[Pancreaticoduodenectomy for pancreatic head cancer, 54 cases]. / Duodenopancreatectomia cefalica in cancerul de cap de pancreas--consideratii asupra 54 cazuri.

UNLABELLED: Pancreatic cancer has an increase rate in western countries. From the first pancreaticoduodenectomy (PD) performed by Kausch in 1909, the value of the resection in the treatment of pancreatic head cancer was disputed. AIM: To assess the PD with or without pylorus preservation as surgical treatment for pancreatic cancer. METHODS: Retrospective review of the clinical records of patients undergoing PD for pancreatic cancer. RESULTS: From January 1995 till December 2005, in the First and Third Surgical Units, "St. Spiridon" University Hospital Iasi, Romania, were performed 137 PD. From these, 54 cases were histologic diagnosed with pancreatic cancer; 23 cases underwent pylorus preserving pancreatico-duodenectomy (PPPD) and 31 patients, classical Whipple procedure (PDW). Mean age was 59.07 +/- 1.42 years old (26-75 years old), and male to female ratio was 29 to 25. Jaundice was presented in 51 cases (94.4%), abdominal pain at 39 patients (72.2%) and Curvoisier-Terrier sign at 37 cases (68.7%). Fever was observe only in 4 cases (7.4%). Other biological and imaging parameters (e.g. main diameter of the biliary duct, tumor and wirsung ) were also discussed, but no significant difference was found between PPPD and PDW. Pancreatico-jejunostomy was performed in 41 cases (28 during the PDW and 13 in PPPD) and 13 pancreatico-gastrostomy (3 during PDW and 10 during PPPD). Mean operating time and mean blood loss in the PDW group were 358.22 +/- 10.53 minutes and 587.74 +/- 60.87 mL. After PPPD, these figures were 326.08 +/- 15.04 minutes and 571.74 +/- 90.50 mL, but no significant difference was noted. Delayed Gastric Emptying (DGE) was presented at 15 patients: 8 in PPPD group and 7 in PDW group (p=0.322). Postoperative morbidity rate (excluding DGE) was 33.33% (8 cases in PDW group and 10 in PPPD group). Pancreatic leak has a rate of 5.55% (3 cases--one in PPPD group vs two in PDW group), biliary leak has a rate of 12.96% (4 in PPPD group vs 3 in PDW group)and duodeno-jejunal anastomotic fistula appeared in one cases (PPPD). Acute postoperative pancreatitis is presented in one case (PPPD group) and postoperative hemorrhage appeared in 4 cases (2 in PPPD and 2 after PDW). Hospital stay was 19.91 +/- 2.28 days in PPPD group vs 18.87 +/- 2.24 days in PDW group (p = 0.751). Postoperative mortality rate was 5.5% (one case after PPD and 3 cases after PDW). Histological exam diagnosed ductal pancreatic adenocarcinoma in 51 cases (94.44%). Mean long-term survival rate was 20.98 months (10.52-31.45 months; 95 CI) and no difference was revealed between PPPD and PDW (log rank test - p = 0.796). CONCLUSION: PD should be performed for any pancreatic tumor even without preoperative histologic confirmation. The results after PPPD (postoperative morbidity and mortality, long-term survival) are similar to that following conventional Whipple procedure, if the principles of viable and tumor free margins are observed.

[The role of fine needle aspiration biopsy in differentiated thyroid carcinoma]. / Utilitatea punctiei cu ac fin in carcinoamele tiroidiene bine diferentiate.

UNLABELLED: Fine needle aspiration biopsy (FNAB) in evaluation of nodular goiter generated a true revolution. It is generally assumed that the use of FNAB reduces the number of surgical procedures by 50%, while doubles the proportion of carcinoma in surgically treated patients. The aim of the study was to demonstrate the utility of FNAB in preoperative diagnosis of thyroid carcinoma. MATERIAL AND METHOD: We have investigated 3240 patients with nodular goiter by FNAB (MGG stain and morphometrical analysis), followed by morphological examination in those who underwent surgery. RESULTS: Globally, FNAB had a good sensitivity (77%) and specificity (95%), which made an accuracy of 92%, proving its diagnostic value. In follicular carcinoma (FC), where the cytological diagnostic cannot be certain, morphometry helped the diagnostic: mean cells diameter was significantly higher (p < 0.001) in FC (9.5 mm) vs. thyroid adenoma (8.6 mm). CONCLUSION: With good statistical value, FNAB remain a useful preoperative diagnostic method.

[The role of lymphadenectomy in the treatment of differentiated thyroid cancer]. / Locul limfadenectomiei in tratamentul cancerului tiroidian diferentiat.

Papillary and follicular carcinoma represent almost 90% of the thyroid malignancies, being responsible for 70% of the mortality generated by thyroid cancer. Lymph node involvement, far more significant in the papillary form, increases the risk of local recurrence and affects long-term survival. Due to the lack of prospective randomised studies to assess the benefit of lymph node dissection in addition to total thyroidectomy, there is no consensus regarding the need of routine vs elective central compartment lymphadenectomy. Routine lymph node dissection of the central compartment is supported by the argument that it reduces the amount of neoplastic thyroid tissue and, therefore, optimises the effectiveness of radioiodine in DTC patients. Moreover, it provides an accurate staging by the detailed histopathological analysis and allows an optimal postoperative thyroid scanning. No additional morbidity of central lymphadenectomy is reported, compared to total thyroidectomy alone, if performed by a specialised surgeon. However, reinterventions for recurrence in the central compartment, carry a significantly higher risk of recurrent nerve and parathyroids damage. Unlike central compartment, it is generally agreed that lymphadenectomy of the lateral neck, as modified radical neck dissection, is employed when there is evidence of neoplastic lymph node involvement, wether macroscopic, imaging or by pathological data.

[Pancreaticoduodenectomy with or without pylorus preservation: a retrospective analysis of 137 patients]. / Duodenopancreatectomia cefalica cu sau fara prezervarea pilorului: analiza retrospectiva a 137 pacienti.

OBJECTIVE: We performed a retrospective study to assess the postoperative results, long-term survival and quality of life after pylorus preserving pancreaticoduodenectomy (PPPD) versus standard Whipple pancreaticoduodenectomy (WPD). METHODS: A retrospective study was performed in a nonselected series of 137 patients who were operated in the Surgical Clinics of "St. Spiridon" University Hospital Iasi, Romania, from January 1st, 1995 till December 31, 2005. Demographics, preoperative and intraoperative data, as well as postoperative morbidity, mortality and follow-up were analyzed. Quality of life, after to at least six months after discharge, was also studied. RESULTS: There were no significant differences noted in demographics data. Jaundice was more frequent in the PPPD group as for WPD patients (p=0.047). For the most patients the digestive reconstruction after resection were performed as in Child technique: the first anastomosis was pancreaticojejunostomy (end-to-end or end-to-side), the second anastomosis was hepaticojejunostomy (end-to-side) and the last anastomosis was gastrojejunostomy end-to-side (duodenojejunostomy in PPPD group). For 31 cases a pancreatico-gastrostomy were performed. We also noted 14 cases with pancreatico-gastrostomy and duodenojejunostomy end-to-end, and a Roux jejunal loop for 3 patients with previous gastrectomy and gastrojejunostomy (Reichel-Polya). The operating time was shorter in the PPPD group as in WPD (p < 10-3), but the mean blood loss was the same. Postoperative morbidity rate was 46.8% in PPPD group vs 39.2% in WPD (p > 0.05), but the reintervention rate was significant higher in PPPD group (30.6% vs 15%; p = 0.027). We also noted no significant differences of Delayed Gastric Emptying, postoperative mortality rate (14.5% in PPPD group vs 10.1% in WPD group) and mean survival time (42.42 months (24.94 - 59.89; 95% CI) in PPPD group vs 46.78 months (28.07 - 61.50; 95% CI) in WPD group; log rank test p = 0.643). Pathological exam diagnosed a malignancy in 109 cases (54 cases with pancreatic cancer); we noted chronic pancreatitis in 22 cases. Quality of life was also the same in the two groups. CONCLUSIONS: PPPD and WPD were associated with comparable results, but, there is a tendency of increase rate of postoperative morbidity and mortality for PPPD patients. We also noted that postoperative quality of life is the same for both procedures.

[A rare complication of colostomy]. / Complicatie rara a unei colostomii.

A case of a 64 years old female patient who had had a Miles operation 6 years ago for rectal cancer and at the present hospital admission she came in with a severe infection around her left colostomy. Initially, she presented a quite localized peristomal infection but, subsequently, the infection has evolved to an extensive necrotizing fasciitis of the abdomen, a large dehiscence of colostomy and severe sepsis. Repeated surgery and transverse colostomy, to put at rest infected left colostomy, plus aggressive medical treatment resulted in a good recovery, with the wounds healing and redo of the left colostomy. Now she is on the waiting list to get rid of the transverse colostomy.

Taylor's method: a therapeutic alternative for perforated gastroduodenal ulcer.

BACKGROUND/AIMS: In the context of actual trends towards an efficient and less aggressive therapy of peptic ulcer, it seems that Taylor's method, in selected cases of perforated gastroduodenal ulcers (PGDU), comes again into attention. The aim of this study was to present our 16 years' experience with Taylor's treatment as an efficient option for sealed perforated ulcers, and to highlight the indications and advantages of this method. METHODOLOGY: A retrospective study, and prospective since 1990, was carried out on a series of 64 patients out of 592 (10%) diagnosed with PGDU between 1987 and 2003. The patients were carefully evaluated, particularly looking for clinical, laboratory and imaging diagnosis factors, indicating potential candidates for conservative approach: short history, hydropneumoperitoneum in small amount on admission. Two thirds of the patients presented in the Emergency Unit less than 12 hours from the onset of the symptoms. The diagnosis of PGDU was established by corroborating the obvious symptoms and abdominal signs with erect chest X-ray and ultrasonography (US) of the abdomen. The efficiency of Taylor's method, consisting of nasogastric aspiration, fluids resuscitation, parenteral broad spectrum antibiotics and antisecretory drugs, was assessed by meticulous repeated physical examinations, dynamics of WBC (white blood cell) and US. In case of failure, this method remained as a part of preoperative treatment. RESULTS: The method was successful in 57 out of 64 (89%) cases of perforated peptic ulcer disease, selected from the 592 cases admitted with perforated peptic ulcer following the clinical and imaging criteria previously mentioned. The presence of pneumoperitoneum certifies the diagnosis of PGDU, but the amount of peritoneal fluid assessed by US predicts the success of the procedure. Seven patients developed complications (10.9%), mainly intraabdominal abscesses and only four of them needed surgical drainage. The mortality was nil. After discharge all patients were referred to gastroenterologists for monitoring the medical treatment and no recurrence was encountered. CONCLUSIONS: The Taylor's method is a reliable alternative in selected cases of perforated gastroduodenal ulcers, the main advantage being the avoidance of anesthetic and surgical stress with their potential morbidity and mortality.

[The assessment of empiric antibiotherapy in acute secondary peritonitis]. / Evaluarea tratamentului antibiotic empiric în peritonitele acute secundare de cauza, digestiva.

UNLABELLED: The adequate use of antibiotics, according to the international guidelines of antimicrobial therapy, is, in addition to surgery, an important part of the management of intra-abdominal infections. The aim of the study was to assess the efficacy of empiric antibiotherapy in acute peritonitis of digestive cause. MATERIAL AND METHODS: A retrospective study was carried out on a series of 75 cases of acute peritonitis, admitted in the IIIrd Surgical Unit, in the period 2003-2005. Perforated duodenal ulcer was the cause of diffuse peritonitis in 46 % of the cases, followed by acute appendicitis (31%) and traumatic perforation of the small bowel (11 %). The most frequent bacteria encountered was E. coli (62 %), while Klebsiella, Enterobacter and Acinetobacter were present in nearly 8% of the cases. Ertapenem as single agent was preferred in 36.8% of the patients and an association of third generation cephalosporins or aminoglycoside with metronidazole in 33.4%. RESULTS: the efficiency of the treatment was assessed in regard to clinical (fever) and laboratory (leucocytosis) data, the duration of treatment and hospital stay. The outcome was appreciated as good in almost 73% of the patients treated with ertapenem, and 52% respectively for combined therapy. CONCLUSION: the authors recommend the use of penems as monotherapy in the empiric treatment of acute peritonitis following digestive perforation.

[Necrotizing fasciitis]. / Fasciita necrozanta.

The management of a right foot necrotizing fasciitis and severe sepsis in an old diabetic patient is presented. The early and aggressive surgery, adequate antibiotherapy and correction of organic disfunction (cardio-circulatory, renal, respiratory) eliminated the vital risk and resulted in a satisfactory morpho-functional recovery of the foot.

[Acute surgical pathology in elderly patients]. / Aspecte ale chirurgiei de urgenta la pacientul vârstnic.

The consequence of demographic aging is an increase of surgical pathology of the elderly, concerning both number and complexity of the cases. To asses the nature of geriatric surgical pathology and the effect of co-morbidities on surgical outcome, a retrospective study was carried out on a series of 401 patients aged over 75, treated in the IIIrd Surgical Unit in the period 2002-2003. 132 patients were admitted as acute cases and 94 of them were operated: 62 required immediate surgery and 32 required delayed operations. According to the nature of the diseases, benign surgical conditions were encountered in majority of the cases (78 cases). The diagnostics requiring immediate operations were: complicated hernias, perforated peptic ulcer, lower limb acute ischemia. Delayed emergency operations were performed for: acute cholecystitis, biliary lithiasis with angiocholitis and complicated gastric cancer. Cardiovascular pathology was recorded as the most frequent co-morbidity. Hospital mortality rate of 32.9% resulted mainly from cases with mesenteric infarction and generalized peritonitis, as well as from delayed emergencies such as complicated gastric and colon cancer. The most frequent causes of death following surgery were: cardiac failure, sepsis and multiple organ failure.

[Differentiated thyroid cancer--staging and prognostic systems]. / Cancerul tiroidian diferentiat stadializare si sisteme de scor prognostic.

Differentiated thyroid cancer (DTC), including papillary and follicular carcinoma with histological variants, has an excellent prognosis; nevertheless a subset of these tumours is clinically aggressive and, in some patients, fatal. Treatment of DTC remains controversial, regarding the extent of primary surgical resection, the need for lymph node dissection and the role of postoperative radioactive iodine ablation. In addition to the widely accepted TNM classification, recognition of significant risk factors and developing of staging systems, such as AMES, AGES, MACIS, MSKCC and NTCTCS, has helped to identify the patients with a potential aggressive course of the disease and high risk of recurrence. This has allowed the development of a rational and selective approach to therapy, thus, avoiding excessive treatment and subsequent morbidity without compromising the oncological outcome.

[Differentiated thyroid cancer--peculiar morphological and clinical forms]. / Cancerul tiroidian diferentiat forme anatomoclinice particulare.

The most common clinical presentation of differentiated thyroid cancer (DTC), consisting of papillary and follicular adenocarcinoma (with their histological variants), is the solitary thyroid nodule. A review of the literature is performed in order to describe particular forms of DTC, in terms of incidence, diagnosis and treatment: occult carcinoma, carcinoma on aberrant thyroid tissue, "functional" thyroid carcinoma and familial non-medullary carcinoma. A particular interest is shown to the coexistence of malignancy with benign thyroid diseases, such as goiter, hyperthyroidism and Hashimoto's thyroiditis, as well as parathyroid adenoma. In conclusion, the authors emphasize that the association of carcinoma with benign thyroid conditions is not rare and it substantiate an aggressive approach in regard to diagnosis and treatment, increasing the indication for surgery and, moreover, for total thyroidectomy.

[Laparotomy in the treatment of severe intraperitoneal infections]. / Laparostomia în tratamentul infectiilor grave intraperitoneale.

A retrospective clinical study was carried out on a group of 18 patients with severe intraperitoneal infections due to various causes. The decision to use laparotomy was supported by the severity of sepsis (APACHE II score varied from 14 to 30), highly septic peritoneal fluid, the features of peritonitis, patients with impaired immunity. Open packing was realized with a Dacron mesh sutured to the fascial margins, associated with multiple peritoneal drainage in all cases. Postoperative mortality was 50%, mainly to rapid evolution of septic shock, unresponsive to intensive care support. Secondary suture was performed after granulation of the wound, on the day 14-21 postoperatively followed at 3-4 months by definitive repair of the abdominal wall in 2 cases. Laparotomy proved to be an efficient treatment in severe peritonitis, that should be used prior to irreversible phases of septic shock.

[Choledochal malignant hemorrhagic cyst, with cholangitis]. / Angiocolita supurata pe un chist coledocian hemoragic, degenerat malign.

The increased risk of cholangiocarcinoma in patients with congenital cystic disease of the biliary tree is well documented. The reason for the malignant transformation is taught to de related to chronic inflammation and bacterial exposure within bile ducts. Total excision of the choledochal cyst notably reduces the risk of cancer. Five to twenty percent of adult patients with unexcused cysts or treated with by pass will develop cholangiocarcinoma. We are presenting the case of a young female diagnosed with a choledochal cyst at age of four, treated with by pass procedure. Fourteen years later she presented with a severe angiocolitis, hemorrhage and malignant transformation within the cyst.

[Completion gastrectomy associated with pancreaticoduodenectomy]. / Totalizarea gastrectomiei asociata cu dudenopancreatectomie cefalica.

The authors present the case of a male patient, aged 56, operated (partial gastrectomy) for peptic ulcer 20 years ago, who is admitted for epigastric pain and distension, frequent vomiting, asthenia and weight loss. Physical examination, barium meal and upper digestive endoscopy with biopsy established the diagnosis of carcinoma of the gastric stump, due to malignant transformation of adenomatous polyps, with duodenal invasion. Completion of gastrectomy and pancreaticoduodenectomy was performed, with good postoperative results. Although the extent of resection may appear excessive, our attitude was justified by the features of the lesion and good biological condition of the patient.