Partial Resection Of Diaphragm Research Articles

A case of eventration of left diaphragm with improved pulmonary function by partial resection of diaphragm under VATS

A case of eventration of left diaphragm with improved pulmonary function by partial resection of diaphragm under VATS

Diaphragmatic stripping in epithelial ovarian cancer at first diagnosis: Impact on morbidity and survival outcomes

ObjectivesDiaphragmatic stripping is a standard procedure that is performed in a significant proportion of patients undergoing surgical cytoreduction for advanced ovarian cancer. The objective of the present study is to evaluate morbidity and survival outcomes among patients offered diaphragmatic surgery for primary diagnosed optimally resected ovarian cancer. Study designWe conducted a retrospective cohort study, identifying patients that were offered surgery between 2016 and 2021 for primary diagnosis of ovarian cancer. Cases that had diaphragmatic stripping or partial diaphragmatic resection were selected and compared to cases that did not require this procedure. Kaplan-Meier and Cox-regression analyses were applied to evaluate survival outcomes. ResultsOverall, 61 patients that had diaphragmatic stripping were identified. Severe postoperative complications (Clavien-Dindo 3 + ) were noted in 19 patients (31 %). Survival analyses denoted that the stage of the disease at the time of diagnosis, as well as the timing of the surgical procedure (PDS vs IDS) and the completion of tumor debulking were factors that significantly affected the recurrence free and overall survival of patients. Severe postoperative morbidity was a significant predictor of the overall survival. Multivariate cox-regression analysis that was adjusted for the stage of the disease revealed that preoperative pleural effusion, optimal (compared to complete) tumor resection and the occurrence of postoperative complications significantly affected the overall survival of patients. Compared to patients that did not have diaphragmatic surgery, patients submitted to diaphragmatic stripping or resection had improved progression free and overall survival rates, irrespective of the stage of the disease at diagnosis or the adequacy of resection status. ConclusionsDiaphragmatic surgery is feasible in advanced ovarian cancer patients with acceptable morbidity that mainly refers to postoperative pleural effusion. Its positive impact on patients‘ survival requires further investigation.

Robotic-Assisted Laparoscopy Excision of a Severe Form of Diaphragmatic Endometriosis: A Retrospective Study of 60 Patients

To assess the feasibility, effectiveness, and safety of the robotic surgical approach in the treatment of severe diaphragmatic endometriosis (DE). Retrospective single-center study using data prospectively recorded in the Franco-European Multidisciplinary Institute of Endometriosis database and the National Observatory for Endometriosis database. Tertiary referral center. Endometriosis care center. Sixty consecutive patients undergoing robotic excision of severe DE from January 2020 to July 2023. Robotic excision of severe DE. Categorical and continuous variables were evaluated and compared using descriptive statistics. A p value of <.05 was considered statistically significant. Full-thickness diaphragmatic resection was performed in 76.7% of patients (46 of 60) and partial diaphragmatic muscle resection in 10% of cases (6 of 60). Peritoneal stripping technique was performed in 60% of patients (36 of 60), divided as follows: as the only technique in the case of extensive superficial diaphragmatic involvement in 13.3% of cases (8 of 60), in addition to full-thickness or partial diaphragmatic resection in the case of concomitant multiple foci in 46.7% of patients (28 of 60). Median operative time was 79.6 minutes with no statistically significative difference related to the surgeon performing surgery (p >.05). Intraoperative and postoperative complications occurred in 1.7% (1 of 60) and 6.6% of cases (4 of 60), respectively. Diaphragmatic hernia (Clavien-Dindo 3b) was the most common postoperative complication and required surgical repair in all cases. Median hospital stay was 24 hours. The rate of patients with complete recovery from DE symptoms has gradually increased during follow-up, reaching 89% after 12 months from surgery. In this case series, robotic treatment of severe DE in expert hands was feasible, effective, and safe.

Clinical application of endoscopic diaphragmotomy and dilation in a congenital duodenal diaphragm.

A congenital duodenal diaphragm (CDD) is a rare cause of duodenal obstruction in infants and children. The traditional approach to treatment has been surgical intervention either with excision and duodenoplasty or with bypass through a duodenoduodenostomy, which is invasive and carries the risk of anastomotic leakage. To summarize the key points of differential diagnosis and treatment of a CDD under gastroscopy and to evaluate its efficacy and safety. The clinical data of patients with a duodenal obstruction diagnosed and treated by gastroscopy in our hospital between January 2019 and December 2022 were retrospectively analyzed. The gastroscopic features of the CDD were summarized. The clinical outcomes of patients with CDD treated by gastroscopy were collected and investigated. A total of 13 children with a duodenal obstruction underwent a gastroscopic examination and/or treatment, and of these, 10 were diagnosed as having a CDD and 3 were finally diagnosed as having an annular pancreas. A dome-shaped structure during inspiration (9/10) and a guidewire that could be inserted through the opening into the distal lumen (6/10) were the gastroscopic features of the CDD, while the annular pancreas had none of these features. The 10 patients, 4 men and 6 women with the CDD, were treated through endoscopic diaphragmotomy and dilation. The age and weight at operation was 15 days to 7 years (M: 2.25 years) and 2.85-22 kg (M: 13.6 kg), respectively. A total of 11 endoscopic operations were performed in the 10 patients. The time of single operation was 15-55 min (M: 38 min). The patients did not experience complications such as bleeding, pneumoperitoneum, and duodenal papilla injury during the operation. Feeding was started 12-24 h after surgery, and the patients were discharged 2-10 days (M: 7 days) postoperatively. The patients were followed up for 3-36 months (M: 17 months), and none of them had a recurrence of vomiting. However, three showed a recurrence of stenosis in upper gastrointestinal imaging, one of whom underwent a partial diaphragm resection again 2 months after the primary treatment. A CDD can be confirmed by endoscopy based on its characteristic features. Endoscopic diaphragmotomy and balloon dilation are safe and effective, which can be a new option for minimally invasive treatment of a CDD.

Catamenial pneumothorax: Not only VATS diagnosis.

Catamenial pneumothorax (CP) is a rare type of spontaneous, recurring pneumothorax occurring in women, from the day before menstruation until 72 hours after its beginning. Conservative treatment is generally associated with recurrence of CP. Video-assisted thoracic surgery (VATS) approach allows not only to obtain diagnosis but also to guide definitive treatment of causing lesions, such as ectopic endometrial implants or diaphragmatic defects and fenestrations. We report our experience in VATS management of CP to focus on its role in CP. In this retrospective observational study, we collected data from women referred to our center for CP, from January 2019 to April 2022. All patients underwent VATS approach, with muscle-sparing thoracotomy when diaphragmatic fenestrations were detected, to perform selective diaphragmatic plication and/or partial diaphragmatic resection. Results were analyzed in terms of pneumothorax recurrence after surgical treatment. All patients were referred to gynecologists for medical therapy. Eight women (median age 36 years, range: 21-45), all with right side CP, were included; three already had pelvic endometriosis and two had already undergone lung apicectomy at other institutions. VATS allowed us to detect diaphragmatic fenestrations in seven patients (87.5%) and apical bullae in five (62.5%). Apicectomy was performed in five cases (62.5%), selective diaphragmatic plication in two (25%), and partial diaphragmatic resection in five (62.5%). Chemical pleurodesis with talc was performed in all to minimize the risk of recurrence. Pathological diagnosis of endometriosis on the resected diaphragm was achieved in five patients (62.5%). No recurrence occurred, except for one woman who stopped medical treatment for endometriosis. In the management of patients with CP, VATS should be recommended not only to obtain an explorative diagnosis of ectopic endometrial implants or diaphragmatic fenestrations but also to allow the most appropriate surgical treatment and obtain pathological specimens for confirmation and definitive diagnosis of thoracic endometriosis. Medical therapy to achieve ovarian rest is mandatory in the postoperative period and should not be discontinued.

8482 An Unusual Presentation of Granulomatous Peritonitis Following Cystectomy for Mature Teratoma

<h3>Study Objective</h3> To highlight granulomatous peritonitis as a potential complication of cyst content spillage during laparoscopic ovarian cystectomy for mature teratoma. To describe the first known case of granulomatous peritonitis infiltrating the right hemidiaphragm, leading to right-sided pneumonia and requiring a partial diaphragmatic resection. To review prevention and treatment strategies of granulomatous peritonitis following ovarian cystectomy for mature cystic teratoma. <h3>Design</h3> Case report. <h3>Setting</h3> Community hospital. <h3>Patients or Participants</h3> 1 patient. <h3>Interventions</h3> Surgical intervention consisting of extensive resection of disease, including laparoscopy converted to midline laparotomy, left salpingo-oopherectomy, omentectomy, partial bladder cystectomy, liver wedge resection, diaphragm stripping, partial resection of diaphragm, mesenteric nodule resection, appendectomy, repair of both large and small bowel; as well as resection of anterior abdominal wall disease. <h3>Measurements and Main Results</h3> Pathology demonstrated recurrent mature cystic teratoma, abundant hair fragments and associated foreign body type granulomatous reaction. The patient was asymptomatic at 9 months after surgical intervention. <h3>Conclusion</h3> Awareness of granulomatous peritonitis, and the potential extent of disease, as a complication of dermoid cyst rupture is paramount. Cyst content spillage is often challenging to avoid, and copious irrigation is advised if spillage occurs - yet may still not successfully prevent peritonitis. Route of cystectomy should be carefully considered to minimize risk of spillage. Ultimately, maintaining an index of suspicion for this diagnosis when a patient presents with vague or unusual symptoms following laparoscopic cystectomy for mature dermoid may expedite appropriate care, which may include extensive surgical resection.

An Opportunity Missed: Managing an Aggressive Adrenal Cortical Carcinoma

Abstract Introduction: Adrenal cortical carcinoma (ACC) is a rare endocrine tumor with an incidence of up to 2 persons per million population. Complete surgical resection is the first-line therapy for localized tumors, while debulking surgery, radiation therapy, and/or chemotherapy may also be options for palliation in advanced ACC. Biochemical and radiographic evaluation of a newly discovered adrenal mass maximizes the opportunity for the patient to undergo a complete, margin-negative resection of the primary tumor, which is the most powerful determinate of long-term survival. Here we present the case of an extremely aggressive high grade adrenal cortical carcinoma that increased from 4 cm to 17 cm within 4 months, metastasizing to the lung, liver and left kidney prior to resection. Case summary: A 42-year-old woman presented to the Emergency Department (ED) with abdominal pain and was found to have hypokalemia and an incidental left adrenal mass measuring 4.9 x 4.6 cm. She was discharged home with instructions to follow up with her primary care physician for further workup. Unfortunately, she was lost to follow-up for 3 months. Her initial biochemical evaluation at follow-up did not show evidence of adrenal insufficiency or elevated metanephrines. A repeat outpatient CT chest abdomen pelvis revealed increased tumor size to 12.3 x 10.8 x 12.5 cm, with unclear renal vs adrenal origin, and multiple liver and lung metastases. She subsequently underwent left radical nephrectomy, adrenalectomy, splenectomy as well as a partial diaphragmatic resection 4 months after her initial ED presentation. The surgical specimen measured 17 x 11.5 x 8 cm. Endocrinology was consulted post-operatively to evaluate for relative adrenal insufficiency given hypotension &amp; altered mental status. Further evaluation revealed new-onset hirsutism, male-pattern hair loss, proximal muscle weakness, and significant weight loss over the prior 3 months. Post-operative laboratory evaluation was significant for sustained hypokalemia of 2.4 mmol/L, 24 hour urine cortisol of 1326 mcg/24 hr (normal 3.5–45), as well as elevated DHEA-S of 994 mcg/dL (normal 27–240), and testosterone of 294 ng/dL (normal 10–75). Surgical pathology demonstrated a high-grade adrenal cortical carcinoma. Oncology was consulted and the patient was started on spironolactone for the hypokalemia, but declined any further therapy for her ACC and subsequently died 2 weeks later. Conclusion: This case illustrates how ACC can behave aggressively and further emphasizes the need for timely and complete biochemical evaluation of adrenal incidentalomas. This is particularly true with the presence of suspicious radiologic features such as size more than 4 cm and heterogeneous appearance. All patients with an adrenal incidentaloma should undergo biochemical and imaging evaluation, guided by thorough history-taking and physical exam, to ensure optimal outcomes.

CRS/HIPEC with Major Organ Resection in Peritoneal Mesothelioma Does not Impact Major Complications or Overall Survival: A Retrospective Cohort Study of the US HIPEC Collaborative.

CRS/HIPEC is thought to confer a survival advantage for patients with malignant peritoneal mesothelioma (MPM). However, the impact of nonperitoneal organ resection is not clearly defined. We evaluated the impact of major organ resection (MOR) on postoperative outcomes and overall survival (OS). The US HIPEC collaborative database (2000-2017) was reviewed for MPM patients who underwent CRS/HIPEC. MOR was defined as total or partial resection of diaphragm, stomach, spleen, pancreas, small bowel, colon, rectum, kidney, ureter, bladder, and/or uterus. MOR was categorized as 0, 1, or 2+ organs. A total of 174 patients were identified. Median PCI was 16 (3-39). The distribution of patients with MOR-0, MOR-1, and MOR-2+ was 94, 45, and 35 patients, respectively. MOR-1 and MOR-2+ groups had a higher frequency of any complication compared with MOR-0 (57.8%, 74.3%, and 48.9%, respectively, p = 0.035), but Clavien 3/4 complications were similar. Median length of stay was slightly higher in the MOR-1 and MOR-2+ groups (10 and 11days) compared with the MOR-0 cohort (9days, p = 0.005). Incomplete cytoreduction, ASA class 4, and male gender were associated with increased mortality on unadjusted analysis; however, their impact on OS was attenuated on multivariable analysis. MOR was not associated with OS based on these data (MOR-1: HR 1.67, 95% CI 0.59-4.74; MOR-2+ : HR 0.77, 95% CI 0.22-2.69). MOR was not associated with an increase in major complications or worse OS in patients undergoing CRS/HIPEC for MPM and should be considered, if necessary, to achieve complete cytoreduction for MPM patients.

MANAGEMENT AND RESECTION OF A COLOBRONCHIAL FISTULA

SESSION TITLE: Medical Student/Resident Cardiothoracic Surgery Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: A fistula is defined as an aberrant connection between two epithelialized surfaces (1). Review of the literature finds less than 50 total case reports of colobronchial fistulas (2). Here we report a rare case of a colobronchial fistula in a 66-year-old male with foul smelling cough. CASE PRESENTATION: A 66-year-old man presented to the ED with a several month history of worsening chronic cough with foul-smelling sputum. In the time preceding the admission, the patient noted intermittent subjective fevers, chills, and night sweats. The patient had a lengthy surgical which includes a 2018 distal pancreatectomy, splenectomy, colonic resection, and partial diaphragmatic resection secondary to Gastrointestinal Stromal Tumors (GIST). Initial imaging with Chest X-ray and CT scan of the abdomen without contrast identified only a subphrenic abscess. X-ray of the colon with lower GI Gastrografin enema confirmed presence of a colobronchial fistula. During this exam, the patient began coughing up contrast and evidence of contrast in the subphrenic abscess was further confirmed on a CT. At first, the cardiothoracic surgery team recommended an initial non-surgical approach. A 10 French drainage catheter was advanced into the abscess and placed on pleurovac -40 suction. The patient was told to irrigate the cavity with 10 cc of saline 3-4 times per day with the hope the cavity would fill with granulation tissue without resection. The patient was discharged on suction and 10 days later returned with worsening cough and fevers. The fistulous connection was unchanged and the patient was taken to surgery. A muscle sparing left lower thoracotomy provided access to the fistulous communication allowing partial wedge resection of the left lower lobe and debridement of the abscess cavity. The diaphragm was partially resected and pulled away from the former fistula site. 3 Chest tubes were placed including one in the marsupialized abscess cavity and the fistula was successfully divided. DISCUSSION: Colobronchial fistulas are slow to develop and have been reported with numerous pathologic and iatrogenic processes including Crohn’s disease, colonic malignancy, diaphragmatic hernia, and postoperative adhesions (2) Identifying the fistulous tract definitively is challenging and is most commonly found by a lower GI contrast enema with X-ray which is concurrent with our case report (2). Treatment for a colobronchial fistula has always been surgical, with all cases of successful recovery requiring this intervention (2). There are no current cases describing the use of a catheter drainage in attempted marsupialization making this case unique. CONCLUSIONS: Colobronchial fistula is a rare finding that often occurs years after the initial iatrogenic or pathologic insult. It is best identified with a contrast enema imaging study and requires surgical intervention for proper treatment. Reference #1: Pickhardt PJ, Bhalla S, Balfe DM. Acquired gastrointestinal fistulas: classification, etiologies, and imaging evaluation. Radiology. 2002;224(1):9-23. Reference #2: Jinbo Zhao, Nan Ma, Zhengwei Zhao, et al. Colobronchial fistula: the pathogenesis, clinical presentations, diagnosis and treatment. Journal of Thoracic Disease. 2017;9(1):187 DISCLOSURES: No relevant relationships by Brenda Affinati, source=Web Response No relevant relationships by Reid Stubbee, source=Web Response

Localized multiple malignant epithelioid peritoneal mesotheliomas arising from the hepatoduodenal ligament and diaphragm: a case report

BackgroundMalignant peritoneal mesothelioma is a rare aggressive tumor of the peritoneum. We report a rare case of resection of multiple localized malignant peritoneal mesotheliomas.Case presentationA 55-year-old Japanese woman was admitted to our hospital because liver tumors were detected by abdominal ultrasonography during a screening examination. Blood examination findings, including tumor makers, were within normal ranges. She had no evidence of exposure to asbestos. Computed tomography showed four hypervascular, round liver tumors, one in the lateral liver segment adjacent to the hepatic hilus, and the other three on the liver surface. Computed tomography angiography revealed that the tumor in the lateral segment had strong enhancement and was fed from the left gastric artery. In contrast, the other tumors showed no enhancement, and were fed from the right inferior phrenic artery. Abnormal accumulation was identified in the four tumors only with 18F-fluorodeoxyglucose positron emission tomography. It was very difficult to obtain a definitive preoperative diagnosis, but surgical resection was performed because we considered potential malignancy. Laparotomy revealed the principal site of the tumor in the lateral segment was on the hepatoduodenal ligament, and all other tumors were on the diaphragm. A left lobectomy and partial diaphragmatic resection were performed. The final pathological diagnosis was multiple malignant epithelioid mesotheliomas. Our patient has had no recurrence for 20 months postoperatively.ConclusionsIn general, malignant peritoneal mesotheliomas are classified as diffuse tumors, which are often unresectable and have a poor prognosis. However, early diagnosis and treatment, particularly with the localized type, as in our patient, could lead to long-term survival of the patient. We recommend that multiple malignant epithelioid mesotheliomas be included in the differential diagnosis for patients with subcapsular hepatic tumors.

Diaphragm disease in advanced ovarian cancer: Predictability of pre-operative imaging and safety of surgical intervention

ObjectivesTo establish the positive predictive values of pre-operative identification with CT imaging of metastatic diaphragm disease in surgically managed cases of advanced ovarian cancer (AOC). Additionally, we have assessed the post-operative morbidity and survival following diaphragmatic surgical intervention in a large regional cancer centre in the United Kingdom. Study designA retrospective review of all cases of AOC with metastatic diaphragm disease surgically treated at the Pan-Birmingham Gynaecological Cancer Centre, UK between 1st August 2007 and 29th February 2016. ResultsA total of 536 women underwent surgery for primary AOC. Diaphragm disease was evident intra-operatively in 215/536 (40.1%) and 85/536 women (15.9%) underwent a procedure involving their diaphragm. Of these 85 cases, 38 peritoneal strippings (38/85, 44.7%), 31 partial diaphragmatic resections (31/85, 35.6%) and 16 electro-surgical ablations (16/85, 18.9%) were performed. There were no significant differences in post-operative complications between the three different diaphragmatic surgical groups. Of those patients who underwent peritoneal stripping or partial diaphragm resection, 12% were upstaged to stage 4A by virtue of pleural invasion.The positive predictive value for pre-operative radiological identification of diaphragmatic disease was 78.6%. CT imaging failed to detect diaphragmatic involvement despite obvious diaphragm disease during surgery in 29.4% of cases, giving a low negative predictive value of 64.8%. The sensitivity and specificity for CT imaging in detecting diaphragm disease was 44.3% and 93.8%, respectively. ConclusionsDiaphragmatic disease is often discovered in AOC. However, pre-operative assessment with CT imaging is not reliable in accurately detecting diaphragm involvement. Therefore, all patients with AOC should be regarded as in potential need for diaphragm surgery and their operation undertaken in cancer centres with adequate expertise in upper abdominal surgery. If there is a suspicion of diaphragm muscle invasion during diaphragmatic peritonectomy, the muscle should be partially resected. This will lead to potential upstaging of disease to stage 4A and therefore, to suitability for targeted therapy. In our Centre, the surgical removal of diaphragmatic disease did not significantly increase surgical morbidity.

AB016. Pleurectomy/decortication for malignant pleural mesothelioma

AB016. Pleurectomy/decortication for malignant pleural mesothelioma

A Large Hiatal Hernia: Atypical Presentation of Gastric Volvulus

Nasuea and vomiting are common side effects of chemotherapy, however, other serious conditions should be considered in order to provide immediate intervention. Gastric volvulus is as an abnormal rotation of the stomach and presents with Borchadt's triad of unproductive retching, epigastric pain, distention and the inability to pass a nasogastric tube. This can result in bowel obstruction, strangulation, ischemia, necrosis, perforation and abdominal sepsis which make it a medical emergency requiring urgent surgery. We report a 56-year-old female with history of non-small cell lung cancer status-post left lower lobectomy with partial diaphragmatic resection undergoing chemotherapy who presented to the ED with one month of worsening nausea, bilious emesis and epigastric pain radiating to the left chest. She was initially discharged home with antiemetics when she was simply noted to have a large hiatal hernia on CXR. A week later, the patient was admitted with the same symptoms along with severe hypokalemia and hypomagnesemia. Repeat CXR revealed marked elevation of the left hemi-diaphragm and thickwalled air-filled structure overlying the left lower thorax. Barium upper GI series showed the stomach antrum above the diaphragm in the left thorax while the antrum was cephelad to the gastric body. Oral contrast could not empty into the duodenum despite repositioning the patient. Contrast enhanced chest, abdomen and pelvis CT confirmed the diagnosis of mesenteroaxial gastric volvulus with gastric outlet obstruction. She underwent emergent exploratory laparotomy for volvulus reduction and diaphragmatic defect repair; no complications were noted. With mortality rates of 30-50%, gastric volvulus must not be missed. Unfortunately, the diagnosis was not made during the first ED visit, as her symptoms, laboratory testing and CXR finding of “a large hiatal hernia” did not raise enough concern for additional imaging studies to be pursued. Our patient did not present with the typical Borchadt's triad. Instead, she presented with migrating pain from the epigastrium to the left chest, likely corresponding to the stomach migrating through the diaphragmatic defect leading to the eventual volvulus. Risk factors include patient age over 50, diaphgragmatic defects, gastric ligament laxity and gastroduodenal tumors. Fortunately, gastric volvulus was identified on the second visit with the appropriate diagnostic modalities of Barium UGI series and CT scan.Figure 1Figure 2Figure 3

Survival after hepatectomy for colorectal metastases

recurrent tumors located in segment VII and VIII or extrahepatic location, such as a subdiaphragm, a transthoracic transdiaphragmatic approach via thoracoscopy is feasible. Since the technique has the advantage of better intrathoracic exposure avoiding severe adhesiolysis, liver mobilization and possible hepatic congestion. We report a case of extrahepatic metastatic hepatocellular carcinoma that was successfully resected by transthoracic thoracoscopic metastasectomy. Methods: A 68-year-old male patient who has undergone posterior sectinectomy with caudate lobectomy (S1,6,7) and cholecystectomy under a diagnosis of hepatocellular carcinoma at 3 years ago, was admitted to our hospital for further evaluation of extrahepatic metastatic tumor. On liver dynamic computed tomography revealed a welldefined mass of 3.5 cm in diameter, in right subphrenic space with invading diaphragm and rt. adrenal gland. The imaging findings suggested an extrahepatic hepatocellular carcinoma that metastasized to the diaphragm. LFT was normal and AFP revealed 94.14 ng/ml. Results: We performed transthoracic thoracoscopic metastasectomy for subdiaphragmatic metastases of HCC and partial diaphragmatic resection and repair. The operation time was 3 hour 30 minutes and blood loss was 100 ml. The patient started a diet POD1 day and discharged POD 11days due to chest tube. The postoperative course was uneventful, and the patient was discharged without any complications. Conclusions: Transthoracic thoracoscopic metastasectomy can be feasible even if the recurrent tumors located in segments VII and VIII or extrahepatic location, such as a diaphragm.

Laparoscopic right hepatectomy combined with partial diaphragmatic resection for colorectal liver metastases: Is it feasible and reasonable?

Laparoscopic right hepatectomy combined with partial diaphragmatic resection for colorectal liver metastases: Is it feasible and reasonable?

Intrathoracic Chemoperfusion Decreases Recurrences in Patients with Full-Thickness Diaphragm Involvement with Mucinous Appendiceal Adenocarcinoma.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) is the preferred treatment for selected patients with mucinous appendiceal adenocarcinoma. Frequently, the hemidiaphragms are infiltrated with tumor, requiring partial diaphragm resection (DR) in order to obtain complete cytoreduction (CC-0). The clinical significance of diaphragmatic invasion and the optimum management to prevent transmission of disease from abdomen to chest is largely unknown. This was a retrospective review of 78 patients with mucinous appendiceal adenocarcinoma undergoing cytoreduction and partial DR at a single institution between 2010 and 2014. Partial DR was necessary in 31 (39.7%) patients in order to obtain CC-0. DR was not associated with increased morbidity or poor survival. Of the 31 patients who had a DR, 26 (83.9%) were treated with thoracoabdominal chemoperfusion. The remaining five (16.1%) patients had the diaphragm closed prior to HIPEC. Thoracoabdominal chemoperfusion was not associated with increased 30-day grade III/IV morbidity or respiratory complications. Overall, five (20%) patients with a DR developed thoracic recurrence. There were two (8%) thoracic recurrences in the 26 patients treated with thoracic chemoperfusion compared with three (60%) in the five patients who had their diaphragm closed prior to HIPEC (p=0.002). In univariate analysis histology, CC-0 and thoracoabdominal chemoperfusion were associated with thoracic disease-free survival; however, none of these were significant on multivariate analysis. DR is not associated with increased morbidity and should be performed, if needed, to obtain a CC-0. Following DR, patients remain at significant risk of developing thoracic recurrence. Thoracoabdominal chemoperfusion reduces this risk without increasing morbidity.

Laparoscopic En Bloc Right Diaphragmatic Peritonectomy for Diaphragmatic Endometriosis According to the Sugarbaker Technique

Study ObjectiveTo evaluate the feasibility of a novel laparoscopic procedure for complete eradication of diaphragmatic endometriosis (DE). DesignA retrospective multicenter study (Canadian Task Force Classification II-2). SettingUniversity tertiary referral centre. PatientsA consecutive series of 9 women with DE. InterventionsLaparoscopic en bloc eradication using Sugarbaker's peritonectomy technique with or without diaphragmatic resection for DE. All surgical procedures were performed by the same surgeon in 2 tertiary referral centers (Charitè University, Berlin, Germany, and Catholic University of the Sacred Heart, Foundation John Paul II, Campobasso, Italy). Measurements and Main ResultsRate of conversion to laparotomy, perioperative outcomes, intra- and postoperative complications, and recurrence rate. The procedures were successfully performed in all patients laparoscopically without conversion to laparotomy. All patients also presented with multiple endometriotic lesions in the Morison pouch, and in 3 cases a deep infiltration of the right diaphragm was observed that required partial diaphragmatic resection. In 2 women, pulmonary nodules were also detected, and lung laparoscopic resection was attempted to eradicate the disease. A chest drain was placed in 7 women and was removed after a median time of 6 days (range, 4–10 days). No intra- or postoperative complications were recorded. To complete the diaphragmatic peritonectomy, the median operative time required was 180 minutes (range, 90–240 minutes). The median estimated blood loss was 100 mL (range, 50–300 mL), and the median hospital stay was 10 days (range, 5–17 days). After a median follow-up of 6 months, we observed symptomatic relief for all study patients without major surgery-related morbidity. In 1 woman, laparoscopic adhesiolysis was performed after 18 months from surgery without signs of recurrent endometriosis. ConclusionLaparoscopic en bloc eradication of DE with Sugarbaker's peritonectomy is highly effective in the management of symptomatic DE, with no major intra-/postoperative complications and very favorable perioperative outcomes.

Laparoscopic right hepatectomy combined with partial diaphragmatic resection for colorectal liver metastases: Is it feasible and reasonable?

The impact of diaphragmatic invasion in patients with colorectal liver metastases (CRLMs) remains poorly evaluated. We aimed to evaluate feasibility and safety of laparoscopic right hepatectomy (LRH) with or without diaphragmatic resection for CRLM. From 2002 to 2012, 52 patients underwent LRH for CRLM. Of them, 7 patients had combined laparoscopic partial diaphragmatic resection ("diaphragm" group). Data were retrospectively collected and short and long-term outcomes analyzed. Operative time was lower in the control group (272 vs 345min, P=.06). Six patients required conversion to open surgery. Blood loss and transfusion rate were similar. Portal triad clamping was used more frequently in the "diaphragm" group (42.8% vs 6.6%, P=.02). Maximum tumor size was greater in the "diaphragm" group (74.5 vs 37.1mm, P=.002). Resection margin was negative in all cases. Mortality was nil and general morbidity similar in the 2 groups. Specific liver-related complications occurred in 2 patients in the "diaphragm" group and 17 in the control group (P=.69). Mean hospital stay was similar (P=56). Twenty-two (42.3%) patients experienced recurrence. One-, 3-, and 5-year overall survival after surgery in "diaphragm" and control groups were 69%, 34%, 34%, and 97%, 83%, 59%, respectively (P=.103). One- and 3-year disease-free survival after surgery in "diaphragm" and control groups were 57%, 47% and 75%, 54%, respectively (P=.310). LRH with en-bloc diaphragmatic resection could be reasonably performed for selected patients in expert centers. Technical difficulties related to diaphragmatic invasion must be circumvented. Further experience must be gained to confirm our results.

A Rare Case of a Primary Squamous Cell Carcinoma of the Stomach Presenting as a Submucosal Mass.

We report a case of a 70-year-old man, with a status after aortic valve replacement, who presented with melena and hypotension. On physical examination, he was hypotensive, but he responded to resuscitation. Esophagogastroduodenoscopy revealed a submucosal mass in the gastric fundus. Imaging of the chest, abdomen, and pelvis showed no evidence of local or distant metastasis. He underwent a partial diaphragmatic resection, gastrectomy, lymphadenectomy, and Roux-en-Y esophagojejunostomy. Pathology showed a gastric squamous cell carcinoma (SCC) invading the diaphragm, with negative margins of resection, and one positive perigastric lymph node. He received chemoradiation, but the patient expired 27 months after surgery.

İntradiyafragmatik Bronkojenik Kist: Diyafragmanın Çok Nadir Bir Kitlesi

ABS TRACT Primary tumors of the diaphragm are rare. Isolated intradiaphragmatic bronchogenic cyst is extremely rare. We report a case of intradiaphragmatic bronchogenic cyst with a 55-yearold woman presenting with left upper abdomen pain symptoms. Imaging studies of the chest, com puterized tomography (CT) revealed a left posterior mediastinal mass that abutted into the left diaphragmatic crus and showed no enhancement after contrast administration on CT. A postero lateral thoracotomy was performed including partial diaphragmatic resection. The histopathologi cal examination revealed a diagnosis of bronchogenic cyst.