous genioplasty and submental lipectomy, and segmentalization of the chin to facilitate narrowing or widening.

Management of the Abdominal Undescended Testicle

Of the orchiopexies performed for abdominal undescended testicles 85 per cent have resulted in satisfactory testicular growth and position. Three-fourths of these cases were in boys with the prune belly syndrome. We are satisfied with our recent experience using the Fowler-Stephens procedure to salvage intra-abdominal undescended testicles. An analysis of the failures in 5 testes early in this series, resulting in partial atrophy, has helped us to avoid technical errors through attention to the following details: 1) preservation of a broad pedicle of peritoneum overlying the mobilized vas, 2) avoidance of any dissection of the spermatic cord and 3) high ligation of the spermatic vessels well above the point of confluence of the vas and spermatic vessels. Although the Fowler-Stephens procedure has some risk of testicular ischemia and atrophy we believe it to be the preferred way to gain mobility on a short tethering gonadal vascular pedicle.

The Resident's Page

<h3>PATHOLOGIC QUIZ CASE 1</h3><h3>J. R. CHANDLER, MD, MIAMI, FLA</h3> For two months a 54-year-old man had noticed a lump growing larger on his right ear. Bleeding occurred with the slightest trauma and had become more troublesome during the past three weeks. Examination revealed a papilliferous and polypoid mass approximately 1½ cm in diameter occupying the concha of the left ear. It grew from a broad pedicle and was friable and bled easily on manipulation. The lesion was biopsied then completely excised (Fig 1). The microphotograph is from the excised specimen. <h3>PATHOLOGIC QUIZ CASE 2</h3><h3>J. R. CHANDLER, MD, MIAMI, FLA</h3> A 25-year-old white man was admitted to the hospital because of swelling of the right cheek and about the right eye of five days' duration. There was some pain and sensitivity in the region of the right upper teeth. A similar swelling responded to antibiotic treatment by a dentist

先天性エプーリスの1例について

A 7-moth-old boy visited us, complaining of a swelling of soy-bean size at the alveolar ridge on the left upper incisor portion. It was already noticed since 7 days after his birth. Since then the swelling has not changed its size. The tumor was spherical in shape and attached to the alveolar ridge with a broad pedicle. Radiogram showed that the left upper incisor is located deeper in alveolar bone than other teeth. This was diagnosed as congenital epulis, follwed by surgical extirpation. The tumor has not shown a recurrence for these 5 months after operation.The crown of the extracted incisor was completed, but the pulp was necrotic. Histo-logic examination of the epulis showed that it consists of a cellular mesenchyma resembling the dental papilla, in which epithelial islands are mingled. Large cell with abundant granular cytoplasm was not presented. It can be cosidered that this tumor belongs to a hamartoma participated with tooth germ, especially its mesenchymal tissue, in its origin.

Value of hysterography in the diagnosis of large submucous uterine fibroids.

Hysterography can be valuable in the diagnosis of large submucous fibroids. These tumors, when they occupy the entire uterine cavity, form a false smooth wall and are difficult to detect by curettage. In the cases to be reported here, curettage was done for menometrorrhagia by different gynecologists without disclosing the nature of the lesion. Because bleeding continued, hysterography was performed and a large submucous fibroid was found in each instance. Case Reports Case I: R. P., a 27-year-old nullipara, was first seen on May 27, 1948, complaining of irregular bleeding for the last eighteen months. Her menses started at the age of thirteen and until the present illness occurred every thirty days, lasting six days. Treatment had consisted mainly of hormones, administered by mouth, without any effect. The basal metabolism rate, determined three months before admission, was −25 per cent. Three grams of thyroid were administered daily with no effect on the menometrorrhagia, and a repeat basal metabolism test on May 2, 1948, showed a rate of −6 per cent. Physical examination revealed no evidence of any abnormality except for the pelvic findings. The cervix was eroded; the uterus was not enlarged but was retroverted. On June 29, 1948, a diagnostic curettage was performed and a small amount of tissue was obtained. No irregularity of the uterine cavity was noted. Microscopic examination revealed proliferative endometrium, and the patient was discharged on July 1 in good condition. Two weeks later bleeding again started. Ergotrate and Oreton were administered, with slight diminution of the bleeding. After three months of intermittent spotting, a hysterogram (Fig. 1) was obtained on Oct. 11. This showed the uterine cavity to be globular in outline, retroverted, and normal in size. A filling defect occupied the entire cavity and a presumptive diagnosis of submucous fibroid was made. On Oct. 16, the patient was prepared for a vaginal hysterotomy. Prior to this operation, a second diagnostic curettage, performed by a different operator, again revealed no evidence of an intrauterine lesion. When the cervix was incised and a finger introduced into the uterus, a submucous fibroid the size of a walnut was detected. It was attached to the posterior wall by a broad pedicle. This was excised and the patient made an uneventful recovery. Follow-up examination revealed a well healed cervix that readily admitted a uterine sound. Since operation, there has been no abnormal bleeding. Case II: A. L., a 25-year-old nullipara, was first seen on Jan. 14, 1949, complaining of considerable bleeding for the last two weeks, with the passage of clots. In March 1948 there had been a similar episode, for which a diagnostic curettage was performed. There was no evidence of any intrauterine tumor, and a diagnosis of functional bleeding was made. Hormones by mouth were administered at that time to check the bleeding, but without success. The hemoglobin was 54 per cent.