[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.

[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.

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.

[Surgical treatment of esophageal strictures secondary to gastroesophageal reflux disease]. / Tratamentul chirurgical al stenozelor esofagiene secundare bolii de reflux gastro-esofagian.

The end point in gastro-oesophageal reflux disease (GERD) evolution is oesophageal stenosis. The aim of this study is merely to establish the absolute requisite of treating simultaneously the oesophageal stenosis and the causal disorder, GERD. This article analyses the diversity of surgical treatment in relationship with the location and length of the oesophageal stenosis using a group of 35 patients with GERD over a period of 25 years. Treatment of this condition has enriched and diversified in the last decades with more conservative and complex techniques, having the task to preserve, whenever possible, the oesophagus. The ability to decide the optimal moment for the surgical treatment, to elect the most suitable procedure, to treat simultaneously the stenosis and to prevent further reflux guarantee a successful, free of recurrence outcome.

[Tailored surgical treatment for post-caustics stenosis of the upper digestive tract with complicated lesions. Clinical experience at our department in the last ten years]. / Diversificarea tratamentului chirurgical al stenozelor postcaustice ale tubului digestiv superior în relatie cu complexitatea leziunilor. Experienta clinicii a III-a chirurgie în ultimii 10 ani.

The ingestion of caustic substances generates severe lesions of superior digestive tract, leading to stenosis in 50% of patients, of which almost 50% will require surgical treatment. A number of 29 patients with caustic lesions were treated in the IIIrd Surgical Unit from 1993 to 2004. The most frequent corrosive agent was a strong alkaline solution. The location of the post caustics strictures was esophageal in 18 cases, esophagogastric in 7 cases and laryngo-pharyngo-esophageal in 4 cases. Surgical procedures consisted of 8 esophagoplasties with ascending colon and ileum, 12 with left colon, 3 with transverse colon and splenic flexure, and in 5 cases transhiatal resection with cervical esophago-gastric anastomosis. 5 patients required gastric resections of variable extent, in addition to the esophageal reconstruction: antrectomy with trunk vagotomy--1 case, subtotal gastrectomy--3 cases and total gastrectomy--1 case. In the group with pharyngeal lesions, esophageal reconstruction followed pharyngoplasty with cutaneous tube performed in the ENT department. Hospital mortality rate was 3,4 % (1 case). Postoperative morbidity of 20,6 % consisted of cervical anastomosis leakages in 2 cases and pleural effusions in 4 cases. Surgical treatment of the post caustics strictures of the upper digestive tract must be adapted to the location and severity of the lesions, requiring adequate operative experience and special pre- and postoperative care.

[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.

Bcl-2 and immunoglobulin gene rearrangements in patients with malaria related chronic splenomegaly.

Two cases of malaria related chronic splenomegaly, one with tropical splenic lymphoma with villous lymphocytes (TSLVL) and the other with hyperreactive malarial splenomegaly (HMS) were analyzed by cytology, histology, karyotyping, immunophenotyping, and polymerase chain reaction (PCR) for detection of bcl-2/JH and FR3/JH rearrangements on blood and bone marrow samples, at diagnosis and 12 months after malarial prophylaxis. The reported data suggest that the detection of FR3/JH rearrangement might contribute to the diagnosis of TSLVL in patients with malaria related chronic splenomegaly, for whom bcl-2/JH rearrangement may be a common molecular event.

[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.