True and false incomplete duplications of the common bile duct and their impact on therapy

The congenital anomalies of the common bile duct (CBD) represent a real challenge for the surgeon, and not recognizing them may have two consequences: either generate incomplete or incorrect surgical solutions, or, even worse, lead to iatrogenic pathology. The association between the anomalies of the CBD and biliary lithiasis, biliary cancer or other hepatobiliopancreatic pathology may lead to a pre/perioperative diagnosis; frequently, the incertitude persists. We present 2 cases: one with an incomplete duplication of the CBD and the other with a false duplication. We wish to underline the sovereign value of cholangio-MRI with 3 D reconstructions in the diagnosis and description of the anatomy of the biliary ducts, superior, in some cases, to the intraoperative cholangiography or ERCP.

The 10 years' experience in the laparoscopic treatment of benign pathology of the eso gastric junction

In the era of mini invasive surgery, the surgical approach of the esogastric junction occupies an important role, which regards both the results and the complete, long-term patient satisfaction.The main benign pathology of the esogastric pole includes hiatal hernia, gastroesophageal reflux disease, cardiospasm, oesophageal diverticula. The present study is based on the experience of our clinic in the laparoscopic treatment of esogastric pathology that contains 85 patients in 10 years. Out of these, 15 were operated on for cardiospasm, 29 for hiatal hernia and 41 for gastroesophageal reflux disease (GERD). The investigation protocol consisted in barium swallows and endoscopy, both pre and postoperatively. The results obtained allowed us to underline the superiority of the surgical treatment over the medical one. Likewise, medical literature reports rates of success of 90% in antireflux surgery. The latter is conditioned by correct determination of the reflux causes and by the choice of the adequate time to perform the surgery, in concordance with the local anatomical conditions. As far as the two techniques used (complete or partial fundoplication) are concerned, there were no significant differences in the postoperative evolution of the patients, but we have to mention, nevertheless, the increased incidence of dysphagia after Nissen. The data presented confirm the superiority of laparoscopic surgery over the classic one, due to the superior aesthetic result, the shortened admission time -with reduced costs and rapid social reinsertion.

Postradiotherapy regression--a prognostic factor in rectal neoplasm

Preoperative radiotherapy is standard procedure in rectal cancer treatment protocols. Experience and analysis of clinical and laboratory features of the results of this procedure have established that the response to radiotherapy, in order to reduce the volume of tumor and adenopathies of stations I and II is highly variable, from complete disappearance of the tumor mass, to the lack of response. The response to radiotherapy in conjunction with pathological and immunohistochemical data could allow assessment of prognosis in the rectal cancer. For this purpose we have proposed conducting a clinical trial to examine the tumor grading, immunohistochemical markers, and possible genetic changes that allow assessment of the degree of post-radic regression and the postterapeutic prognosis. Based on these criteria would be possible to establish a group of regression in which the patient stands still from the pretherapeutic phase. In this way the type of the presurgical radiation would shade, sometimes this standard being made ineffective. We come with a lot preliminary statistics, with the value of working hypothesis.

Retropancreatic approach in the treatment of pancreatic suppurations

The authors present an additional retropancreatic access path used in the treatment of suppurations that are subsequent to severe acute pancreatitis. The approach utilized by them, namely the submesocolic one, involves the performance of the decollement and reclining to the right of Treitz's angle, thus granting full access to the pancreatic compartment situated to the left of the superior mesenteric vascular pedicle. The indication for the use of this retropancreatic approach is determined on CT scan criteria, after receiving the data offered by the oral and intravenous contrast media. The ratio between the collections and Treitz's angle can be evaluated accurately. The usage of this access path is not isolated, classical approaches being concomitanlty used as a rule through the omental bursa and the retroduodenopancreatic approach. The method presented is meant to complete the range of already accepted approaches and offer some guarantee with regard to the decrease of retropancreatic suppurative processes, with the purpose of reducing either planned or selective reinterventions. The experience of the authors is still limited (12 cases), and their presentation must be appreciated as a preliminary note which impels to reflection upon a complete debridement of suppurated necroses. It offers a short and direct path to the retropancreatic space, which is often impossible to reach through the wide access path of the omental bursa.

[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.