Anterior transperitoneal laparoscopic approach of retroperitoneal tumour - clinical case

We present our personal experience in the anterior transperitoneal laparoscopic approach of a retroperitoneal tumour.The case we have in view is that of a 48-year old female patient P.V., with congenital single left kidney. The patient has a retroperitoneal tumour mass of the right flank. Following investigations (ultrasound, CT with contrast), the tumour appeared well defined, of small dimensions (approximately 6-7cm diameter) and without anatomical relationships with large retroperitoneal vessels (inferior vena cava). For the laparoscopic excision of the tumour, we used an operating device adapted from the one used in right hemi-colectomy. After the coloparietal dissection, the access into the right retroperitoneal flank by means of laparoscopy is achieved by applying our procedure.The surgical intervention was quick and of a minimally invasive nature. Postoperative evolution was favourable, without any complications; the patient was discharged after 48 hours. In anatomic situations where the tumour anatomy is well defined and its size is acceptable, without dangerous anatomic relationships with large retroperitoneal vessels, attempted laparoscopic transperitoneal removal is the preferred option.

[Benefits of mechanical suture in our experience]

The evolution of mechanical suture technology experienced a continuous improvement but the implementation of these devices in current practice of Romanian surgery encountered difficulties related mostly to increased costs.

PURPOSE

Review of casuistic related to the use of mechanical suture devices.

METHODS

We studied the casuistic between 2008 and July 2011. More parameters were analyzed compared to cases in which manual suture was used.

RESULTS

74 patients benefited from using mechanical suture. Circular staplers EAEC type were used in 53 cases, TA staplers in 48 cases and Endo GIA in 19 cases. Operations performed were: 44 colo-rectal anastomoses (2 laparoscopic), 9 eso-jejunal anastomoses, 17 gastric resections, 2 duodenal stump closures and 2 rectal stump closures. One (2.56%) colorectal anastomotic fistula was found which led to death. There was a single anastomotic imperfection where we performed ileostomy with favorable evolution. Duration of Dixon's operation was shortened by 36 minutes average. The anastomosis could be lowered to 3 cm from the anal verge. There were 3 late local rectal cancer recurrences, 1 recto-vaginal fistula and 1 rectovesical fistula. There were no anastomotic stenoses.

CONCLUSIONS

There were two main advantages of using mechanical anastomosis: (1) the opportunity of palette broadening of laparoscopic operations, (2) the possibility of making safe anastomosis in difficult to access areas (rectum, esophagus). The use of mechanical staplers offers advantages especially in patients with rectal tumors, especially in obese male patients with narrow basin, where we can save many cases from rectal amputation. Staplers bring more comfort to the surgeon offering physical and psychological feeling of a perfect anastomosis. Although staplers cost is high, in selected cases, this disadvantage is offset by reducing the duration of operations, hospitalization and subsequent cost of stomas maintenance.

[Prognostic factors in breast cancer]

Survival in breast cancer is determined by many factors, their influence is different. The aim of the study is to assess the impact on survival of various prognostic factors.

MATERIAL AND METHODS

We studied a total of 198 cases of histologically confirmed breast cancer patients, and we evaluated the impact of prognostic factors on survival.

RESULTS

The most important factor influencing survival is the preset of axillary metastasis(p: 0.0001). Other important prognostic factors are: tumor size (p: 0.003), tumor grading (p: 0.0025), N stage (p: 0.0001.) lymphovascular invasion (p 0.0005) and Nottingham Prognostic Index (p: 0.0109). The factors with no impact on survival were: histological type (p: 0.82), number of lymph nodes affected(p: 0.23), tumor necrosis(p: 0.49) and inflammatory infiltration (p: 0.2).

CONCLUSIONS

The most important prognostic factors are: axillary metastasis followed by tumor grading, NPI and lymphovascular invasion.

[Axillary lymph node metastases in breast cancer. Anatomo-clinical correlation and surgical approach]

AIM

To establish the incidence of the axillary lymph node metastasis in breast cancer and some anatomo-clinical correlations useful for surgical act orientation.

MATERIAL AND METHOD

The data from 450 patients, who underwent surgery for breast cancer between 2000 and 2007, were analyzed statistically according to some parameters: the age of the patients, the size and the location of the tumor, the hystopathological type, the elapsed time from the discovery of the tumor until surgery.

RESULTS

The tumoral stage was: stage 0--1.1%, I--7.11%, II--50.67%, III--33.78%, IV--7.33%. From the total amount of patients who underwent surgery, only 56.44% had axillary lymph node metastasis. The patients in the forth decade of life had more frequently axillary lymph node involvement, and also those from rural habitat (65.88%). The correlation between tumor dimension and lymph node involvement was: <2 cm--1.36%, 2-5 cm--48.71%, >5 cm--86.67%. The palpation of the armpit was associated in almost a quarter of cases with false negative or false positive diagnosis. There are a lot of locally advanced cases without axillary lymph node metastases.

CONCLUSIONS

Axillary lymph node status is strongly correlated with the tumor dimension and the elapsed time between diagnosis and treatment. The numerous cases of axillary lymphadenectomy without lymph node metastases (43.55%), even in locally advanced cases, advocate for a wider application of lymphatic mapping and sentinel lymph node biopsy, to avoid the pathology associated with those axillary dissections.

[Surgical emergencies in elderly]

BACKGROUND

A higher number of elderly are seeking surgical care in the last years for different affections. The aim of the study was to analyze the characteristics of surgical emergency pathology in elderly and to establish several prognostic factors.

MATERIALS AND METHODS

We did a retrospective study on 22.803 patients admitted in the First and the Third Clinic of Surgery from Targu-Mures between 1999 and 2006. The data were statistically processed.

RESULTS

The elderly (> or =70 years) represented 15.10% of all cases and 20.70% of all emergencies. Almost half of them (47.80%) were admitted in emergency conditions, compared to only a third (32.53%) of the younger group. The malignancies represented 16.72%, meanwhile in the younger group only 6.98 %. Abdominal emergencies represented 83.59%, mostly due to intestinal occlusion and digestive hemorrhages. The operability ratio was 68%, close to the younger group (72%). The global mortality rate was 3.95%.

CONCLUSIONS

Surgical emergencies affect elderly in a higher percentage than the younger group. The emergency condition, the elder age and neoplasia are the most important factors of negative prognosis, and more important when they cumulate, increasing the mortality rate up to fivefold compared to the elderly admitted in elective condition.

[Intestinal obstruction caused by abdominal pseudotumoral endometriosis mimicking a peritoneal carcinomatosis--case report]

A 40-year-old woman was admitted in emergency condition with the symptomatology of bowel obstruction. Intraoperative findings consists of a pelvic fixed tumoral mass, and numerous other tumors spread in the whole abdominal cavity mimicking a peritoneal carcinomatosis without liver metastases. Three of the tumors where about 4 cm in diameter producing stenosis of the terminal ileurn and sigma. We considered the case as it was a peritoneal carcinomatosis caused by an uterus or ovarian cancer and we decided for palliative surgery, performing ileo-transversostomy and sigmoidostomy above the obstruction. The histopathologic findings from more pieces of tumors revealed endometriosis without cancerous changes. Postoperative the patient underwent cytostatic and then hormonal therapy. After 3 month the CT scan revealed an important reducing in volume of the pelvic tumoral mass and the barium enema didn't showed any stenosis under the colostomy so, we closed it extraperitonealy. At 16 month after the first operation the patient was reoperated for a parietal defect. At the second look we found no tumors. The pelvic tumoral mass has disappeared, the uterus seemed to be normal but two big ovary cysts were present. We performed bilateral adnexectomy and the repair of the parietal defect. Postoperative evolution was favorable without any complication or complains at 3 month after the last operation.

[Colon cancer in the experience of Surgical Clinic No. 1, Tîrgu-Mureş. Late postoperative results]

We analyzed the informations concerning the late postoperative evolution for 405 (60%) of 760 patients with colon cancer operated between 1968-1996 in the Surgical Clinic from Tg.-Mureş and we found a global 5-year survival rate of 35.57%. The conclusion after this study was that the most important worsening prognostic factors were the advanced stage evolution of the tumor and the occlusion. The females had a better prognosis than the males. The rural patients had a better prognosis than the urban. In our study the younger age isn't a worsening factor for survival. The patients with a longer history of the symptoms had an unexpected better survival rate than the others. Localization of the tumors at the site of the descending colon and flexures is an important negative prognostic factor. The penetrating feature of the tumor is more important than the lymphatic invasion for prognosis. Subtotal colectomy performed for stenotic tumors of the left colon, even in emergency for occlusions gave us one of the best 5-year survival rate (75%). The histopathologic type of undifferentiated carcinoma and the mucinous adenocarcinoma are associated with the poorest survival rate. The lymphoma has a better survival rate than the carcinoma. The perioperative blood transfusion, even though is associated with a low survival rate it is not an important prognostic factor.