Prophylactic Percutaneous Endoscopic Gastrostomy (PEG) - The Importance of Nutritonal Support in Patients with Head and Neck Cancers (HNCs) or Neurogenic Dysphagia (ND).

BACKGROUND: We evaluated the effectiveness and safety of prophylactic PEG performed for the enteral nutrition support during the oncological treatment of patients with HNCs and as a part of the management of neurological patients experiencing neurogenic dysphagia. METHODS: In 2013 we followed up on a group of 23 HNC patients subjected to prophylactic PEG. We assessed the duration of the procedure, intraprocedural incidents and their causes, time to tube-refeeding and discharge after intervention, post interventional analgesia, early and late complications,toleration, costs and postoperative course of these patients after radical surgery maintaining PEG in place. In parallel we followed up on a group of 10 neurological patients who have undergone a PEG placement to improve the nutrional status and to prevent recurrent chest infections due to ND related silent aspiration. RESULTS: The procedures were performed under sedation with Midazolam and the mean duration was about 7 minutes.Postoperative analgesia was minimal. Refeeding through the tube was initiated 2-4h hours later and the patients were discharged 12-24h after the procedure. Early complications were not observed and later we noted 2 cases of peristomal infections, succesfully managed conservatively. After oncologic surgery we noted 2 (8.69%) pharyngocutaneous fistulas.Conservative care obliterated the fistulas at 6 weeks, maintaining the feeding tube in place. We also compared the results with a group of 27 patients fed through the naso-gastric tube and a group of 20 cases with open gastrotomy-tube prophylactically inserted. The 10 neurological patients had varied conditions but degenerative diseases like motor neuron disease (3 cases" 30%) and multiple sclerosis (2 cases -20%) took the lead we encountered one case of peristomal infection and one case of tube blockage resolved by replacement. We evaluated the nutritional status by controling the weight of these patients before and after PEG placement. A mean weight gain of 3.1 kg(range 1.2 â€" 7) was documented. CONCLUSIONS: PEG is a simple minimmaly invasive procedure performed safely under sedation. It takes a very short time and is virtually free of major complications. The requirements of analgesics are minimal. The refeeding is started early and the tube is well tolerated by the patient. PEG has an important role in the conservative healing of pharyngocutaneous fistula.PEG is the procedure of choice for the neurological patients.It prevents weight loss and aspiration pneumonia in patients with neurogenic dysphagia with a low rate of complications.

CT vs. MRCP in choledocholithiasis jaundice.

RATIONALE: Obstructive jaundice can raise problems to diagnostic imaging. The radiologist must choose the most appropriate examination that delivers the most important diagnostic information because the differences between a lithiasic obstruction and a tumoral one are vital. This information helps the surgeon speed up the process of decision-making, because the treatment may be very different in relation to the nature of the obstruction. OBJECTIVE: This study tries to demonstrate the diagnostic accuracy of computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP) in detecting the obstacle in the common bile duct (CBD) and the possibility of establishing the lithiasic nature of the obstruction. METHODS AND RESULTS: A retrospective analysis was analyzed during an interval of 18 months that included jaundice patients admitted in the General Surgery Department of "Coltea" Clinical Hospital. They were examined by CT scanning and by MRCP, being suspected of choledocholithiasis. 63 patients were included in the study, 34 females and 29 males. 33 CT scans and 30 MRCP exams were performed. DISCUSSION: CT scan is useful in detecting residual or iterative choledocholithiasis in patients after cholecystectomy, contrast enhanced CT (CECT), being able to differentiate between lithiasic and non-lithiasic obstruction. MRCP delivers important anatomic details of the biliary tree; it is superior to CT in diagnosing the hepatocholedochal lithiasis; MRCP tends to replace endoscopic retrograde cholangiopancreatography (ERCP)--the diagnostic "gold standard" reducing the number of unnecessary invasive diagnostic procedures.

Multimodal treatment of aggressive forms of breast cancer.

UNLABELLED: Aggressive breast cancer is an invasive form with G3, G4 differentiation degree, the absence of receptors for estrogen and progesterone and the absence or presence of HER2 (+ or 3+) gene. The final diagnosis is established by cumulating the clinical, paraclinical, histopathological and immunohistochemical diagnosis. MATERIAL AND METHOD: 84 out of 268 aggressive breast cancer cases were presented in the study, which were operated in October 2011-September 2013. The inclusion and exclusion criteria are exposed in the study lot and the treatment schemes. RESULTS: For the study lot (lot A made up of 36 cases, lot B made up of 41 cases, lot C made up of 7 cases) the distribution was presented on age groups, histopathological and immunohistochemical classification, etiologic factors, type of surgery, postoperative staging and complications. CONCLUSIONS: The treatment of aggressive breast cancer depends on the level of the aggressiveness of the disease, the biologic status and the age that imposes the order of chemotherapy, radiotherapy, surgical treatment and target therapy.

Localisation and preservation of the autonomic nerves in rectal cancer surgery - technical details.

Iatrogenic surgical injury to pelvic autonomic nerves followed by genitourinary dysfunctions are well known problems after total partial mesorectal excision for rectal cancer. The purpose of our paper is to present the useful anatomical landmarks for a safe nerve-sparing surgery in rectal oncology. Over the course of a total mesorectal excision we describe and illustrate the key risk zones of autonomic nerve injury based on our experience in rectal surgery and on the revised literature.

Temporary protective loop ileostomy in open low rectal resection -- an alternative technique.

The paper presents a simplified method for performing a temporary protective loop ileostomy as a result of our experience in 33 cases of low rectal resections for cancer.The particularities of this technique are: the skin incision is smaller than the muscle one, the seromuscular layer of the loop is fixed at the skin level only by marking a small portion of the antimesenteric wall, with no mucosal eversion. No supporting rod is used. The reversal requires resection of the thickened freemargins and enterorrhaphy. It involves a direct approach and avoids median laparotomy and segmental bowel resection.There was no case of peristomal abscess, bleeding, prolapse,retraction of the loop after the stoma was formed. Four patients(12.12%) had peristomal dermatitis. Five patients (15.62%) had high output fluid losses with electrolyte disorders, one of them(3.12%) with acute renal failure. Closure was performed after 6 weeks on average for the colorectal anastomoses and 10 weeks for the coloanal ones. We recorded a case (3.12%) of enterocutaneous fistula that was managed conservatively and 4 cases(12.12%) of incisional hernia, all of them surgically treated. No mortality was attributed to either creation or closure of the temporary loop ileostomy. It is a simple and fast technique in accordance with the temporary character of its indication.

Laparoscopic treatment of a hepatic subcapsular abscess secondary to gallbladder perforation: case report.

We present a rare case of type II Niemeier gallbladder perforation(GBP) developed as a complication of acute calculous cholecystitis. A 76-year-old man was admitted to our surgical unit with the presumptive diagnosis of acute cholecystitis. CT scan revealed a subcapsular collection developed on the visceral surface of the right hepatic lobe. It was communicating through a thin hypodense band with the cystic duct, distal to an impacted stone. Through laparoscopy the collection was confirmed to be a subcapsular liver abscess secondary to GBP.The cholecystectomy and the abscess cavity treatment were completely handled via laparoscopic approach. The paper demonstrates that laparoscopic approach can be a safe and feasible method in order to treat both the cause and the complication in this situation. Early diagnosis and appropriate minimally invasive approach are the key to manage this rarity.

The role of immunohistochemical tests in multimodal treatment of the aggressive forms of breast cancer.

UNLABELLED: Aggressive breast cancer is an invasive form with a differentiation degree G3/G4, the absence of estrogen receptor and progesterone and the absence or presence of the gene HER 2(+ or 3+). The immunohistochemical tests have an important role in establishing the diagnosis and the therapy. MATERIAL AND METHOD: It was shown that the aggressive breast cancers, 97 out of 316 cases were operated in the period October 2011 - February 2014. The criteria of inclusion/ exclusion in the study groups and the treatment schemes were exposed. RESULTS: For the study group (group A=43/ group B=45/ group C=9 cases), the distribution according to the age group and immunohistochemical classification, were shown and, histologically, the type of surgical intervention, postoperative staging, postoperative complications were highlighted. CONCLUSIONS: The treatment of the aggressive forms of breast cancer, neoadjuvant and adjuvant can both be set only by IHC tests.

Analysis of several BRCA1 and BRCA2 mutations in a hospital-based series of unselected breast cancer cases.

BACKGROUND: The distribution of BRCA mutations varies significantly between populations. The spectrum of BRCA1 and BRCA2 mutations in breast cancers in the Romanian population is incompletely known. The aim of the present study is to investigate the presence of nine BRCA mutations in patients with breast cancer identified in a surgical clinic from Bucharest. METHODS: Unrelated women diagnosed with breast cancer from Coltea Hospital (n=114) and healthy controls (n = 150) were selected for this study. Seven mutations in BRCA1 (185delAG, 5382insC, 943ins10, E1250X, 1294del40, E1373X, R1443X) and two in BRCA2 (IVS16-2A4G and 6174delT) were tested using PCR based protocols. In addition, the presence of BRCA1 185delAG, BRCA1 5382insC, BRCA2 6174delT mutations were tested with a post amplification mutation detection system, based on the ELISA method. RESULTS: Two patients with sporadic breast cancer (2%) and one patient with family history of the disease (7.14%) have the BRCA1 5382insC mutation. No other mutation was detected in patient and control groups. The mutations were not present in the control lot. CONCLUSIONS: Our results indicate that BRCA1 5382insC is a common mutation in Romanian women with breast cancer (3 114).

The use of gastrostomy procedures in HNC patients.

PURPOSE: To analyse the gastrostomy procedures performed in HNC patients admitted to Coltea Clinical Hospital in order to underline the similarities and differences to the data published worldwide. PATIENTS AND METHODS: Our retrospective study contains 64 HNC cases that met the inclusion criteria between 2008 and 2011. RESULTS AND DISCUSSIONS: The study group presents numerous specific characteristics (a larger number of cases aged over 55 than younger patients; elective use of classic gastrostomy instead of newer techniques; approximately two thirds of the gastrostomies were performed in patients with laryngeal carcinoma; only one third approximately of the cases benefited from prophylactic gastrostomy; etc.). CONCLUSIONS: 22% of the gastrostomies were made after the appearance of a pharyngocutaneous fistula. Therefore we will begin a future prospective study in order to ascertain the value of prophylactic PEG in preventing the appearance of pharyngocutaneous fistulas.

[Synchronous gastrointestinal stromal tumor (GIST) and multiple digestive neoplasms, benign and malignant]. / Tumora gastro-intestinala stromala (GIST) asociata sincron cu multiple neoplazii digestive benigne, precursoare si maligne.

Gastrointestinal stromal tumors (GIST) are a broad category of mesenchymal, non-epithelial primary tumors of the digestive tract, located in the wall of hollow viscera, from the esophagus to the anus and often in adjacent mesentery and omentum. They are clinically unpredictable (may be discovered incidentally during an imagistic investigation or during surgery for other pathological entity, or at necropsy) and also have an unpredictable behavior (GISTs with very low risk, with low or moderate malignancy, which have benign histopathologic features but can recurr or can metastasize). The case we present here represents a rare association between a synchronous gastrointestinal stromal tumor (GIST) and multiple gastric benign and malignant tumors.

Conservative surgery for borderline ovarian tumors--emphasis on fertility preservation. A review.

BACKGROUND: Borderline ovarian tumors account for 15-20% of all ovarian epithelial tumors. Since their original description in 1929, our knowledge of their natural history and molecular pathology has advanced most dramatically over the last two decades. This improved knowledge of BOT has permitted to drastically decrease the therapeutics of these tumors, which remains mostly surgical. METHOD: We studied the available literature on surgical management of BOT accentuating the most important aspects on this topic: radical vs. conservative treatment, fertility preservation. RESULTS: Although there are conflicting reports about some of the aspects of surgical management of these tumors, since BOTs commonly affect women of reproductive age, who have not completed childbearing, have an excellent overall prognosis and the majority of them (approximately 50% to 85%) are stage I at diagnosis, conservative surgery (unilateral salpingo-oophorectomy or cystectomy) can be safely performed after comprehensive surgical staging, in order to preserve fertility. CONCLUSION: Conservative surgery could be safely performed in young patients treated for BOT, provided that they are carefully followed-up.

MTRR polymorphism and the risk for colorectal and breast cancer in Romanian patients--a preliminary study.

BACKGROUND: The risk of colorectal cancer (CRC) and breast cancer (BC) is influenced by polymorphisms located in the genes encoding enzymes of the folate pathway. The aim of this study was to evaluate if A66G MTRR (rs1801394) polymorphism is involved in predisposition for colorectal and breast carcinogenesis in Romanian patients. MATERIALS AND METHODS: In the present case-control study, 300 individuals divide in four groups: sporadic CRC patients (n = 120), control CRC (n = 60), BC patients (n = 60) and control BC (n = 60), were genotyped by PCR-RFLP method. RESULTS: Frequency of genotype AA was 11.7% in CRC control and 5% respectively in BC control. For cancer groups the frequency of genotype AA was 9.2% in CRC and 0% in BC. CONCLUSIONS: Study results do not demonstrate an association between A66G MTRR polymorphism and CRC or BC in Romanian patients.

[Three centuries of surgery at Coltea Hospital]. / Trei secole de chirurgie la Spitalul Coltea.

The authors present the evolution of surgery at Coltea Hospital during the last three centuries. After a brief history of the Coltea hospital and its masters surgeons, the attention is drawn on the masters efforts to optimize the care, equipment and surgery techniques, things that became of national and world-wide importance.

[Adenoid cystic carcinoma of the breast--two case reports]. / Carcinom adenoid chistic mamar--prezentare a doua cazuri.

Adenoid cystic carcinoma is a rare type of breast carcinoma with a good prognosis. It represents less than 0,1% of breast carcinomas. We present two cases of adenoid cystic carcinoma diagnosed in the Surgical Department of Coltea Hospital in the last 3 years. The first case is a 66 years old patient with a breast tumor that has clinical and imagistic features compatible with a benign diagnosis. The frozen sections established the diagnosis of adenoid cystic carcinoma, confirmed by histopathologic examination of paraffin embedded tissue and immunohistochemistry. The second case is a 68 years old patient with a breast tumor located in the central quadrant of the left breast, with skin infiltration. Preoperatory fine needle aspiration is sugestive of a papillary tumor, so the cytologic exam cannot establish malignancy. The frozen sections established the diagnosis of ductal invasive carcinoma and histopathologic examination of paraffin embedded tissue and immunohistochemistry established the diagnosis of adenoid cystic carcinoma associated with ductal invasive carcinoma grade I and adenomyoepitelioma. The cytology had a false papillary aspect, in fact there was amorphous material contained in pseudoluminal spaces. In both cases the treatment was surgical resection with tumor excision and free resection margins. In the second case lymphadenectomy was also performed.

[Umbilical hernia in adults: laparoscopic approach with prolene mesh--is it a safe procedure?]. / Hernia ombilicala (HO) la adult: plasa de prolene montata laparoscopic este un procedeu eficace?

INTRODUCTION: The laparoscopic approach for umbilical hernia is more and more used, but few results are reported. The aim is to evaluate the efficacy and safety of using the Prolene mesh placed laparoscopically in umbilical hernia treatment. MATERIAL AND METHOD: Between 2004-2006, 21 patients with umbilical hernia, aged of 34 to 77 years, were submitted to intraperitoneal application of a Prolene mesh to cover the umbilical ring. The mesh was sewed by Protack staples or transfascial stitches. Before deflating the patients, the greater omentum was interposed between the mesh and the bowel. It is notice that 8 patients were obese, 6 patients had omental or bowel adhesions to the peritoneal sac and 5 patients had ascites due to liver cirrhosis. The patients were discharged 24 to 48 hours after the operation and followed up for 6 to 12 months. RESULTS: All patients were alive at the end of follow-up, without hernia recurrence or complications due to the Prolene mesh in the abdominal cavity. In 3 patients we registered subcutaneous seromas for 1 to 3 weeks (imposing evacuation by punction) and 5 patients kept a mildly deformed umbilical scar after the cure of large hernias. DISCUSSIONS: In the literature are mentioned the techniques using composite or two-layers meshes. Prolene meshes are not agreed by some authors, for the supposed risk of bowel lesions. In our trial were no such complications. CONCLUSION: Laparoscopic repair using Prolene intraperitoneal mesh in umbilical hernia is a safe, efficient and rapid method, avoiding infections complications in obese or cirrhotic patients.

[The sentinel lymph node technique in colorectal cancer using in vivo dye--utility and limits]. / Ganglionul santinela in cancerul colorectal folosind colorant intravital--utilitate, limite.

The aim of this work is to analyze the importance of sentinel lymph node technique in the treatment of colorectal cancer. There are presented data from literature concerning sentinel lymph node, especially papers about the place of sentinel lymph node method in the treatment of colorectal cancer. This work also shows the experience of Surgical Clinical Department of Coltea Hospital in the use of sentinel lymph node method in colorectal cancer (8 patients with colon cancer and 9 with rectal cancer). There are presented the criteria for inclusion in the study group (26 patients initially proposed for the study) and the exclusion criteria, the diagnostic method using an in vivo dye and the pathology study. The study of the literature and our experience leads to the conclusion that the identification of the sentinel lymph node in colorectal cancer doesn't modify the dissection of the lymphatic area. This procedure may change the adjuvant treatment for colorectal cancer. The discussion is still open concerning the importance of lymphatic micro metastases found by RT-PCR and immunohistochemistry methods. More studies are necessary to clarify these problems.