[Recurrent benign cystic peritoneal mesothelioma]

The benign cystic peritoneal mesothelioma (BCPM) is a rare neoplasm affecting mainly females at reproductive age. The natural history and physiopathology of the BCPM are not entirely known. It is mainly characterized by the lack of malignant elements, no tendency to metastasis and by a pervasive tendency to generate local recurrences after surgical removal. The clinical manifestations are insidious, uncharacteristic; the benign cystic peritoneal mesothelioma is often discovered during a surgical procedure addressing another condition. Imaging tests can raise the suspicion of BCPM but the diagnostic can only be confirmed by histopathological examination corroborated with an immunohistochemical analysis. There are no long term studies dictating a single therapeutic attitude but a high risk of local recurrences and the possibility of transformation into malignant mesothelioma have lead to the current tendency towards an aggressive treatment of the tumor. We present the case of a recurrent benign cystic peritoneal mesothelioma in a 40 years old female patient, emphasizing the therapeutic approach and the role of radical surgery in the treatment of BPCM.

[Liver rupture of a subcapsular haematoma after pharmacologic revascularization (Streptokinase) for acute myocardial infarction--case report]

We report the case of a 56 years old male patient, smoker, obese, with untreated arterial hypertension, hospitalized on 16.02.07 with the diagnosis of inferior acute myocardial infarction, for which he received thrombolysis with streptokinase, followed by anticoagulation with non fractioned heparin. Two days later he started to complain of acute abdominal pain, and laboratory findings showed a low hemoglobin level. Imaging findings (ultrasonography and CT scan) showed evidence of subcapsular liver haematoma, caused by bleeding at hepatic and splenic level. He received red blood packed cells, fresh frozen plasma, cryoprecipitate, activated factor VII and was transferred by helicopter to Fundeni Clinical Institute--Intensive care unit (ICU). On admission, the patient was conscious, anxious, dyspneic, with mild hypoxia, with no signs of low cardiac output and with a painful abdomen. ECG, echocardiography and elevated myocardial necrosis enzymes confirmed myocardial infarction. Shortly after admission there was a worsening of his clinical condition, with a decrease in hemoglobin level despite red blood packed cells administration (Hb=7.8 g/dl) and thrombocytopenia (82000/mmc), with normal coagulation tests, thus suggesting active intraabdominal bleeding. Echography and CT scan confirmed bleeding. Emergency surgery was performed, showing massive haemoperitoneum (approx 4.5 L of blood), due to spontaneous rupture of a subcapsular hematoma in the liver. The surgical hemostasis was performed on the liver parenchyma laceration. Duration of surgery was 4 hours. There were no significant cardiac events during surgery (no signs of ischemia on ECG, no ST elevation), despite the need for inotropic agent. After surgery, the patient was referred to the ICU, intubated and ventilated, with inotropic support - dobutamine. Sequential ECG's, enzymatic trend and echocardiographies were performed to monitor myocardial ischemia. The outcome was favourable, no further bleeding and no postoperative myocardial infarction occurred. Secondary prevention was started early (thromboprophylaxis, selective beta-blocker, angiotensin inhibitors and statins). The patient had a favorable outcome and was discharged from the ICU the fourth day after surgery. He had a total length of stay in hospital of seven days, with a follow-up in the cardiology department.

[Difficulties in diagnosis and surgical treatment of the angiodysplasia of the gastrointestinal tract]

BACKGROUND

Angiodysplasia (AD) of the gastrointestinal (GI) tract is a rare cause of surgical GI bleeding. It frequently poses difficult problems in diagnosis and treatment. The purpose of this study is to find answers to these problems for a better management of the AD patients.

MATERIALS

From 1982 to 2006 a total of 75 patients suffering of AD of the GI tract were operated in our center. They represent about 3.6% of total patients operated for GI bleeding in the same period. The age of the patients was between 9 and 81 years old, with two peaks: one between 21 and 40 years old and the other between 51 and 70 years old. The localisation of the lesions was: righ colon +/- ileum 31 patients (41.33%), stomach 13 patients (17.33%), jejunum 6 patients (8%), descendent colon +/- sigmoid 5 patients (6.66%), rectum 4 patients (5.33%), pan-colonic 4 patients (5.33%), sigmoid colon 2 patients (2.66%), cecum + transverse colon 2 patients (2.66%), ileum 2 patients (2.66%), sigmoid colon + jejunum 1 patient (1.33%), cecum + sigmoid colon 1 patient (1.33%), cecum +/- sigmoid colon + jejunum 1 patient (1.33%), jejunum + ileum 1 patient (1.33%), pan-colonic + rectum 1 patient (1.33%). According to Moore classifications 29 patients were type 1 (38%) and 45 patients were type 2 (60%). In one patient AD was associated with Crohn disease (type 4 Fowler).

RESULTS

The main symptom in AD was repetitive GI bleeding, of various amplitude, often obscure in origin, the patients having many hospital entries. The medical examination that give us the best help was selective angiography which was positive in 34 of 40 patients (85%). Upper and lower endoscopy were give to 50 surgical patients, being diagnostic in 32 (64%). Histopathologic examinations confirm the diagnosis of AD in all cases, without using injection techniques. All patients were operated for symptomatic AD. Other 11 patients non included in this study were find to have angiodysplastic lesions on operatory specimens for other diseases. The main indications for operative in AD were: continuing digestive hemorrhage of growing amplitude with detected source (54 patients = 72%), inefficient endoscopic and angiographic hemostasis (8 patients = 10.66%) and patients with massive bleeding without any preoperative evaluation (13 patients = 17%). Intraoperative exploration produced little information because of the mucosal and submucosal localisation of the lesions. Operative panendoscopy was the most rewarding investigation. Various types of resections were practiced depending on the site(s) known or presumed of the lesions. Perioperative morbidity was 23% (21 patients), rebleeding being in 4 patients (5.33%). Perioperative mortality was 12% (9 patients) a consequence of advanced age, comorbid conditions and frequent extreme emergency of the operations.

CONCLUSIONS

Although rare as a cause of surgical digestive bleeding, AD poses often difficult problems of diagnosis and treatment. In patients with GI bleeding, without evident cause, multiple investigated, especially elderly but not always, we must think of an AD.

An unusual indication for central pancreatectomy--late pancreatic metastasis of ocular malignant melanoma

INTRODUCTION

Pancreatic involvement in metastatic melanoma is not an uncommon feature in disseminated disease, but isolated metastasis to the pancreas is a rare entity. Management of the pancreatic metastatic melanoma is controversial and the role of surgery is poorly defined. Most of the resectable pancreatic metastases were treated by standard pancreatectomies, and the role of limited resections (as central pancreatectomy) was not yet established.

CASE REPORT

A 43-years old woman with previously right eye enucleation for primary melanoma (4 years ago) developed three metastases (one located into the body of pancreas and two into the right inferior pulmonary lobe). The diagnosis of the pancreatic metastasis was done by endoscopic ultrasound -fine needle aspiration biopsy. A two step operation was performed: first a central pancreatectomy for pancreatic metastasis and after three weeks a right inferior pulmonary lobectomy for lung metastases.

RESULTS

The postoperative outcome after central pancreatectomy was complicated by a bleeding from distal pancreatic stump, requiring a re-laparotomy for hemostasis and a pancreatic fistula conservatively treated. At 12 months after operation the patient is asymptomatic, with no clinical and imaging signs of recurrence.

CONCLUSION

Surgical resection remains the single hope for cure for patients with metastatic melanoma. Central pancreatectomy could be an optimal choice for metastatic malignant melanoma to the body of the pancreas only if a complete resection of the tumor can be achieved and can be accomplished by other surgical procedures for other sites of metastatic melanoma.

The robotic-assisted left lateral hepatic segmentectomy: the next step

INTRODUCTION

During the last decade, minimally invasive surgery had an astonishing development, progressing from minor hepatic interventions to major hepatectomies, thus creating a rich background for robotic-assisted hepatic surgery. Left lateral hepatic segmentectomy (left lobectomy, II-III bi-segmentectomy) is the first anatomic hepatic resection on the learning curve. The purpose of this report is to demonstrate that, due to the anatomical characteristics of the left lobe and to the technical facilities of the robot, this intervention is also feasible with the Da Vinci S robotic system.

MATERIALS

In our department, robotic-assisted left lateral lobectomy was performed for both benign and malignant lesions by a surgeon experienced in both hepatic and laparoscopic surgery but traversing the beginning of the learning curve in robotic surgery. A Da Vinci S robotic system with three arms was used and two additional laparoscopic ports for the assistant surgeons were added.

RESULTS

The lobectomies were safely performed in an average operatory time of 140 min (+/- 20), with minimal blood loss and without using the Pringle procedure. The dissection was carried out with the bipolar forceps on the left arm of the surgeon and the Harmonic curved shears on the right arm. The division of the vascular pedicles for segments II and III was performed with the LigaSure Atlas device. The other additional port was used for retraction. There were no conversions or reinterventions

DISCUSSIONS

Robotic-assisted left lateral hepatic lobectomy was a feasible technique with the potential to reduce surgical trauma and pain and to improve surgeon's technical comfort.

[Pancreaticoduodenectomy in elderly patients--a safe operation?]

The aim of this study was to analyze the impact of age in mortality and morbidity after duodenopancreatectomy (DPC), setting the age of 70 as a cut-off. A retrospective study was made of two groups of patients (under 70 and over 70 years old) who underwent DPC in the Center of General Surgery and Hepatic Transplantation, Fundeni, Bucharest between 2001 and 2006 for malignant and benign tumors of the pancreatic head, distal biliary tract, duodenum, Vater's ampulla and chronic pancreatitis. 245 DPC were performed, 207 in patients under 70 years old (group A) and 38 in patients over 70 years old. Postoperative global morbidity rate was 58% in group B vs 49,9 % in group A. Postoperative mortality rate was 5,2% in group B and 4,8 % in group A. No significant differences were recorded in survival when comparing the two groups, both in pancreatic head cancer or distal biliary tract cancer. Under these circumstances, increased age is not determining an increase in postoperative mortality after DPC, but is associated with a higher risk of postoperative medical complications.

Gallbladder adenoma with focal adenocarcinoma

The majority of polypoid lesions of the gallbladder are cholesterolosis pseudopolyps. True neoplastic GB polyps are represented mainly by adenomas. The case of a 52-year old male patient with an adenomatous polyp of the GB with focal adenocarcinoma is presented.

Large multilocular serous cystadenoma of the pancreatic head

We present the case of an 88-year-old female, investigated for upper abdominal pain and upper abdominal mass, exhibiting at the computed tomography a large tumour located in the head of the pancreas, compressing the common bile duct and with uncertain preoperative diagnosis (benign/malign). The histopathological findings of the operative specimen (cephalic pancreatoduodenectomy) revealed a large serous multilocular cystadenoma. There are presented the clinical, imaging and pathological correlations in the present case, also analysing the limits of the imaging preoperative diagnosis and indications for surgery in cystic tumours of the pancreas.

Gastrointestinal stromal tumors

Gastrointestinal stromal tumors (GIST) are rare neoplasias, but they represent the most common non-epithelial (mesenchymal) tumor of the digestive tract. GISTs originate in an intestinal pacemaker cell called the intestinal cell of Cajal and express the cell-surface receptor KIT (CD117). They were first defined as a separate category in 1983, and since then important data regarding their clinical behavior, histopathological particularities, immunohistopathology, molecular biology and therapeutic possibilities were reported. In this article we aim to present a review of the information concerning this subject available in the medical literature at the moment.

[Laparoscopic left lateral segmentectomy of the liver: indications, technique, results]

INTRODUCTION

The laparoscopic approach of the hepatic lesions located in the left lobe is a frequently used procedure in liver surgery for both benign and malign tumors because of the minimal invasive character, anatomical particularities and modem devices used in hemostasis and biliary-stasis. The purpose of this study is to analyze our experience and report it to the literature data.

METHODS AND MATERIAL

The study starts from the basic indications of laparoscopic left lateral segmentectomy, it emphasizes the main operating steps and analyzes the results of this method in a cohort retrospective study in which we included all the laparoscopic resections performed in our center between 1998-2007, both laparoscopic and hand-assisted laparoscopic procedures. We excluded exploratory laparoscopies and the cases in which after the tumor exploration, we decided conversion to open approach in the absence of any intraoperative incidents.

RESULTS

Between 1998-2007 we performed 84 laparoscopic hepatic resections out of which 20 were located in the left liver lobe. There were 12 left lateral segmentectomy and in 4 cases we used hand assisted laparoscopy due to bigger tumour dimensions. The hepatic lesions approached laparoscopically were both benign (5 cases out of which 3 hemangioma and 2 adenoma) and malignant (7 cases hepatocellular carcinoma). The tumor diameter ranged between 2-10 cm. The Pringle manoeuvre was never used.

CONCLUSIONS

Left lateral segmentectomy can be routinely performed laparoscopically in the absence of any contraindications. This intervention can be accurately performed respecting the limits of oncological security. The results obtained in our center are in accordance with the literature and emphasize the advantages of the minimal invasive approach. On a medium and long term, the results are comparable with those obtained in open surgery.

Hepatocellular carcinoma in Riedel's lobe

We present a rare case of 65-year female with right abdominal mass and abdominal discomfort; a combination of Doppler ultrasonography, computed tomography and laparotomy was utilized to make a diagnosis of tumoral Riedel's lobe. In our case, laparotomy with resection of Riedel's lobe was the proper therapeutical solution.

[Risk factors for malignant evolution of gastrointestinal stromal tumors]

Gastrointestinal stromal tumors are the most frequent non-epithelial digestive tumors, being classified in the group of primitive mesenchymal tumors of the digestive tract. These tumors have a non predictable evolution and where stratified regarding the risk for malignant behavior in 4 categories: very low risk, low risk, intermediate risk and high risk. We performed a retrospective non randomised study including the patients with gastrointestinal stromal tumors treated in the Department of General Surgery and Liver Transplantation of Fundeni Clinical Institute in the period January 2002 - June 2007, to define the epidemiological, clinico-paraclinical, histological and especially evolutive features of the gastrointestinal stromal tumors from this group, with a special regard to the risk factors for their malignant behavior. The most important risk factors in gastrointestinal stromal tumors are the tumor size and the mitotic index, based on them being realised the classification of Fletcher in the 4 risk categories mentioned above. In our group all the local advanced or metastatic gastrointestinal stromal tumors, regardless of their location, were classified in the group of high risk for the malignant behavior. The gastric location and the epithelioid type were positive prognostic factors, and the complete resection of the tumor, an other important positive prognostic feature, was possible in about 80% of the cases, probably because the gastrointestinal stromal tumors in our study were diagnosed in less advanced evolutive situations, only about one third being metastatic and about 14% being locally advanced at the time of diagnose. The association with other neoplasias was in our cases insignificant, only 5% of the patients presenting concomitant malignant digestive tumors and 7.6% intraabdominal benign tumors. Gastrointestinal stromal tumors remain a challenge for the medical staff, regarding their diagnose and therapeutical management, the stratification of the risk for their malignant behavior being essential for the evolution of these patients.

Combined liver and islet transplantation using steroid-free immunosuppression

Due to a vicious circle in which HCV favors insulin resistance and, alternatively, insulin resistance facilitates the persistence of HCV, HCV patients have often diabetes associated with liver cirrhosis. We present the case of combined liver and pancreatic islets transplantation performed in a patient with HCV liver cirrhosis associated with insulin-dependent diabetes. This is also the first case of islet allotransplantation in Romania. A 40-year-old male diagnosed with liver cirrhosis due to HCV infection and insulin dependent diabetes underwent combined liver and islet transplantation. Our therapeutic design was based on data provided by both the use of Edmonton immunosuppressive steroid-free protocol in islets cell transplantation and the findings of international studies on the effects of this protocol in liver transplantation for patients with HCV infection. Good metabolic control of the diabetes was obtained. The absence of anti beta cell autoimmunity could explain also the good tolerance for the transplanted islets, proved by the rapid and durable decrease of the insulin need, from 64 U/day to 20 U/day at one month post-transplantation, dose that was maintained for 16 months when the patient died due to recurrent HCV hepatitis. Islet transplantation can be associated to liver transplantation in order to improve the associated diabetes in cirrhotic patients.

[The Pringle maneuver in laparoscopic hepatic surgery: is it useful? Analysis of a series of 38 cases]

The Pringle maneuver is the most feasible method to control bleeding in hepatic resections in both open and laparoscopic approach. However its role in the mini-invasive surgery is still questionable. The aim of this study is to analyze our experience and to compare it to the literature data. This is a retrospective cohort study that includes all hepatic laparoscopic resections performed in our department between 1998-2007 and excludes all exploratory laparoscopies and all cases in which conversion to open procedure was imposed after the lesion assessment and in the absence on any intraoperative event. 38 hepatic laparoscopic resections were performed for both benign lesions (20 out of which 13 hemangiomas, 2 focal nodular hyperplasia, 1 liver cell adenoma, 2 hydatic cysts, 2 inflammatory lesions) and malignant lesions (18 out of which 8 metastases, 9 hepatocellular carcinoma, 1 cholangiocarcinoma). The tumor diameter ranged between 2 and 10 cm. There were 2 conversions to open procedures due to bleeding from hepatic veins collaterals. Pringle maneuver was never used. Pringle maneuver did not prove to be useful in our series because, on one hand, we performed only limited laparoscopic hepatic resections and, on the other hand, intraoperative bleeding was mainly due to lesions of the hepatic veins collaterals which cannot be influenced by clamping the hepatic pedicle. Even if there is no consensus, major laparoscopic hepatic resections may benefit from Pringle maneuver.

[Soft tissue reconstruction after total pelvic exenteration]

Total pelvic exenteration leaves a major defect in pelvic-perineal region. Delayed healing, bowel fistulae, occlusion or protrusion and infection are frequent complications of this procedure. During 2000-2006, in General Surgery and Liver Transplantation Fundeni, 73 patients with advanced pelvic cancer and invasive recurrences were operated. For 42 patients, various procedures for pelvic and vaginal reconstruction (omental flap, muscular and musculo-cutaneous flaps--rectus abdominis and gracilis) were performed in order to fill the pelvi-perineal defects and restore form and function. Technical principles, indications, contraindications, advantages and disadvantages of these procedures are outlined. We found that complications related to total pelvic exenteration dramatically decreased and primary healing of the perineal wound was superior, facts that correlate with the literature data.

[Hemodynamic changes induced by positive pressure capnothorax during thoracoscopic thymectomy]

Low-flow insufflation of CO2 into the thorax helps the surgeon by increasing the surgical field during thoracoscopy, but older studies performed on animals (pigs and dogs) showed that positive pressure capnothorax had negative hemodynamic impact on animals and strongly recommended against using it on humans. We included in our study 24 ASA I-II myasthenic patients (20 females and 4 males) age 29 yo (+/- 10.2) weight 62.8 kg (+/- 10.6) whose thymuses were surgically removed by thoracoscopy. Using thoracic electrical bioimpedance (TEB) we assessed noninvasively cardiac index (CI) stroke index (SI) systemic stroke vascular resistance index (SSVRI) and end diastolic index (EDI). Well known for its hemodynamic stability we chose sevoflurane for induction and maintenance of anesthesia (VIMA). According to Copenhagen scale, adding minimal iv dose of fentanyl (3 mcg/kg) to sevoflurane induction, allowed us to endobronchial intubate in good and excellent conditions. During anesthesia almost all measured parameters (CI, SI, MAP, EDI) recorded statistically significant decrease but with minimal clinical significance. Thus, the maximal drop was measured during application of 10 mm Hg capnothorax: CI and SI dropped by 1.16 1/min/m2 (19%) (p = 0.02) and respectively 16.58 ml/m2 (21%) (p = 0.001). Thereby we are applying low-flow positive pressure insufflation of CO2 into the thorax, to almost all thoracoscopies performed in our clinic.

EBV-specific CD8+ T cell reactivation in transplant patients results in expansion of CD8+ type-1 regulatory T cells

Posttransplantation lymphoproliferative disorders (PTLD) are life-threatening complications of solid organ transplantation, triggered by EBV infection in chronically immunosuppressed (IS) patients. Our goal is to establish DC-based protocols for adoptive immunotherapy of refractory PTLD, while understanding how the immunosuppressive drug environment may subvert DC-EBV-specific T cell interactions. Type-1 CD8(+) T cells are critical for efficient immune surveillance and control of EBV infection, whereas type-2 or Treg/type-3 responses may provide an environment conductive to disease progression. We have recently reported that chronic IS inhibits DC function in transplant patients. Here, we have analyzed the comparative ability of mature, type-1 polarized DCs (i.e. DC1) generated from quiescent transplant patients or healthy controls, to boost type-1 EBV-specific CD8(+) T cells in vitro. Our results show that unlike healthy controls, where DC1 loaded with MHC class I EBV peptides preferentially reactivate specific type-1 CD8(+) T cells, DC1 generated from transplant patients reactivate EBV-specific CD8(+) T cells that produce both IFN-gamma and IL-10, up-regulate FOXP3 mRNA, and suppress noncognate CD4(+) T-cell proliferation via cell-cell contact. These data support a novel regulatory pathway for anti-EBV T-cell-mediated responses in IS transplant patients, with implications for the design of adoptive immunotherapies in this setting.

[Total pelvic exenteration in the treatment of advanced pelvic cancer]

Total pelvic exenteration (TPE) is a radical and aggressive procedure performed in the local advanced pelvic cancer started from any pelvic organ. The experience of 73 TPE performed for local invasive cancer and centro-pelvic recurrences with initial malignancy at the cervix (45 cases), rectum (19 cases), vagina (5 cases), endometrial (3 cases) and urinary bladder (1 case), in 61 females and 12 males with age range 27-78 years, are analysed. The procedures were performed for advanced pelvic cancer in 24 cases and also for invasive centro-pelvic recurrences in 49 cases (67.5%). In 5 cases, TPE was extended laterally. In 42 patients reconstructive procedures were added. All patients survived to surgery but 5 postoperative deaths (6.8%) were recorded. Complications occurred in 52% of cases, 38 from 73 patients had one or more than one complication with an average of 1.5 per patient. 22 among these patients (30%) requiring operative treatment. The average survival was 49.07 months, the median survival of 55 months and the estimated survival at 11 and 78 months was 66%, respectively 50%. The procedure is indicated in the absence of pelvic wall invasion and secondary distant dissemination and lengthens significantly the life span and increase the quality of life.

[Evidence-based surgery: the contemporary approach of medical practice]

Evidence-based medicine is one of the most frequently used operational concepts in medical practice. It is the result of integrating the best research evidence with clinical expertise and patient values. The practical use of evidence-based surgery requests correctly formulated clinical questions and critical appraisal of the best available medical resources. By comparing evidence-based surgery with the surgical traditional paradigm, the advantages of this method can be easily stated but an expert surgeon should also be aware of its limitations.

[Human pancreas procurement for pancreas and islet transplantation]

Insulin-dependent diabetes mellitus is a disease characterized by a deficiency of insulin secretion by beta islet cells. Integral pancreatic transplantation and islet cell transplantation represent two possibilities of replacing the beta islet cells. The aim of this paper is to analyze the main aspects of selection criteria of the pancreas donor and surgical methods of preservation for integral pancreas or islet cell transplantation. There are described the pancreas procurements realized by the Center of General Surgery and Liver Transplantation team from Fundeni Clinical Institute between December 2005-December 2006 and correlation between the donor's and pancreas features and the quality of islet cell isolation. The selection of pancreas donor and the accomplishment of pancreas procurement represent important factors in the post-transplantation course of the graft. The data from pancreas/islet cell transplantation centers suggest that the factors that influence positively the course of graft are: the donor's age, body mass index, cold ischemia time.

Recurrent spontaneous pneumothorax in renal transplantation

Renal transplantation could be associated with severe complications. Pneumothorax is a rare and severe complication among renal transplant recipients. The relationship between pneumothorax and post transplantation status, pulmonary infections or immunosuppressive treatment is controversial. We report the case of a young female with normal renal graft function who developed recurrent pneumothorax after three years of kidney graft.

Laparoscopic hand-assisted adrenalectomy for a 20 cm benign tumor

Since its introduction in 1992, laparoscopic adrenalectomy (LA) has become the technique of choice in the surgical treatment of both secreting or non-secreting benign adrenal pathology. Although traditionally, laparoscopic approach was recommended only for tumor sizes less than 6-8 cm--as larger tumors were known to have an increased risk of malignancy--the currently growing experience and improvement of surgical techniques has allowed for an extension of the therapeutic indication, as shown by the recent case report of LA use for a benign 22 cm tumor (1). We report the case of a young patient operated in our Department for a benign 20 cm adrenal tumor for which laparoscopic "hand-assisted" adrenalectomy yielded a good postoperative outcome and minimal complications.

Digestive tumor bank protocol: from surgical specimens to genomic studies of digestive cancers

Cancer is a complex polygenic and multifactorial disease, resulting from successive dynamic changes in the genome of somatic cells and from the accumulation of molecular alterations in both tumour cells and host cells. For the majority of cancers, including many malignancies of the gastrointestinal tract, our current means of diagnosis and treatment of the tumors are grossly insufficient. In recent years the development of several gene expression profiling methods such as comparative genomic hybridization (CGH), differential display, serial analysis of gene expression (SAGE) and DNA arrays, together with the sequencing of the human genome, has provided an opportunity to monitor and investigate the complete cascade of molecular events leading to tumor development and progression. Given the central role played by surgeons in the current management of patients with solid cancers, it is of paramount importance for them to know the principles characterizing this laboratory tools to critically assess the results originating from this biotechnology. We describe in this article the scientific partnership between Fundeni Clinical Institute Bucharest, Romania and RNtech Company, Paris, France for the development of a center of biological resources (Biobank) as well as the standardized protocol of working with the biological samples, the ongoing projects and the future perspectives.

[D2 lymph node dissection in gastric cancer surgery: long term results--analysis of an experience with 227 patients]

AIM

The main objective of the study was to evaluate the postoperative mortality and 5 year survival in gastric cancer patients undergoing a minimum of D2 lymphadenectomy.

MATERIALS AND METHODS

A retrospective study was conducted on 1170 patients operated for gastric adenocarcinoma in the Department of General Surgery and Liver Transplantation of Fundeni Clinical Institute, between 1997 and April 2005. Only 443 patients underwent a curative resection, from which 216 patients had D1 resection and in 227 cases a D2 or D3/D4 lymphadenectomy was performed. Information about survival was available for 189 patients of those who had a D1 resection and for 210 of those who underwent a D2 or D3/D4 lymphadenectomy.

RESULTS

Postoperative mortality was 6.5% in the group of curative resection, with 9.2% for D1 and 3.9% for D2/D3 D4. Five year survival according to Kaplan Meier curves was 32 % in the D1 group vs. 51,8% in D2/D3-D4 (p <0.0001). Significant differences were noted in the median survival-- D2/D3-D4 group 63 months vs. 28 months in D1 group.

CONCLUSIONS

Our data support the gastric resection with a minimum of D2 lymphadenectomy in the radical surgery of gastric cancer. However, an accurate interpretation of the statistical interpretation between the different groups of patients is difficult, mainly because of the retrospective character of the study.

Two-stage hepatectomy: an analysis of a single center's experience

Hepatic resection remains the only potential curative treatment for either primary or secondary liver tumors. In order to increase the resectability of initially unresectable tumors and to decrease the posthepatectomy morbidity and mortality, ligation and section of a portal branch with consecutive hepatic resection is recommended. Between September 1st 1999 and January 1st 2006, in the Department of General Surgery and Liver Transplantation of Clinical Institute Fundeni (Bucharest), the ligation of a portal branch was performed in 15 patients with gross hepatic tumors: hepatocellular carcinoma (2 cases), peripheral cholangiocarcinoma (6 cases) and hepatic metastases for colorectal cancer (7 cases). Two-stage hepatectomy was performed in 8 cases. The interval between the two operations ranged between 4 weeks and 2 months (except one case that returned to us only after 6 months, when was reevaluated and resected). Hepatic resection could not be performed in 7 cases due to the local and regional progression of the disease (4 cases) or to the absence of the hypertrophy-atrophy process (3 cases). In the 8 resected cases, hepatic failure occurred posthepatectomy in 2 patients, resulting in the death of one patient; that means a mortality of 12.5%. Other two patients died at 4 and 10 months respectively, as a result of distant metastases. The rest of 5 patients are alive, free of recurrence; two of them have more than 5 years from the operation. CONCLUDING: portal vein ligation can be performed in selected cases of unresectable gross hepatic tumors. Two-staged hepatectomy is not always feasible. Moreover, the hypertrophy of the contralateral lobe does not always prevent the postoperative hepatic failure. For the cases that can be resected, both survival and quality of life are significantly improved.

[Resection of the celiac axis increase resectability rate in locally advanced pancreatic body and gastric tumor]

Celiac axis involvement in locally advanced neoplasia was considered in the past a criteria of non resectability. Carcinoma of the body and tail of the pancreas is often diagnosed at an advanced stage or metastatic stage. Gastric carcinoma (particularly antral localization) can also be locally invasive. Celiac axis can be invaded in both neoplasias. In order to increase resectability rate in those two types of neoplasia celiac trunk resection was proposed (en bloc with distal pancreatectomy, loco-regional lymph node excision with or without total gastrectomy). We report our experience on 3 patients and some considerations about this surgical technique from medical literature.

[Minimally invasive combined surgical treatment in a case of bilateral pulmonary hydatidosis]

The minimally invasive surgical techniques had an explosive development in the last 15 years. In thoracic surgery, these techniques were rapidly adopted, especially because of medical advantages, but also for aesthetic reasons. We present the case of a 33 years old patient, with bilateral pulmonary hydatidosis, treated in one-stage surgery, by VATS (video-assisted thoracic surgery) and thoracoscopic approach. The post-operative course was uneventful and the patient was discharged in five days. In selected cases, of patients with uncomplicated hydatid cysts, the minimally invasive surgical approach is not only possible, but probably also indicated.

[Surgical treatment of liver metastases from colorectal cancer]

We analyze our experience over a 10-year period in the surgical treatment of liver metastases from colorectal cancer. Between 01.01.1995 and 08.31.2005 189 liver resections were performed in 171 patients with liver metastases from colorectal cancer (16 re-resections - 2 in the same patient and a "two-stage" liver resection in 2 patients). In our series there were 83 patients with synchronous liver metastases (69 simultaneous resections, 12 delayed resections and 2 "two-stage" liver resection were performed) and 88 metachronous liver metastases. Almost all types of liver resections have been performed. The morbidity and mortality rates were 17.4% and 4.7%, respectively. Median survival was 28.5 months and actuarial survival at 1-, 3- and 5-year was 78.7%, 40.4% and 32.7%, respectively. Between January 2002 and August 2005 hyperthermic ablation of colorectal cancer liver metastases has been performed in 6 patients; in other 5 patients with multiple bilobar liver metastases liver resection was associated with radiofrequency ablation and one patient underwent only radiofrequency ablation for recurrent liver metastasis. In conclusion, although the treatment of colorectal cancer liver metastases is multimodal (resection, ablation, chemotherapy and radiation therapy), liver resection is the only potential curative treatment. The quality and volume of remnant liver parenchyma is the only limitation of liver resection. The morbidity, mortality and survival rates after simultaneous liver and colorectal resection are similar with those achieved by delayed resection. Postoperative outcome of patients with major hepatic resection is correlated with the surgical team experience. The long-term survival was increased using the new multimodal treatment schemes.

[Single-stage operation in simultaneous pulmonary and liver hydatic disease]

The most frequent association of hydatic disease lesions is hepatic and pulmonary localisations. It is generally admitted that surgical treatment is the only effectiveness treatment in hydatidosis. The classic approach is the two-stage surgical interventions of pulmonary and liver localisation or one-stage extensive thoraco-phrenic-laparotomy, exclusively reserved to right pulmonary hydatic cysts associated with hepatic dome localisations. The study presents single-stage operation by thoracotomy or mini-invasive thoracic surgery and laparotomy or laparoscopy, or single-stage thoracic approach, as alternative of classic attitude and evaluates the results in 10 patients with synchronous pulmonary and liver hydatic cysts. Overall observations are-encouraging.

[Thoracoscopic splanchnicectomy--a method of pain palliation in non-resectable pancreatic cancer and chronic pancreatitis]

Severe upper abdominal pain is a dominant and distressing feature in advanced pancreatic cancer and in chronic pancreatitis. A way of palliation needs to be practiced in the non-resectable pancreatic cancer in order to control the pain. Between the many methods of palliation the thoracoscopic splanchnicectomy seems to be the best due its simplicity, no risk to the patient and the good results. In the Center of General Surgery and Liver Transplantation from Fundeni Clinical Institute we have practiced 50 thoracoscopic splanchnicectomies in a number of 49 patients during a period of 3 years. The morbidity was 2% and the mortality 0. We noticed a significant improvement in the pain score, the quality of sleep and the overall quality of life and consecutively a quick social reintegration of these patients. The quality of life is greatly improved (with a significant reduction of the pain score in 92% of the cases) after this minimally invasive procedure, a fact the qualifies this procedure as the technique of choice in these patients.

Telementoring versus on-site mentoring in virtual reality-based surgical training

BACKGROUND

Telementoring can be an adjunct to surgical training using virtual reality surgical simulation. Telementoring is hypothesized to be as effective as a local mentor for surgical skills training.

METHODS

In this study, 20 Romanian medical students trained using a virtual reality surgical simulator (LapSim) with a telementor or local mentor. All the students watched an instructional module at the beginning of the exercise. The telementor, in the United States, interacted by videoconferencing. Before and after training sessions, tool path length and time for task completion were measured.

RESULTS

Instructional media and training with mentoring resulted in similar levels of performance between locally mentored and telementored groups. Right- and left-hand path length and time decreased significantly within each group from the initial to the final evaluation (p < 0.05) for most tasks (grasping, cutting, suturing). No significant difference was achieved for clip-applying.

CONCLUSIONS

Integration of instructional media with telementoring can be as effective for the development of surgical skills as local mentoring.

[Double localization of pancreatic insulinoma. Diagnostic and therapeutic difficulties]

Insulinomas are the most common cause of hypoglycemia resulting from endogenous hyperinsulinism. Because most of insulinomas are less than 2 cm in size and rarely they not may be visible by CT scan or transabdominal ultrasonography. Intraoperative ultrasonography may be a solution. Although as surgical method is preferred enucleation because operative time is shorter and easier and the low frequency postoperative complications, pancreaticoduodenectomy Whipple is indicated in selected cases. We report a case of double insulinoma located in the head of the pancreas in which the diagnosis and surgical treatment presented difficulties which determined a particular clinical evolution.