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.

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.

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.

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.

"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.

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.

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.

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.

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.

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.

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.

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.

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?

Gallstone disease in young population: incidence, complications, therapeutic approach.

OBJECTIVE: The purpose of this study is to highlight the high incidence of gallstones and the etiology in young people, as well as the fact that the onset is associated with complications: i.e. acute pancreatitis, jaundice. MATERIAL AND METHODS: This retrospective study was conducted between January 2007 and February 2012 on patients admitted to the two surgical wards of Pitesti District Hospital and was based on the analysis of observation charts and theatre records. A total of 1905 cholecystectomies were performed, 1023 laparoscopic and 882 classic, respectively. RESULTS: A total of 36 patients aged between 16 and 25 years were included in the study. Laparoscopic cholecystectomy was performed in 34 patients, only two patients being operated by the classical open approach. 6 patients developed postoperative jaundice, which resolved under medical treatment in 3 patients within 3-5 days. The remaining 3 patients underwent endoscopic retrograde cholangiopancreatography (ERCP) 4-5 days postoperatively. CONCLUSIONS: The most important risk factors for gallstones are: age, female gender, pregnancy and obesity. Common complications of gallstones in young people are: duct stones and acute pancreatitis.

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.

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.

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.