Elective Laparoscopic Cholangiography in Lithiasic Pathology. Intraoperative Selection Criteria

INTRODUCTION

The introduction of laparoscopic techniques has caused the dispute between supporters of routine or elective intraoperative cholangiography to continue, but at present most authors recommend its elective practice on the basis of well-established preoperative and / or intraoperative indications, thus avoiding to carry out a large number of unnecessary procedures, with their inherent disadvantages and risks.

METHOD

A retrospective study was conducted over 20 years, comprising 100 elective laparoscopic cholangiographies.

RESULTS

The most representative parameter for the indication of intraoperative laparoscopic cholangiography in choledochal lithiasis suspicion has proved to be common bile duct dilation of over 3mm, optionally accompanied by cystic calculi and / or main bile duct dilation over 10mm.

CONCLUSIONS

According to the analysed data, laparoscopic cholangiography proved to be a safe method of intraoperative exploration, with mortality and morbidity specific to the null method, but also with an excellent reliability in highlighting MBD lithiasis.

Pancreaticojejunostomy - Risk Anastomosis after Cephalic Pancreaticoduodenectomy

INTRODUCTION

The authors bring to attention pancreaticojejunalanastomosis (PJA) performed after cephalic pancreaticoduodenectomy(CPD). This type of anastomosis is renowned forits high risk of complications. Among these complications, pancreatic fistula (PF) is distinguishable due to a significant frequency, averaging 10%. It is perhaps the most unsafe type of anastomosis in digestive surgery, due to its pancreatic partnership. Performing a sealed APJ can be considered a great achievement: a digestive lumen is set in contact with a brittleparenchymal structure, centred by a delicate excretory channel, difficult to anastomose in itself.

MATERIAL AND METHODS

We studied two distinct groups of patients undergoing CPD. A first group - 58 cases operated on between 1967 and 1983, and the second one - 70 cases operated on between 1984 - 2013. In all cases we performed PJA; by in-continuity loop technique in the first group, and with separate loop in the second group. In the second group we used a variant own technique that does not allow anastomotic loss of pancreatic fluid. Thus, a decline in the incidence of PF from 20% to 8% was obtained, the final percentage corresponding to group two. Of the 8% of patients with PF losses were recorded strictly at pancreatic level, with no bile or food contamination. Stenting was recorded for biliary- and pancreaticojejunal anastomoses in group two.

DISCUSSIONS

The percentage of PF after CPD did not show anynotable revival when comparing the 1980s period to the present. Also, mortality due to FP is approaching 40%, adaunting figure. The multitude of technical options for restoring bowel movement after CPD, over 80 procedures, further confirms the lack of safety and trust in relation to PJA.The authors bring forward several surgical gestures addressing PJA, gestures capable of providing an 8% frequency of PF,percentage which we consider to be reasonable.

CONCLUSIONS

The authors consider PJA stenting mandatory.Placing an isolated PJA on the short branch of the "Y", separate from the biliary and food flow, prevents the formation of a complex fistula. The proposed technique does not require a"duct - to - mucosa" type or "telescoping" type pancreaticojejunalanastomosis.

Clinical and Paraclinical Criteria of Patient Selection for the Non-operative Treatment in Completely Responsive Rectal Cancer (after Neoadjuvant Radiochemotherapy)

INTRODUCTION

Neoadjuvant radiotherapy is included in the treatment protocols for rectal tumors in stages = T3. The use of neoadjuvant radiotherapy allowed the limit of surgical oncologic safety margin to decrease with 1-2 cm and the abdominoperineal resection to be able to be performed in tumors situated at 4 cm from the anal verge. This modification of the treatment strategy increased the use of low, ultra low and colo-anal anastomoses.

GOAL

Through the analysis of these types of anastomoses and of the disadvantages of the abdomino-perineal resection, we aimed at performing a study on the patients which responded completely to radiotherapy by taking into account the criteria of oncologic safety and the sparing of the patients from surgical complications.

MATERIAL AND METHOD

We performed a retrospective study on 171 patients with rectal cancer treated in the 1st Clinic of Surgery from the Bucharest Oncology Institute between October 2007 and December 2013.

RESULTS

141 patients received radiotherapy, out of which 9 responded completely. 5 of those 9 were not operated on and after variable clinical and paraclinical follow up (2-6 years),they did not present with local recurrence.

CONCLUSIONS

Not performing surgery in the patients with rectal cancer with a complete response to radiotherapy is a good solution and must be taken after a correct information of the patient about rectal surgery with the condition of strictly observing the selection criteria of the patients.

The laparoscopic management of simple hepatic cysts

The hepatic polycystic disease represents a hereditary condition with a reduced prevalence in the general population, sometimes associated with polycystic kidney disease. We present a retrospective observational study applied to 49 patients. The study aimed to observe the laparoscopic surgery of simple hepatic cysts. Laparoscopic approach is a simple and successful surgery management of these types of cysts.

"Difficult" Colorectal Polyps - Therapeutic Approach

INTRODUCTION

Endoscopic polypectomy is the gold standard in the treatment of colorectal polyps. The importance of polypectomy rests primarily on the fact that polyp-type lesions present a high risk of malignant degeneration, colorectal polyps being able, if left unattended therapeutically, to generate a colorectal cancer (CRC) - a lesion with a far more negative prognosis. Although preferable, endoscopic polypectomy of colorectal polyps is not always possible, multiple factors generating difficulties in performing this therapeutic measure.

MATERIAL AND METHOD

We performed a retrospective study in the First Surgical Clinic of the "Prof. Dr. Alexandu Trestioreanu" Bucharest Oncology Institute, spanning a period of 3 years (2008-2011), in which time 224 patients were diagnosed by colonoscopy with colorectal polyps, of whom 222 patients benefited from endoscopic polypectomy. The aim of the study was to identify "difficult" polyps and to identify the criteria for endoscopic surgery versus classic surgery as a therapeutic indication.

RESULTS

Presence of "difficult" polyps was observed in 37.56% of the patients diagnosed with colorectal polyps. In over 88% of cases endoscopic polypectomy was possible, and for the remaining patients classic surgery was the therapeutic solution opted for.

CONCLUSIONS

Presence of "difficult" polyps generates inconveniences in performing endoscopic polypectomy, increasing the risk of postoperative complication occurrence, as well as the duration of the operation. If the criteria for characterizing polyps as "difficult" are relatively well-established, the choice between endoscopic and classic surgery as a therapeutic measure is left at the free will of the operating surgeon, with the exception of situations in which classic surgery is resorted to for oncological reasons.

Morbidity after Ultra Low Anterior Resection of the Rectum

Anterior resections of the rectum, used as an alternative to amputation of the rectum, are performed more and more frequently, being presently indicated for neoplasms located ata distance of 7 to 4 cm from the anus. Complications of low and ultra low anterior resections are not at all negligible, and local neoplastic recurrence rate is significantly higher than after amputation of the rectum. However, literature data recommends low and ultra low anterior rectal resections, even if sometimes the method indications are pushed to the limit or the interventions are performed at the patient's request, in order to avoid permanent colostomy. The authors of this article aim to outline a true picture of the changes caused by anterior resections of the rectum, low and ultra low, so that, without denying the merits of these resections, the entire postoperative pathology that occurs in these patients is depicted and understood. Ultra low rectal resections, up to 3-4 cm from the anus, bring important morphological and functional changes to the act of defecation and to anal continence. These changes in colo-anal bowel movement have a much higher incidence than postoperative genitourinary disorders. Another important aspect emerging from the present study is related to the increased incidence of anastomotic disunity, stenosis and various degrees of incontinence, complications that often can only be solved by completion of rectum amputation and permanent colostomy. In addition, the functional outcomes of these ultra low resections are not always at the level expected by the patient. Also, in terms of surgical performance, the higher share of specific complications of the procedure raises questions with regard to the technique. For all these reasons the authors consider it necessary to review the lower limit to which an anterior rectal resection can descend.

The configuration of biomolecular markers in cancer of the uterine cervix. Personalized therapy. Monitoring and prognosis

INTRODUCTION

The paper deals with the diagnosis of some aggressive forms of uterine cervix cancers, resistant to radio chemotherapy, using biomolecular markers.For this study, the destruction of tumours in stages II-IIIBis carried out by hyperthermia induced by different sources of energy. The aimed targets are toembed a quick and simple technique of haemostas isused in bleeding uterine cervix tumours associated with acute an aemiain the treatment protocols and to identify biomolecular criteria revealing tumour aggressiveness and treatment response.

METHOD

The proposed method consists in radio frequency ablation (RFA) applied touterine cervix bleeding tumours with acute secondary anaemia. Studying 16 patients displaying aggressive cancer forms resistant to radio chemotherapy treated by the above mentioned method, we assessed that the commonly present markers: Ki67, p53 and Bcl-2, may be a substantial indication of such cases. Aggressiveness and treatment resistance was defined based on clinical and paraclinical investigations.

RESULTS

RFA haemostasis achieved in approximately 20 m inproved the efficiency of this method. A secondary important effect was local tumour volume decrease, resulting in the improvement of radio-chemotherapy responsiveness.

CONCLUSIONS

Once an aggressive and radio-chemotherapy resistant cancer is diagnosed,the quantitative, qualitative and associative presence of the biomolecular markers mentioned herein before, could influence the personalised treatment attitude (radiofrequency, neoadjuvant chemotherapy), which onthe long term, may increase patient survival and life quality improvement.

Choleperitoneum due to intrahepatic bile duct rupture - case report

Non-traumatic perforations of the bile ducts are unfrequently encountered entities, all the more when they affect the intrahepatic bile ducts, exteriorizing their biliary content in the great peritoneal cavity. Reporting such a case has determined the authors to perform a careful overview of the cases present in the literature. An observation that can be made based on these is that the obstruction of the main bile duct due to lithiasis determines, by pressure increase, the dilation of the bile system branches, all on the background of an unknown malformation of the intrahepatic bile ducts.

Intestinal obstruction management in patients with advanced abdominal neoplasia

BACKGROUND

The present study describes the difficulties encountered in the diagnostic process and treatment of intestinal obstruction developed by patients with advanced abdominal neoplasia.

METHODS

This unicentric and retrospective study evaluates patients suffering from intestinal occlusion operated on at the First Surgical Clinic of the Oncology Institute in Bucharest, over a period of 4 years (2010 - 2013). Of these, 61 cases in which the occlusion occurred on the background of an advanced abdominal neoplasia were selected. We considered as advanced those cases of abdominal cancer where curative oncologic treatment is no longer possible due to the evolution stage.

RESULTS

The random selection of the study period, the introduction of all the patients identified with this type of pathology, as well as the concentration of advanced abdominal neoplasia at the Oncology Institute in Bucharest are the elements that allow us to state that the results of this study are representative. Particularities related to the clinical aspects of the intestinal occlusion in these patients, as well as difficulties in establishing the correct diagnosis were encountered.Surgical cure of the occlusion, with palliative aim of course,was possible in only 47 cases (representing 77.05%).

CONCLUSIONS

A standard treatment course cannot be devised for this type of patients. Palliative care, indispensable in cases of advanced neoplastic disease, remains the sole therapeutic method available for patients with no surgical cure for the obstruction. The main objective, for the entire study lot, was to ensure an as high as possible quality of life,a factor we must bear in mind as often as possible when choosing a surgical solution. Of course, when surgical treatment can be applied, overcoming the occlusive episode prolongs these patients' life and can even allow for other courses of complementary treatment to be undertaken.

Conserving surgery - balance between good cosmetic aspect and local disease control in incipient breast cancer

New acquisitions in the study of breast cancer, based on several retrospective and prospective studies, have led over the past decades to the possibility of applying conserving methods of treatment for breast cancer (breast conserving therapy -BCT) in incipient stages. Starting with 1996, a single surgical team, among others at the Bucharest Oncology Institute,performed BCT in 497 patients out of the total 2,256 cases of breast cancer treated. Work protocol consisted of tumour excision with safety margins, intraoperative histology exam,samples from all the walls of the remaining cavity, with intraoperative histology exam, axillary lymphadenectomy, followed by mandatory irradiation of the entire breast, associated or not with systemic or hormonal adjuvant treatment. 38 patients developed local disease recurrences, 14 of which in the first 5 years. In this paper we present the results obtained through BCT, as a means of supporting this type of treatment adequate for patients with initial stage breast cancer, with cosmetic results visibly superior to those of mastectomy.

Multiple polyps and colorectal cancer

INTRODUCTION

Malignant degeneration as a possible course of evolution of colorectal polyps renders their diagnosis and therapeutic management a prophylactic act in the prevention of colorectal cancer (CRC).

MATERIAL AND METHOD

The study was conducted over a period of 3 years (2008-2011), during which 1,368 colonoscopies were performed in our service. The aim of the study was to identify patients presenting multiple colorectal polyps and to determine their risk factors for developing CRC, as well as to establish the appropriate therapeutic conduct.

RESULTS

Presence of multiple polyps was recorded in over 40% of the patients identified with colorectal polyps of any kind. Dysplastic modifications observed during the histopathology exam presented a high incidence in the case of patients with multiple polyps, ranging from low-grade dysplasia to incipient CRC.

CONCLUSIONS

Dysplastic modifications and carcinomatous foci were identified mostly among patients with multiple polyps.Only benign lesions or in situ carcinomas benefited from endoscopic treatment, poorly differentiated carcinomas or those invading the submucosa being treated by conventional surgery. Patients diagnosed with colorectal polyps require a rigorous post-therapy follow-up protocol, able to identify any eventual polyposis recurrence.

The place of radiofrequency ablation in the multimodal treatment of cervical cancer. Our experience

INTRODUCTION

Genital cancers benefit from standardized treatment plans which include: surgery and radio chemotherapy.Lately, treatments involving thermal ablations have entered the clinical use, as they destroy the tumors by the use of different energy sources. Our study aims at establishing a precise role of RFA in current treatment protocols of cancer of the uterine cervix.

MATERIAL AND METHOD

We performed a 5-year (2008-2013)prospective study in which we analyzed the use of RFA inpatients treated for cancer of the uterine cervix at our clinic.RFA was used, on selective criteria, in bleeding tumors of the uterine cervix in patients with acute secondary anaemia(Hb=7-11g dl). The results revealed the haemostatic role of the method, RFA being the only non surgical method through which one can achieve quick haemostasis (20 min.). 61 patients were clinically observed, with ages between 39 and 73, and the number of procedures performed was 61.

CONCLUSION

RFA is useful in the treatment of cancers of the uterine cervix, in all stages of the disease, and it achieves quick haemostasis. RFA can be considered an additional treatment option in neoadjuvant tumor palliation. The method can be associated with surgery and radio chemotherapy. Its assets are low specific morbidity (1,6%) and mortality (0%). We consider that RFA is on its way to an important place in oncology treatment protocols.

Therapeutic approach in locally advanced colon tumours (T4NxM0) - clinical experience in 18 consecutive cases

INTRODUCTION

Surgery holds a central seat in the treatment of colon cancer, its objective being R0 resection. Chemotherapy and an appropriate oncological follow-up complete the treatment.

AIM

To establish an adequate therapeutic conduct in patients with advanced colon tumours, with no hepatic metastases.

MATERIAL AND METHOD

retrospective study on a group of 150 patients with colon neoplasm treated in the First Surgery Clinic of the Bucharest Oncology Institute in Bucharest,between 01 01 2008 -01 03 2013.

RESULTS

18 patients presented locally extended colon tumours which required multivisceral resections. Patients with hepatic metastases were excluded from the study. The most frequently affected organs were: the small bowel and the internal genital organs, followed by the urinary bladder, spleen, duodenum and diaphragm muscle. Patients were oncologically followed-up according to current protocols and submitted to chemotherapy.When a maximum response was reached in R2 patients or when recurrence occurred in R0 and R1 patients, surgical intervention was required. When necessary, the operation was performed by multidisciplinary teams. 5 patients died due to local recurrence, disease progression, metastatic disease, and also due to comorbidities.

CONCLUSION

Treatment applied by oncological committees and multidisciplinary surgical teams, along with correct oncological follow-up and surgical reintervention when maximum response to chemotherapy was reached in R2 or when recurrences occurred in R0 and R1 patients represents the adequate therapeutic conduct in patients with locally advanced colon tumours.

Morphological and immunohistochemical criteria of tissue response to radiotherapy in rectal cancer

AIM

Given the context that rectal tumours respond to a certain degree to radiotherapy, a necessity arises for estimating a tumour's capacity to react to radiation from the very moment of diagnostic biopsy.

MATERIAL AND METHODS

We have histologically and immunohistochemically analysed tissues coming from 52 patients with rectal adenocarcinomas.

RESULTS

Of the studied parameters, the ones presenting significant variation under radiotherapy in terms of statistics(p 0.05) were: colloid type (p=0.001), EGFR in the tumour(p=0.00045), EGFR in the normal epithelium (p=0.0017),VEGF in the tumour (p=0.0132) and VEGF in the tumour stroma (p=0.030).

CONCLUSIONS

Our study follows the same trends as the medical literature we have consulted regarding the variation of EGFR and VEGF with radiotherapy, and the distinct note of our study relies in the observation that normal stroma in case of rectal tumors also reacts to radiotherapy, sometimes more aggressively than the tumor itself, especially in which concerns the nerve and muscle fibers.

The role of intraoperative ultrasound in establishing the surgical strategy regarding hepato-bilio-pancreatic pathology

Intraoperative ultrasound examination plays a more and more important role in open or laparoscopic abdominal surgery,satisfying the surgeon's need to correctly characterize lesions,bringing various benefits regarding topography and local regional extension, relations between neighbouring structures and, finally, disease staging. Intraoperative ultrasound is used especially in hepato-bilio-pancreatic tract interventions, given its diagnostic and therapeutic values. Between 2009-2012 in the IOB First Surgery Clinic 57 intraoperative echo graphies were performed, in patients with hepato-bilio-pancreatic pathologies, leading to intraoperative guided punctures with diagnostic or therapeutic purpose (in case of hepatic abscesses),detection of new hepatic metastases, their ablation under ultrasound guidance, exploration of the local-regional topography with the aim of an optimal hepatic resection. Intraoperative ultrasound allowed radioablation under echographic guidance in 43 patients, the majority presenting multiple hepatic metastases in different areas, this method also enabling control over complete lesional destruction. Also, in 11 cases (22.915), a number of hepatic 20 metastases which had not been visible on preoperative imaging scans were detected, and afterwards treated through RFA; also, in 14 cases intraoperative echography revealed the presence and nature of the hepatic tumours, leading to a correct histopathological diagnostic and an adequate therapy. The method was useful in pancreatic pathologies as well, in complicated forms of acute or chronic pancreatitis, tracking the Wirsung duct within the scleral and calcified mass of pancreatic tissue, through an ultrasound guided puncture, as well as in locating pancreatic cystic masses,determining the optimal puncture or pericystic-digestive drainage areas. Intraoperative ultrasound is an inexpensive, easy method, which allows real time exploration throughout the entire surgical process of hepato-bilio-pancreatic lesions, aiding the surgeon in modifying decisions regarding the intervention and preventing complications.

Aseptic mesenteric lymph node abscesses. In search of an answer. A new entity?

Mesenteric lymphadenitis constitutes a frequent cause for abdominal pain and may manifest acute abdominal symptoms. Very often, it is difficult to achieve a differential diagnosis as there are many diseases that can generate mesenteric lymphadenopathy. Many times, it is impossible to determine the diagnosis of the disease that has triggered mesenteric lymphadenopathy even after surgical intervention with biopsy. The failure in determining the precise cause of the mesenteric lymphadenoapathy, as well as its unresponsiveness to conservative treatments increases the difficulty in the management of this disease very much. In this paper we have reviewed the diseases that can trigger mesenteric lymphadenitis in detail, with reference to our experience. To the best of our knowledge, this is the most extensive review on this theme in current specific literature. The case reported by us, with a history of mesenteric adenitis, splenic and ganglionic abscesses, vasculitis skin nodules, pseudotumoral ileal stenosis and remission-recurrence pattern over 25 years, has raised extremely difficult problems of differential diagnosis. Its enlistment as a Crohn's disease, vasculitis or aseptic abscess syndrome seems unsatisfactory. The analysis of the data in this case can raise the legitimacy of the question: should we recognize and define a new entity?

The management of colon cancer in case of coexistence with an abdominal aortic aneurysm

Colorectal cancer with the presence of an abdominal aortic aneurysm as a comorbidity factor is rare (0.5-2%) (1). Both diseases, while untreated, have a high degree of mortality (2,3). Management of such cases is a challenge for the surgeon, who confronts multiple dilemmas due to the particularity of this dual pathological entity. We present two clinical cases of adenocarcinoma of the colon concomitant with AAA, similar in many ways. Both cases were successfully treated regarding tumor excision by practicing right hemicolectomy. For each case a different strategy for vascular surgery was chosen. In the first case an EVAR (endovascular aortic repair) was performed. In the second case, because of the high risk of the aneurysmal sac operation, we opted for an expectation tactic. The presentation of these cases was chosen due to the rarity of their occurrence as well as because of the intention to highlight certain characteristic aspects. The main controversies debated are the necessity of treating the diseases simultaneously or in two stages, their approach order and the choice of an open surgery or an endovascular technique. From our experience and according to most literature, a staged therapy with EVAR in the first step is a method of choice. As surgical technique evolves, possibilities of endograft placement are expanding, thus, cases with more challenging anatomy can be approached.

Prognostic factors for the primary and secondary retroperitoneal sarcomas. Impact on the therapeutic approach

BACKGROUND

There is little knowledge on retroperitoneal sarcoma, but there are many controversies. The objective of the current study was to define the common and distinctive features of primary and secondary retroperitoneal sarcomas in terms of presentation, prognostic and therapeutic approach to improve the current management of these tumors. Vascular involvement impact was assesed in the two sets of patients.

PATIENTS AND METHODS

We have performed a retrospective and prospective study on a group of 34 patients diagnosed with primary and secondary retroperitoneal sarcomas.

RESULTS

We have found that primary and secondary retroperitoneal sarcomas have many common features, but hold distinctive aspects in terms of manifestation, predictors of survival and treatment.

CONCLUSIONS

Vascular involvement is one of the most important predictors of poor survival in primary retroperitoneal sarcoma patients, because it often limits radicality. In this group, radicality is a major prognostic factor for a higher survival. Instead, secondary retroperitoneal sarcomas appear to be less dependent on the radicality of the treatment and their survival can be increased by complementary treatments.

[Gastroesophageal reflux disease -- current trends]

GERD has long been recognized as a significant public health concern in USA generating along the time, many disscusions between gastroenterologists and surgeons. Once antireflux barrier was identified, and mechanism of reflux established, GERD can be defined as the failure of the antireflux barrier (represented especially by the lower esophageal sphincter, by gastric empty disorders or failed esophageal peristalsis), allowing abnormal reflux of gastric contents into the esophagus. Positiv diagnosis is setting by the presence of documented esophageal mucosal injury (esophagitis) or excessive reflux during 24 hours intra-edophageal pH monitoring. Medical treatament is efficient in acid suppression, but does not address the mechanical etiology, is too expansive and affect the quality of life of pacients. Miniinvasive surgery was a boom in management of GERD, offering great sathysfaction to pacients, low costs and rapid social integration. We present in folwing pages the role of surgery in GERD, therapy GERD which occur 85-93% control of reflux simptomathology, providing data from the literature on the techniques used, their advantages and limitations.

Primitive retroperitoneal tumors. Vascular involvement--a major prognostic factor

Primitive retroperitoneal tumors, although very rare, arouse an increased interest, because of the poor prognosis, unsatisfactory surgical and complementary therapy results. Up to now, the very low number of cases has impeded the acquisition of a unitary view of these tumors, a unanimously accepted algorithm of diagnostic and treatment being absent. Randomized trials regarding the effects of different therapies have not been possible. The main factor that can fundamentally increase the survival of these patients is radical resection, some authors even recommending compartmental surgery. We found no significant statistical difference between the survival rates of the patients with different types of non-radical interventions, that shoud be therefore, as much as possible, avoided. Our study evidences that vascular involvement is the main limiting factor in achieving radicality. The involvement of large retroperitoneal vessels makes often impossible a radical intervention, usually because of the lack of an adequate material and human endowment for ample vascular resections followed by laborious reconstructions. That is why, in our study, vascular involvement was associated with a decreased survival rate for operated patients. Therefore, we underline the necessity both of a solid material base and of establishing multidisciplinary surgical teams for adequate vascular interventions in oncologic general surgery.

An unusual sarcomatous retroperitoneal metastasis. A rare case report with a brief literature review

Retroperitoneal sarcomas are rare tumors associated with a high rate of recurrence and very bad prognosis. Their only efficient treatment is a negative- margin surgical resection that is extremely difficult to achieve. Retroperitoneal metastases from extremity sarcomas are considered unusual. In literature, such a metastatic pattern is described extremely rarely. In this paper we report a case of a very aggressive extremity chondrosarcoma, associated with local recurrence, multiple distant metastases, that finally led to a retroperitoneal metastasis. The recurrence and progression of the sarcoma in this localization were impressive, with a fast overcome of therapeutic options. Chemo- and radiotherapy have not proved to be efficacious in this context and they could have had a role in the deterioration of patient state of health. New tumor markers for the detection and follow-up of these tumors should be considered.

Extending indication for radiofrequency ablation (RFA) in cancer surgery

Radiofrequency ablation (RFA) represents one of the successful methods for the thermal ablation of unresectable tumors. The tumoricidal effect of this method consists in the tissular conversion of electromagnetic energy into thermal energy. The term refers to the electric current, whose frequencies reach high values, 480 KHz on average. The method involves the insertion of bipolar needles in parenchymal tumors. The thermal tissue damage depends on both the temperature reached and the duration. The most frequent use is for unresectable hepatic tumors (metastases, hepatoma) or for those with a contraindication for surgery, visible on ultrasound. We have also widened the indications to other tumoral locations: cervical cancer (stages II, III, IV) accompanied by metrorrhagia, RFA being used hemostatically and with the purpose of reducing the size of the tumor, genital tumors, lateral-aortic lymph blocks to reduce the tumoral mass, metastases (the psoas muscle, the sacrum), retroperitoneal sarcoma, with a hemostatic role and also to reduce the size of the tumor. The paper aims to present a preliminary situation based on 24 cases. The results have shown the usefulness of the application of RFA with the purpose of reducing the tumoral mass and the hemostatic role of the method. No complications were recorded.

[Radiofrequency ablation for liver metastases--mini invasive therapeutic option for patients with unresecable tumors]

Radiofrequency ablations (RFA), a new therapeutic option for liver metastases, proceeded by open surgery or laparoscopic approach, provide an acceptable control of local tumor process, involved lower risks than resection surgery.

OBJECTIVES

We analyzed this procedure, for classic indication in hepatic metastatic tumors, based on four years experience, focused on perioperative complications, recurrence rate and long distant evolution.

METHOD

Between December 2006 and December 2010, 61 patients with liver metastases underwent RFA; 46 cases had metastatic lesions from colo-rectal cancer, 9 cases from breast cancer, 4 cases from gastric cancer and 2 cases from ovarian cancer. RFA was performed in 55 patients via open surgery and laparoscopic approach in 6 patients. Postoperative course was followed with CT scan at 1 month, and then at 3 month interval, in correlation with tumor markers level.

RESULTS

Perioperative complications occurred in 8 cases, consist of prolonged fever, severe hepatic cytolysis, without other complications such, biliary tract injury, hemorrhage, and peritonitis; no mortality caused by RFA procedure. 10 cases had local recurrence, at 6 and 25 month after post RFA procedure.

CONCLUSIONS

Initial experience shows that RFA is a safe procedure for treatment of liver metastases, with low rate of morbidity and local recurrence, indicated for patients with unresecable lesions or high risks for surgical resection.

Double suturless hepaticojejunostomy

In iatrogenic lesions of the main bile duct, especially when the injury is above the level of the hepatic bifurcation, the surgeon ought to use two short and thin biliary stumps. It is necessary to perform separate anastomoses, using a "Y loop" and creating a double hepaticojejunostomy. Technical difficulties increase when the biliary ducts are thinner, tighter and separated from one another for a distance more than 2 cm. In such case we have attempted to develop a double sutureless hepaticojejunostomy by simply keeping the bilioenteric partners in apposition with continuous traction exerted via the biliary stents.

[Pregnancy--a factor in favour of biliary lithiasis]

OBJECTIVE

The purpose of the analysis accomplished is to identify how much pregnancy influences the occurrence of gravel at young women.

MATERIAL AND METHOD

This retrospective analysis was realized between January 2007 and April 2009 in the two surgery departments of Pitesti county Hospital and it was based on the analysis of the medical history and operational standards. During this period, there were operated 762 cholecystectomys, out of which, 348 through laparoscopics and 414 usual.

RESULTS

Out of 605 female patients, 10 patients were operated during the first 6 months after giving birth. The cholecystectomys at 10 patients were realized through laparoscopics. Two patients had postoperatoric icterus. Under medical treatment icterus was relegated in the 3 postoperator day. The second patient who had icterus, a retrograde endoscopy of common biliary duct was aplied in the 5 a postoperator day

CONCLUSIONS

During pregnancy period, profound functional gastro intestinal, gall bladder and pancreas changes occur. Following this changes, there can be formed gravel which can lead the characteristic symptomatology: gall bladder colic, icterus, fever, vomit.

Juxtapapillary duodenal diverticula early and late clinical and therapeutical implications

The aim of this paper is to identify the early and late implications of JPDD for biliary pathology, as well as for endoscopic therapy and classical surgery dealing mainly with lithiasis. This paper is based on a retrospective study comprising a number of 675 ERCP performed on 601 patients between 1997-2007, out of which 399 cases were followed by therapeutic measures. A total of 79 procedures were performed on 65 cases with JPDD. The main criteria were: gender, age, indications regarding the performance of ERCP+/-ES, complications that occurred while carrying out these procedures. In all the cases examined (601) the percentage of JPDD reported was of 10.81%. The rate of complications in the sphincterotomized patients without JPDD was 5.75% and the rate in the sphincterotomized patients with JPDD was 14.89%. In conclusion, the paper discusses the clinical and therapeutic implications of JPDD in biliary pathology. It has been found that JPDD is an important etiological cause for the late diseases occurring after cholelithiasis surgery. JPDD also leads to immediate therapeutic implications such as: difficult cannulation and high incidence of ERCP+/-ES complications.

[The reassessment of indications in laparoscopic cholecystectomy]

The gallstone, with its potentialy complications, claims a surgical solution in asymptomatic forms too, often traced out with the abdominal echography investigations circumstances. In all the countries, the symptomatic gallstone, is a surgicaly section, but, the asymptomatic gallstone is a surgicaly indication in some countries, too. A number of transplantation surgeons have begun to recommend pretransplant cholecystectomy for asymptomatic patients to have gallstones. The indications can be extended to: young children, pregnant women, patients with very large gallstones diabetics, immuno-depressed (AIDS, radiation and multiple drug treatments). The asymptomatic gallstone seems to obtain in the last years, an extention of the surgicaly approach indications, the paper, suggesting a laparoscopic cholecystectomy assessment indications.

External drainage of the hepatic post hydatid remnant cavity

BACKGROUND AND AIM

The surgical management of the hepatic post hydatid remnant cavity includes conservative and radical methods. External drainage of the remnant cavity (with or without cavity-minimizing) is a simple conservative method that can be safely performed, and can be associated with endoscopic papillo-sphincterectomy (EPS) in case of cysto-biliary fistula.

METHODS

A retrospective study was performed on 112 patients operated in the Department of Surgery, "Caritas" Clinical Hospital, Bucharest between Jan 1997 and Feb 2007. Cavity was drained and the completely extraperitoneal approach for exteriorizing the drain was preferred, an original method conceived and put into practice by Prof. Dr. Burlui, using as pathway the round ligament, more precise the hepato-umbilical territory.

RESULTS

The mean hospital stay was 12 days, and follow-up till complete recovery was performed by clinical, ultrasound, CT-scan and X-ray contrast on the drainage tube. The drainage of the remnant cavity was maintained a mean period of 55 days (ranging 20 to 80), in accordance with the X-ray contrast control on the drainage tube. The postoperative morbidity was acceptable (remnant cavity infection was registered in 11% of the cases). Neither reintervention, nor mortality was registered.

CONCLUSIONS

the study shows that external drainage of the hepatic post hydatid remnant cavity can be applied in most of the parasite locations, especially for the central segments, with no hepatic parenchyma sacrifice, while total cavity fibrosis is achieved in a mean period of 55 days. This way we avoid a risky and laborious procedure (the anatomic or non-anatomic removal of a variable amount of normal hepatic tissue).

[Retroperitoneal pyogenic infections with uncertain etiopathogenesis. Diagnostic and therapeutic difficulties]

Retroperitoneal pyogenic collections can appear in most distinct pathological situations. Establishing the topography and pathogenic route are essential steps in developing the therapeutic attitude. Diagnosis of suppurative retroperitoneal process complicating a previously attested disease is less difficult. The challenges appears in that cases with atypical, clinical picture, which presents associated pathological states (diabetes mellitus, chronic alcoholism, behavioral disturbances), as well as in primary retroperitoneal infections (psoas abscess, infected retroperitoneal tumors) or in that situations in which the patient presents toxico-septic shock on admission. A retrospective study on the patients with retroperitoneal infections admitted in our Clinic between 1996 - 2006 was carried out. We selected the cases in which preoperative etiopathogenic diagnosis was uncertain (in some situations the exact etiopathogenic route remaining unknown even postoperatively). The aim of this study is to evaluate the factors contributing to this, and how therapeutic attitude was influenced.

[Surgical approach in acute necrotising pancreatitis]

Acute necrotising pancreatitis is a dramatic and often life-threatening disease with a high rate of mortality, varying between 30-70% and necessitating heavy medical care. The surgical attitude regarding acute necrotising pancreatitis is disputed between the supporters of drainage with closed abdomen and the supporters of laparatomy with open drainage. The goal of this study is the evaluation of the number of intervention required, the timing of the interventions and the mortality and morbidity in a group of patients with necrotising pancreatitis. The studied group consists in 112 patients with necrotising pancreatitis, treated in Surgical Clinic of Caritas "Prof. Dr. N. Cajal" Clinical Hospital, Bucharest during 1983-2005. Infection of pancreatic necrosis supervened in 55,35% of patients in this group, not any pancreatic necrosis becomes infected. Infected necrosis is not synonymous for abscessed of necrosis, in the same patient pancreatic necrosis, infected pancreatic necrosis and abscessed necrosis may coexist. Clinical and biological criteria are the decisive factors in the indication for surgical treatment, the radiology being decisive in the choice of the laparotomy approach. In the study group 50,89% of patients necessitated only one surgical intervention. Implicitly, more than half of the patients would have been suffered multiple useless planned staged relaparotomies. The mortality in our study group treated by the method of closed drainage was 25,89%.

Late choledochal pathology after cholecystectomy for cholelithiasis

After "simple" cholecystectomy for lithiasis, biliary disorders can appear, with the onset more than 3 years postoperative, like cholangitis or transitory jaundice. Meantime, a whole range of congenital abnormalities initially ignored can become manifest: biliary tract congenital dilatations, duodenal para-Vater diverticulum, Oddi stenosis.

AIM

to establish the pathological circumstances that determine late choledochal syndrome, including an analysis concerning the therapeutical approach in these cases. Patients with cholecystectomy complains of late biliary disorders (least 3 years symptom-free) between 1997-2005, were retrospectively studied. Exclusion criteria were intraoperative incidents or accidents, recognised incomplete surgical procedure, early difficult postoperative course. Therapeutical approach was endoscopical, surgical or conservative. 46 patients entered the study group; 38 underwent open cholecystectomy. Mean interval between operation and disturbances onset was 10 years. Following etiopathologic causes of late choledochal pathology were recorded: incomplete cholecystectomy, retained or primary common bile duct (CBD) stones, choledochal cyst or stenosis, Oddi stenosis, duodenal para-Vater diverticulum, anomaly biliary tree. Thirty patients undergone successful endoscopic treatment; in 8 cases endoscopy failed, in 2 cases open surgery was the first choice; 5 diagnostic endoscopic cholangiography with conservative treatment were performed; 1 patient refused any procedure. Cholecystectomy indication is regularly based on clinical and ultrasound examination criteria. Even a simple cholecystectomy can be followed after first 3 years by cholangitis, obstructive jaundice, caused by initially ignored biliary tract pathology. To avoid such omissions, routine intraoperative cholangiography and duodenal endoscopy should precede cholecystectomy. On the other side, cholecystectomy itself can cause late complaints: retained CBD stones, gallbladder stump, and iatrogenic stenosis. The duodenal para-Vater diverticulum seems to have a more important role in biliary disturbances, before and after cholecystectomy.

[Carcinoid tumors, leiomyosarcoma and invasive adenocarcinoma metastasis of the Treitz angle]

Our paper studies the quite rare occurrence of the digestive superior occlusive pathology, namely some causes which might induce partial or even total obstruction of the digestive tract, at the distal anatomical limits of the duodenum, also known as the Treitz angle. The first two described cases were carcinoid tumors, obstructive and ulcerated in the lumen of the same angle. The last two cases were an obstructive leiomyosarcoma and an invasive mesenteric metastasis from a right colon cancer, which cause a total external compression of the Treitz angle, clinically manifested as a complete food intolerance, as a first symptom. Concerning the clinical evolution, these are totally different lesions, malign, metastasis and neuroendocrine tumors, which occurred at the same level, had a totally different clinical evolution and surgical approach, only three of them developing at good postoperative course. The imaging, clinical and pathological diagnosis problems, the different specific surgical solutions, the postoperative care and finally the rarity of this level of obstruction of the small bowel, are the aim of this paper.

[Particular evolution of a jejunal tumor in one patient with multiples neoplasia]

The authors present the case of one male patient, 71 years old, known with serial neoplasia (right colon neoplasm 1983, left colon neoplasm 1987) for which there were performed several interventions. The patient was admitted first time in our Department in 1998 for a non specifically symptomatology; in particular anaemic syndrome. The first intervention was performed in June 1998, without finding anything pathological, despite the presumption of a third tumor on the remaining colonic territory, theory that was partially sustained by the paraclinical examinations. The second intervention was performed in February 2001, when it was found and extirpated a jejunal tumor, under Treitz angle, but after 9 months, when a new intervention was performed, we found a relapse tumor which was not extirpable. The aim of this study is to present the unpredictable versatility of small bowels tumors and the difficulty of establishing an early positive diagnose.

[Recessive hiccup of rare cause (compressive pleuro-pericardial lymphocele). Case report]

The authors discuss the case of a 40 year-old woman, which was performed surgery for a stenosant duodenal ulcer by bilateral troncular vagotomy and hemigastrectomy, using the Pean-Billroyh 1 anastomosis. Immediately after surgery untractable hicongh gradually set in which lasted over a 14 year, till the moment when a compressive pleuropericardic lymphocele, of the right phrenic nerve was revealed, a very long time growing cyst. After the surgical removal of the lymphocele was performed, which had compressed the right phrenic nerve, singultation totally disappeared, the patient has been monitorized through periodical medical checkings for more than 4 years. The period of 14 years when the patient constantly complained of steady untractable singultation has comprised 30 admission or more, to various surgical, gastroenterology and psychiatry wards. The patient was finally considered an incurable psychotic and was medically pensioned. The authors discuss a number of possible sequels of the initial gastric surgery which could have triggered untractable singultation, without being able to control them or totally ruling out the psychotic causes. There is natural suspicion cast of either existence or beginning of this cyst simultaneous with surgery since clinical tests and explorations were able to reveal it only after 14 years.

[Therapeutical options in lithiasic biliary fistula]

Chronic lythiasic cholecystitis is a disease distinguished by the pathologic changes because of the chronic inflammation of the biliary extrahepatic tree. Sometimes these morphological changes are associated with internal biliary fistulas arising spontaneously in patients with advanced calculus cholecystitis. The vast majority of fistulas result from the adherence of the inflamed gallbladder or common bile duct to an adjacent viscus and erosion of the gallstones into the adherent organ. The authors analyze an amount of 43 patients with bilio-biliary and bilio-digestive lythiasic fistulas, caused by the long evolution of chronic lythiasic atrophic cholecystitis, for 126 cases which were operated in the Surgery Department of the Caritas Clinic Hospital along 20 years. In these 126 cases the surgical strategy was determinated by the method of dealing with the pericolecystitis sclerotic blocks, by the identification methods of the biliary elements and by the approach of the main billiary way and digestive loops injuries occurred after suppressing the fistulae. The surgical solutions adapted for each separate case and the advantages of the axial drainage of prostheting the surgical reconstructions of the main biliary way as well as the results obtained along this project, are in fact the aims of this presentation.

[Controlled stomach fistula for acute operated ulcer. Case report]

The authors analyze the case of a 65 old woman which was hospitalized for sigmoidian stenosant and haemorrhagical neoplasm, confined to the colic wall, without peritoneal or hepatic metastases, and without peritoneal or parietal invasion. Surgical management included sigmoidectomy and termino-terminal anastomosis for reconstructing intestinal transit followed by peritoneal drainage. In early postoperative stage the aspect of generalized peritonitis occurs and there is suspicion of anastomotic fistulae. On surgery, acute and perforated gastric ulcer is found, located in close vicinity to the cardia, on the anterior side of the stomach. Suture of the perforation is undertaken with drainage of the peritoneal cavity, but successfully because fistulization of the sutured perforation followed. Under the given circumstances controlled drainage of the gastric fistulae was carried out, using a Folley probe extended through the fistulae orifice and through the anterior abdominal wall, lateral to the median incision. The blowing of the intragastric balloon and the setting into tension of the gastric wall to the front abdominal wall allowed the sealing of the fistulae route but it took about three months. This technical contrivance has afforded good postoperative evolution and recovery of the patient, who after five years from surgery is in a good condition and has no subjective complaints.

[Unusual hemorrhagic complication after surgery for severe generalized appendicular peritonitis]

The 22 year old male patient, was admitted in hospital for severe generalized peritonitis subsequent to acute perforated appendicitis and toxico-septic shock. On examination and relying on the previous history of the patient onset of the perforation was start assessed to have occurred some days earlier. Severe generalized, putrid peritonitis was found on surgery of the peritoneal cavity. Appendectomy was successfully carried out with a simple ligature of the appendix stump, and the ligature of the mezooappendix was performed without identifying the appendicular artery. Early in the postoperative stage there occurred diffuse bleeding localized in the peritoneal cavity. The source of the bleeding could not by found at the first reoperation. Subsequently the septic syndrome evolved simultaneously with the bleeding in a milder form, however, leading to growth in size of retroperitoneal hematoma. On marking the diagnosis, relying on CT examination, a new, second surgery was performed which afforded evacuation and drainage of the retroperitoneal hematoma. The authors have remarked and have tried to clear up the circumstances which had been conductive to the occurrence of hemorrhage, a thing absolutely unusual in the evolution of diffuse peritonitis by perforated acute appendicitis.

[An endoscopic treatment method for postoperative stenoses]

The endoscopic procedures include a great variety of procedures for the treatment of the upper and lower gastrointestinal bleeding of the benign and malign jaundice, of the primary or secondary gastrointestinal strictures. The authors present the case of a patient with a postcaustic oesophageal stricture for whom the surgical treatment was an esogastroanastomosis. Quite early in the postoperative course the anastomosis got, very tight due to a anastomotic fistula, and we succeed to dilate it with endoscopic procedures.

[Intraoperative exploratory endoscopy in surgery of the digestive tract]

The intraoperative endoscopy as a way of the range of the surgical exploration of the abdomen is a valuable procedure combining surgical and endoscopical maneuvers. It proved useful in following conditions: A. delicate surgical approach of the anatomical segment; B. equivocal findings of the conventional endoscopy; C. as a way of achieving therapeutical goals. In 56% of the cases a transperitoneal approach was used and in the rest of the cases a conventional technique. Sterilization was performed using glutaldehide 2%, 20 minutes before the intervention. The methods was used in 50 cases, concerning reinterventions, as well as primary diseases of unclear origin. Some were high-risk patients. Therapeutically benefit was proven in all cases.

[A rare cause of postoperative digestive hemorrhage]

Despite all the diagnosis's technical progress achieved in the past years, there are possible haemorrhagic complications after abdominal surgery, creating problems of diagnosis and treatment. The author presents a rare case of postoperative gastrointestinal bleeding due to an ulcer of the jejunal mucosa, located quite close to a hepaticojejunostomy. The mucosal ulcer, with consequent severe, massive bleeding was caused by the migration of a thread from the hepaticojejunostomy, proved by histopathological examination.

[Splenic hemangiosarcoma]

The authors present a case of splenic hemangiosarcoma which was encounter-a group including some 600 splenectomies. Hemangiosarcomas represent only 3% of all malignant splenic tumours. This clinical observation is of particular interest because of the extreme rarity of such cases. It is also interesting because of the conditions which have determined the intervention, as well as by the prolonged survival of the patient.

[Particular operations in surgery of gastric ulcer under the protection of vagotomy]

There are particular situations in the frame of the surgery of gastric ulcers, when the use of classical techniques--such as extensive resections, or sub-total resections--represents a risk factor and raising doubts about the vital prognosis of the patient (dehiscence, fistula, etc.). This is especially true for highplaced lesions, the removal of which supposes either an upper polar resection, or an almost total gastrectomy. This raises some problems with suture which are doubtful, as well as the risk of the "small stomach" syndrome or the risk of accelerated evacuation. The authors suggest several possibilities for the surgery of gastric ulcers under the protection of vagotomy, which allow a good immediate and late evolution. These include the medio-gastric resection, the so-called "saddle" resection, and the excision-suture resection, all being carried out under the protection of vagotomy associated to piloro-plastia. Making use of these procedures the authors have been able to maintain a more conservative attitude with regard to the stomach pouch, and to avoid some of the sequellae of the operated stomach.

[Surgery of operative lesions of the principal biliary passages]

The authors present their experience acquired in 30 cases of surgical interventions performed for the correction of accidental lesions of the main biliary pathway. The essential parameters are discussed in this paper, which determine the degree of difficulty of the corrective interventions. Indications are also discussed concerning tactical and technical aspects depending on the level of the lesion, as well as in relation with its type. The authors present some particular aspects of prostheses used in the derivations which they have made with a corrective purpose.