Empty pelvis syndrome: the use of breast prosthesis in the prevention of complications

AIM

Empty pelvis syndrome and radiation-induced bowel injury are two major clinical issues resulting from the pelvic dead space after pelvic exenteration (PE). In order to avoid these complications, different methods of pelvic floor reconstruction have been proposed. We report our experience on the use of breast prosthesis.

METHOD

Fifty-three patients who underwent PE and three who underwent palliative surgery with silicone breast prosthesis placement were included.

RESULTS

Forty-seven posterior PE, six total PE and three palliative procedures were identified. Sphincter preservation was feasible in 34 patients (62.3%). There were no deaths. Overall morbidity was 37.5%. There were no complications such as sepsis or obstruction related to the prosthesis. Adjuvant radiotherapy was delivered in 16 cases (30.1%) without any side-effects. Reconstruction of intestinal continuity was possible in 12 patients (36.3%) with sphincter preservation and the prosthesis allowed a prompt identification of the rectal stump.

CONCLUSION

Breast prosthesis placement is a simple and safe method to minimize complications resulting from empty pelvis syndrome and can be adopted to exclude bowel loops from the radiation field. Reconstruction of intestinal continuity after resection is also simplified.

High risk for microcarcinoma in thyroid benign diseases. Incidence in a one year period of total thyroidectomies

Over the last few years, incidental thyroid microcarcinoma (TMC) has become a frequent disease and its incidence in some reports is considerable. The discovery of new cases depends on the progress of the diagnostics (US scan, fine needle biopsy and cytology, CT, MRI), on the extended indications to thyroidectomy for benign disease and on the attention in pathologic examination of the specimen. The clinical evolution of this disease is not well known: in spite of a high incidence reported in some autoptic series, suggesting that this tumour could have a good prognosis, some authors report an overall incidence of up to 11% of local recurrence, metastasis and mortality. For these reasons the treatment of TMC is still controversial today. Aim of this study was to estimate the incidence and the clinico-pathological findings of TMC over a one year period of total thyroidectomies for diffuse benign thyroid diseases, and to evaluate, on the basis of the frequency of incidental microcarcinoma, if the surgical procedure of complete removal of the gland should be adopted in any case. In this series no patient had pre-operative diagnosis or tentative diagnosis of carcinoma and the incidence of TMC at the final histologic examination was 27.4%. Total thyroidectomy confirmed to be the treatment of choice for diffuse benign diseases and appeared necessary to obtain both, diagnosis and treatment of incidental TMC.

Marginal donors in liver transplantation

Marginal liver donor criteria included the following: obesity (weight >100 Kg or BMI >27), age >50 years; macrovesicular steatosis >50%; intensive care unit stay >4 days; prolonged hypotensive episodes of >1 hour, and <60 mm Hg with high inotropic drug use (dopamine, [DPM] > 14 microg/kg per minute); cold ischemia time >14 hours, peak serum sodium >155 mEq/L; sepsis, viral infections, and alcoholism; high levels of bilirubin, ALT, and AST, or extrahepatic neoplasia. Between August 1992 and May 2003, we performed 251 liver transplants in 241 patients of whom 155 are presently alive. We used 124 (49.4%) standard donors and 127 (50.6%) marginal donors. Among the group that received a standard donor, 81 (65.3%) are still alive. Among recipients of organs from marginal donors. 81 (63.8%) are still alive. We also assessed the quality of donors according to the severity of recipient disease. For standard donors these outcomes were 61.5% for UNOS 1, 37.5% for UNOS 2A, 73.2% for UNOS 2B, and 80% for UNOS 3 for marginal donors they were 46.1% for UNOS 1, 53.6% for UNOS 2A, 70.7% for UNOS 2B, and 63.6% for UNOS 3. Among the patients who received a liver from a donor >60 years old, there were no survivors in UNOS 1 and 2A, but there were good results in groups 2B and 3. These results suggest there is no difference between marginal and standard donors, even in sick patients, with the exception of donor age.

Liver transplantation in the presence of portal vein thrombosis: report from a single center

Portal vein thrombosis (PVT) is a frequent finding in liver transplantation, the management of which depends mainly on its extent. In cases of mild to moderate PVT, a low dissection of the portal trunk, a jump graft, or direct implantation of graft portal vein into large venous collaterals or thrombectomy offer alternatives. For severe PVT anecdotal reports suggest that cavoportal hemitransposition, portal arterialization, or combined liver and intestine transplantation may be attempted, although the results to date are not satisfactory. When extensive perivenous and venous inflammatory changes reach the infrapancreatic region, liver transplantation probably should not be performed due to the high mortality rate.