Retrosternal goiters.

UNLABELLED: The term of retrosternal or substernal goiter means that more than 50% of thyroid gland descends in the thorax. MATERIAL AND METHODS: There is a retrospective study on retrosternal and substernal goiter and its patological features among 2482 patients who underwent thyroidectomy between 2000 and 2010 in the First Surgery Clinic of Iasi. Retrosternal goiter was identified 54 patients (2.17%). All patients were refered to surgery from the Clinic of Endocrinology. RESULTS: Mean age at diagnosis was 55.3 +/- 3.58 years, and most cases were found in women (83.3%). The clinical pictures of retrosternal goiter was dominated by compressive disorders. Thyroid function abormalities were identified by hormonal assays performed on Endocrinology Clinic lasi in 15 cases (27.7%). The diagnosis of retrosternal goiter was suggested by clinical examination and confirmed by imagery: thorax X ray, ultrasonography, CT scan. The cervical approach was being safely performed. Only in 8 cases (14,8%), sternotomy was necessary. There was no mortality and morbidity was 5.5% (3 cases). The length of stay in the hospital was 4.3 days. We compared our recent data with a previous report on retrosternal and thoracic goiter treated in First Surgery Clinic of lasi during 1950 to 1979 and published in the journal "Chirurgia" in 1981. CONCLUSIONS: Retrosternal goiter is a particular form of thyroid surgical pathology presentation with declining incidence. Diagnosis and treatment of retrosternal goiter involve a multidisciplinary team. The endocrinologist has an important role in diagnosis and postoperative follow-up. Surgery is the treatment of choice for substernal goiters, but there are still some controversies on surgical approach, and complication rate. The cervical approach can be safely performed in almost all cases but when required, sternotomy should be performed without hesitation.

Familial syndromic papillary thyroid carcinoma report of two cases.

AIM: to describe two cases of familial papillary thyroid carcinoma. MATERIAL AND METHODS: patients were investigated by fine needle biopsy, MRI imaging and tumor biopsy, (first case) and histological examination of colonic and thyroid tumors (first case) and histological examination of thyroid tumor (second case). RESULTS AND DISCUSSION: case presentation: first case, 68 years old man had a colonic polyposis (attenuated form with only a few polyps) and a thyroid nodule. After hemicoleCtomy for a supposed colonic carcinoma with liver and lung metastases, histological examination revealed no malignant colonic disease. Two month later the diagnosis of invasive thyroid tumor with lymph node metastases was made, but only an open biopsy was done because tumor invasiveness demonstrated on MTI imaging. The biopsy identified a papillary thyroid carcinoma. Case 2: the son of the patient (30 years old) without known diseases was invited to be assessed for thyroid disease. Ultrasound examination discovered a large nodule with microcalcifications. Microscopic examination done after total thyroidectomy revealed a cribriform morular variant of papillary thyroid carcinoma, a variant that is known to be associated with FAP. Radioiodine ablation was made followed by suppressive thyroxine treatment. In the second case adenomatous polyposis was not found yet. In our knowledge these are the first cases of familial thyroid papillary carcinomas in our setting. Familial history allowed an earlier diagnosis and a good management of the disease in the second case. CONCLUSIONS: according to the literature and our first experience, screening for thyroid cancer must be done in all patients with FAP and in those with a FAP proband in the family.

[Parathyroid glands involvement in multiple endocrine neoplasia]. / Interesarea paratiroidelor in neoplaziile endocrine multiple.

UNLABELLED: Multiple endocrine neoplasias are syndromes characterized by the involvement of at least two endocrine glands. Parathyroid gland involvement is usually noted in Multiple Endocrine Neoplasia (MEN) type I and type II. Parathyroid glands tumor associated with endocrine pancreatic tumor, as well as pituitary tumors is the typical pattern of MEN I. The parathyroid gland is the most frequent abnormality in MEN I. CASES REPORTS: We presented five cases with MEN I and parathyroid glands involvement. In three cases with young ages (28-33 years old) and familial setting, the MEN I syndrome was "complete" (parathyroid adenoma, gastrinoma or insulinoma and pituitary adenoma--prolactinoma or GH-secreting tumors), and, in the other two cases, with 57 and 68 years old respectively, the MEN I syndrome was "incomplete" with parathyroid glands and pituitary gland involvement. The cases with gastrinomas were operated in emergency for complication of peptic ulcer (perforation associated with peritonitis and gastro-intestinal bleeding); then the pancreatic tumors were diagnosed and left pancreatectomy with spleen preservation and respectively, tumor resection have been performed. Hyperparathyrodism was then diagnosed and subtotal parathyroidectomy has been performed in both cases. Unfortunately one patients died due to severe endocrine disorder. During the necropsy, the pituitary adenoma has been diagnosed. The third case with "complete" MEN was a women of 33 years old, admitted for severe hypoglycemia. The imagistic and laboratory test diagnosed a tumor situated into the pancreatic body, and an parathyroid adenoma. The resection of pancreatic tumor associated with resection of the parathyroid adenoma, in the same time, were performed. The other two cases with "incomplete" MEN were older then the first patients, and were diagnosed with hyperparathyrodism and pituitary gland tumor. The resection of parathyroid gland adenoma has been performed in both cases, with uneventful postoperative course. The literature data was also discussed. CONCLUSIONS: The parathyroid glands involvement in MEN is common. There are two kinds of MEN associated with parathyroid gland involvement: the "complete" form, especially in young patients, with diffuse involvement of the parathyroid glands, and the subtotal parathyroidy is the best choice, and the "incomplete" form, especially in elderly, with the involvement of a single parathyroid gland; in this way, the resection of the adenoma associated with biopsy from the other parathyroid gland is the best approach. The presence of gastrinomas, complicate the disease prognosis and the surgical approach. The treatment of these patients is challenging and has to be done in multidisciplinary team.

Superior mesenteric artery syndrome: an unusual case of intestinal obstruction.

Superior mesenteric artery (SMA) syndrome is an uncommon cause of proximal intestinal obstruction, frequently occurring in patients who have had an important weight loss. The diagnosis can be difficult and usually is made by exclusion. The most characteristic symptoms are postprandial epigastric pain, fullness, voluminous vomiting and eructation. These symptoms are due to the compression of the third portion of the duodenum against the posterior structures by a narrow-angled SMA and surgical management is necessary. We report a case of SMA syndrome in a 23 year old patient, with a long history (since childhood) of voluminous vomiting, epigastric pain and an important weight loss. We performed small bowel enteroclysis, upper gastrointestinal series and endoscopy, biopsy of gastric and duodenal mucosa, abdominal computer tomography and ultrasonography to establish the diagnosis. Finally, the patient successfully underwent duodenojejunal anastomosis with a postoperative favourable outcome.

[Congenital cystic disease of the biliary system in adults]. / Dilatatia chistica congenitala a cailor biliare la adult.

Congenital cystic disease of the biliary system is a complex syndrome of ectasies of the intra-, extra- or both situation of biliary tree. This disease has an unsure etiopathogeny. It is uncommon through the third age, with a greater incidence in child, teen-ager and young adult. The goal of our study is to evaluate the symptoms, diagnosis, treatment and histological aspects of the congenital biliary cysts. We performed a retrospective study from March 1988 to July 2003 about 11 patients with this disease treated in our surgical clinic. Clinical features, methods of diagnosis and surgical treatment were assessed. All patients were females with mean age 51 years (extreme 26-77 years). The symptoms were: right upper quadrant pain--11 cases (100%), jaundice--6 cases (54.5%), fever--3 cases (27%), palpable abdominal mass--2 cases (18%), weight loss--1 case (9%). The imaging diagnosis was helpful (ultrasonography, CT, ERCP, percutaneous cholangiography and preoperative cholangiography). In concordance with Todani classification the patients were included in the following types: Ia--3 cases (27%), I b--1 case (9%), I c--3 cases (27%), IV a--2 cases (18%), IV b--1 case (9%), V--1 case (9%). All patients were operated on: after cholecystectomy and transcystic cholangiography (11 cases--100%) we performed the total excision of the cyst--9 cases (82%) with choledochal jejunostomy (Roux-en-Y)--6 cases (54.5%), choledochal jejunostomy (omega)--1 case (9%) and choledochal duodenostomy--2 cases (18%). In one case of neoplasic cyst with portal invasion we performed a cyst-jejunostomy (omega) and in one case of Caroli disease with total obstruction of the distal choledoc, the solution of choice was choledocal-duodenostomy. The microscopic pathology of the cyst wall showed: chronic intramural inflammation--9 cases (82%) and the absence of the nervous intramural terminations--1 case (9%). The additional lesions was: hepatic cirrhosis--1 case (9%) and hepatic fibrosis--3 cases (27%). We found three cases with neoplasia: malign cyst with advanced local invasion--1 case (9%), pancreatic carcinoma--1 case (9%) and gallbladder carcinoma (microscopic finding)--1 case (9%). The postoperative morbidity includes biliary fistula--2 cases (18%) and wound infection--2 cases (18%). Long-term follow-up revealed cholangitis in one case--9%. The cystic dilatations of the common bile duct is an exclusive indication for surgery as soon as it was discovered.

[Splenic hydatic cyst. Observations upon 38 cases of splenic echinococcosis]. / Chistul hidatic splenic. Observatii asupra a 38 de cazuri de echinococoza splenica.

15 patients with spleen hydatic cysts have been operated between 1986-1998, in percentage of 4.6% from the total number of hydatic cysts--8 females and 7 males with mean age of 44 years (17-70). They have been admitted for abdominal pain (66.6%) and at the clinical examination they presented a cystic tumor at the level of the spleen. In all the patients we performed splenectomy. In conclusion the hydatic cyst of the spleen is rare, but possible, the treatment being only surgical.