T4 Colon Cancer - Current Management.

Colorectal cancer is the third most often encountered type of cancer and represents the third leading cause of cancer related deaths, on both sexes. One of the most important prognostic parameters is the tumor's stage at the time of the diagnosis. T4 cancers represent advanced tumors associated with penetration of the visceral peritoneum (T4a) and/or direct invasion in adjacent structures (T4b). Preoperative diagnosis is influenced by the inability of the existent imaging modalities to accurately differentiate the true invasion from the simple, inflammatory adherence to the neighboring structures. As a consequence surgical treatment must follow the principle of en bloc resection; however the ability of achieving an R0 resection depends on the tumor location, invaded organ, and the type of the surgical procedure required. Neoadjuvant treatment for advanced colon cancer it may be very difficult to be applied. This review is focused on preoperative workup, therapeutic strategies and subsequent results in advanced T4 colon cancers.

Thyroglossal Duct Cyst Carcinoma in Child and Adult. Two Case Reports.

Thyroglossal duct cyst carcinoma is rarely mentioned in literature representing only 0,7-1,6% of cases with these embryonic remnants. Two patients with thyroid duct cyst carcinoma, a 14-year-old girl and a 44-year-old man operated on in our department, both diagnosed postoperatively are described. In the first one a classical Sistrunk operation was performed removing a 3 cm asymptomatic mass, a milimetric papillary carcinoma being incidentally discovered at paraffin section pathology. The second case presented a 4 cm cyst with benign clinical and ultrasonic features excepting a 8 mm nodule in the right thyroid lobe. Cytology was inconclusive such as a Sistrunk procedure together with a right thyroid lobectomy were done. Pathology revealed a limited carcinomatous focus in the cyst wall but also a papillary thyroid microcarcinoma. Both cases was thereby diagnosed only after microscopic examination. Conservative approach adopted due to "œinnocent" clinical appearance, subcentimetric size and absence of any risk factor in the two cases achieved stable, verified over time healing confirming the favorable prognosis of this rare pathology.

Cardiothyreosis: Pathogenic Conjectures, Clinical Aspects and Surgical Approach.

INTRODUCTION: The presence of striking cardiovascular manifestations were noted in the first descriptions of hyperthyroidism owing to Parry (1825) and Basedow (1840) in his famous Merseburg triad. Hyperthyroidism may either cause cardiac complications in individuals with a normal myocardium (genuine form of disorder) or complicate preexisting cardiac troubles. MATERIAL AND METHOD: An homogenous series of 49 cardiothyreosis, 11 males and 38 females, aged 12 - 78 (mean 45) years selected between 138 thyrotoxic patients operated on in a period of two decades is herein presented. There were registered 15 Basedow diseases, 16 toxic adenomas and 18 multinodular toxic goiters. Among these were found isolated or dominating when combined together, 21 cases with rhythm troubles (4 with extrasistolic arrhythmia and one with fibrilloflutter, 10 cases with cardiac failure and 9 cases with coronary cardiac disease. To these 7 hypertensive patients and two with mitral valvulopathy were added. In hyperthyroidism clinical diagnosis was confirmed on imaging exams and hormonal determinations while cardiovascular disturbances was ascertained by interrogatory, clinical signs, EKG and echocardiography. All our cases were operated on performing 33 total or near total thyroidectomies and 16 lobectomies without morbidity recording however 5 postoperative tachyarrhythmias but finally most of them with good clinical results (87,7% cured or significantly ameliorated). DISCUSSIONS AND CONCLUSIONS: Pathogenic diagnosis of such so-called "cor thyreotoxicosis" is not always easy on account of cardiovascular syndrome which frequently overshowed the thyroid subclinical pictures or emergencies of new described entities as amidarone induced thyrotoxicosis. The single administration of a whole calculated dose of I 131 with subsequent treatment with thyrostatics and B-blockers till remission of toxicosis is achieved can be chosen opposing to thyroidectomy after short medicamentous preparation which is effective in large thyromegalies and toxic adenomas.

Clinicopathological phenotype of parathyroid carcinoma: therapeutic and prognostic aftermaths.

Parathyroid carcinomas (PC) are rare and "devastating"€ causes of hyperparathyroidism (HP), frequently discovered fortuitously,with not always doubtless pathological confirmation, and dissociate post-therapeutic outcomes and prognosis even after well-performed surgery. We herein report four PT neoplasms,three of them proving to be authentic PCs, and one an atypical parathyroid adenoma. There were three females and one male, aged 32-49 (mean 44) years. In three circumstances PC was associated with primary HP and in one case the tumor had developed on a CKD-BMD (renal HP) background. All patients presented marked clinical and biochemical phenomena related to hypercalcemia with greater intensity of renal, bone, neuromuscular and psychological signs and symptoms to which in one observation specific uremic manifestations were added. Preoperative and intraoperative diagnosis was suspected only in two cases (one of them being in fact an atypical PT adenoma), but in the other two it was established by paraffin section on histological evidence of definitive stigma of malignancy. Our little experience underlines the wide and protean range of the origins, clinical aspects, course and prognosis of PC, which adds to the difficulties of pre- and intraoperative diagnosis. Awareness of this lesion must be permanent to detect its presence in any unusual eventuality, imposing a radical en bloc resection at the initial operation, assuring the best chance of cure.

Unusual malignant tumors of the thyroid gland.

BACKGROUND: Although situated on the last places among the statistical hierarchy of human malignancies, thyroid cancers (TC) are the most common tumors of the endocrine system. Follicular epithelium neoplasms account for more than 90% of these lesions with a favourable prognosis, while resting tumors (medullary, anaplastic, lymphoma, sarcoma etc) generally present a rapid unfavorable evolution with a low rate of survival. PATIENTS AND METHODS: In a series of 464 thyropathies personally treated, 72 cases of TC (15.5%) were identified. Fifty-seven patients presented epithelial TC a 34 papillary variant, 20 follicular variant and 8 mixed forms. Alongside these there were two medullary TC, 9 anaplastic TC and insular TC, and primary lymphoma and metastasis to the thyroid of a lung carcinoma each single case. Four cases have been described in patients who were aged 2-6 years at the time of the Chernobyl disaster. Out of the common types, based on our own taxonomic criteria, we selected a group of 36 TC with unusual clinical, histological and behavioural characteristics or particular pathological associations. RESULTS: Seven cases of occult TC, 7 cases with precessive adenopathy TC and 11 patients with TC associated with hyperthyroidism were registered. All of them underwent adapted thyroidectomies in which the presence of cancer was decisive for the extent of surgery. Medullary, insular and anaplastic TC were the most aggressive lesions and even extended surgery and complementary therapy failed to improve the prognosis of these patients. In the same category we included the cases presenting the coexistence of two TC types, pathologic dedifferentiation in recurrences and concurrent presence of another endocrine or nonendocrine cervical lesion. The a surgical dogma of total thyroidectomy cannot always be respected, so complementary therapeutic solutions must be applied. RESULTS were complex, registering steady recoveries in occult, hyperfunctioning and even in coexisting pathological lesions, but many recurrences and reinterventions with poor survival rates (a few weeks up to 2 years) in cases with reduced or absent histologic differentiation were also noted. Some lesions were inoperable. DISCUSSIONS AND CONCLUSIONS: Increasing clinician, surgeon and pathologist awareness of these distinct, but not rare anatomoclinical contingencies could contribute to their adequate diagnosis and treatment. Recent progress in knowledge of molecular carcinogenesis and promising successes of targeted chemotherapy trials with new drugs offer promising perspectives in the management of advanced or metastatic TC. Surgery still remains the cornerstone treatment for thyroid cancers.

[Indications for surgery in thyroiditis]. / Indicatii ale tratamentului chirurgical în tiroidite.

INTRODUCTION: Inflammatory processes of the thyroid represents a main proportion of the gland's pathology but the majority of them are treated by medical methods, surgery being indicated. PATIENTS AND METHODS: In 14 cases (3%) from 464 operations for different thyroid conditions we have encountered authentic inflammatory lesions in 9 cases of Hashimoto's thyroiditis (two associated with papillary thyroid carcinoma and one with malignant lymphoma), two cases of Riedel's thyroiditis and respectively de Quervain thyoiditis, tuberculous thyroiditis and actynomicosis one case each. The common lymphoplasmacytic infiltration in Basedow's disease was not considered likewise as the inflammatory nespecific lesions encountered in benign and malignant pathology of the gland. The clinical and imagistic data, biological evaluation and titer of anticorps but particularly the paraffine examination together with intraoperative estimations are decisive for the diagnosis. RESULTS AND DISCUSSIONS: Firm diagnosis of thyroiditis was rarely affirmed before operation, surgical indication being formulated on clinical criterions dominated by cancer suspicion. Among these are diffuse or (multi)nodular thyromegaly with a dominant nodule with recent appearance and rapid growing in temporal and geographic proximity of Chemobyl disaster, with hard consistence, celsian or compressive features and adenopathy. More added the imagistic signs but especially suspect aspects of the FNAB (follicular or with Hürthle cells smears) and also of the frozen sections. Certainty diagnosis was established by paraffine examination not always without hesitations or reexamination (Hashimoto's thyroiditis diagnosed in one case was finally a malignant lymphoma). Large removal decided after intraoperative findings induced for the most of patients a definitive hypothyroidism. CONCLUSION: All the diagnosis resources must be exhausted for the diagnosis of the inflammatory lesions of the thyroid to avoid unnecessary surgery. On the other side the chronic overstimulation by the TSH of the glandular tissue affected by the immune process, represent an important factor of producing neoplasia.

Mesenchymal (non-epithelial) "non-GIST" tumors of the digestive tract.

Morphological, immunohistochemical and ultrastructural but also clinical and prognostic differences between multiple types of mesenchimal (stromal, nonepithelial) tumors of the gastrointestinal tract prompted us the remembrance of an anecdotic series of sixteen observations of mesenchymal "nonstromal" gastrointestinal tumors (MNSGIT) encountered in four decades of surgical practice. The diagnosis was mainly established on clinical grounds (dyspepsia, pains, digestive hemorrhage or obstruction, palpable tumor) - some lesions being incidentally discovered - and confirmed by radiology, endoscopy, intraoperative exploration and microscopic pathology examination which revealed 9 schwannomas, three leiomyomas, two lipomas, fibroma and "mixoma" one case each. Our cases were located on the stomach (n=12), small bowell (n=1) and right colon (n=3). All the cases were operated on being practiced tumor exeresis with mucous or parietal ruff excision, atypical, conservative and standard (segmentar or sectorial) visceral resection. There was no postoperative morbidity or mortality in our series. Median follow-up for our cases was 24 (range 6 - 60) months and there are not evidence of recurrences or metastatic disease. Even if the actual concerns are prioritary oriented towards the study of GIST, the current nosology of the tiny subgroup of mesenchymal (non-epithelial) "non-GIST" lesions of the digestive tract must be reloaded helping the practioner which can be confronted with this pathology to a better evaluation and optimal therapy.

Parathyromatosis coexisting with papillary thyroid microcarcinoma.

UNLABELLED: The aim of this report is to describe a fortuitely discovered association between parathyromatosis and papillary thyroid microcarcinoma. CASE DESCRIPTION: A 56-year-old woman presented with a pyelic relapsed stone, bone pains, neurovegetative com-plaints and iPTH = 348 ng/l as manifestations of recurrent primary hyperparathyroidism after a right inferior parathyroid adenoma exeresis done elsewere six years ago. Ultrasonography showed a 5 mm hypoechoic zone at the lower pole of the right lobe of the thyroid. At the operation an irregular, unbounded, white-yellowish mass 5 mm in diameter was identified lateral and below the thyroid pole together with 15-20 nodules of 1-2 mm scattered on the distal surface of the gland and also in the areolar fibrofatty surrounding atmosphere. Excision and biopsy of the mass and of two main nodules showed the presence of parathyroid issue and the operation is finally completed to a thyroid lobectomy. Definitive paraffin examination evidencied multiple poorly outlined nests of benign parathyroid tissue but also a minute foci of papillary thyroid carcinoma. Two years after the operation the patient is symptom free without any local recurrence and in normal biological parameters. DISCUSSION: Coexistence between parathyromatosis - a rare but challenging cause of hyperparathyroidism - and thyroid (micro)carcinoma a more frequent encountered lesion is an entirely coincidental occurrence. The preoperative diagnosis of both conditions - particularly of the latter one - is rarely anticipated. In such intraoperative fortuitous finding the intervention must include an en bloc thyroid lobectomy together with periglandular and retro-sternal fibrofatty tissue. This strategy is beneficent also for the eventually nonidentified thyroid microcarcinoma. CONCLUSIONS: Preoperative and intraoperative evaluation for recurrent primary and renal hyperparathyroidism must be exhaustive considering possible coexisting thyroid lesions. Indeed in our knowledge there have been no reports in the literature mentioning this unprecedented entity.

[Total parathyroidectomy without autotransplantation in the management of "refractory" renal hyperparathyroidism]. / Paratiroidectomia totala fara autotransplant glandular in tratamentul hiperparatiroidismului renal "refractar".

UNLABELLED: The optimal surgical treatment in patients with refractory renal hyperparathyroidism (RHP) on hemodialysis for end stage renal disease is still a point of controversy. The high percentage of recurrences after standard surgical procedures i.e. subtotal parathyroidectomy (SPTx) and total parathyroidectomy with autotransplantation (TPTx + At) reactualised the practice of total parathyroidectomy (TPTx). MATERIAL AND METHOD: Fortythree patients with RHP underwent surgery between 1994-2009. There were 24 SPTx and 6 TPTx + At, both procedures determining 20.7% (6 cases) recurrences so in the last five years TPTx was performed in a series of 13 cases (7 men and 6 women, with median age 43, 6 years; range 22 - 65 years and median dialysis time before PTx 8,2 years; range 3 -12 years. Parameters studies included demographics, preoperative and follow-up laboratory tests, surgical techniques, pathology results and postoperative immediate and medium term results. RESULTS: Main indications for PTx were severe bone disease, soft tissue calciphycations, neuro muscular phenomena, grossly elevated iPTH and sometimes hypercalcemia. TPTx was done in 12 patients, the 13th one suffering a completion PTx one year after outward exeresis of only two glands. Postoperatively the majority of symptoms markedly improved and the values of calcaemia, phosphatemia and alkaline phosphatasis normalised together with low or no measurable level of iPTH. One patient required a re-exploration for a cervical hematoma but no one presented permanent hypocalcemia or recurrent hyperparathyroidism. Pathology revealed nodular hyperplasia in all the cases, a parathyroid carcinoma but also an incidental thyroid papillary microcarcinoma in a complementary thyroidectomy. CONCLUSIONS: TPTx alone proves to be an equally safe and successful as another techniques currently used in management of RHP eliminating the hyperparathyroid status but being superior with regard to aparition of recurrences. The procedure is indicated especially in cases with aggressive, refractory forms of RHP without the prospect of renal transplantation.

Surgical management of renal hyperparathyroidism: a preliminary series report.

BACKGROUND: Renal hyperparathyroidism (RHPT) is a frequent complication of uremic patients on hemodialysis and despite various advances in medical therapy parathyroidectomy is necessary in a semnificative number of cases. PATIENTS AND METHODS: We reviewed our experience (first in Romania) regarding fortythree patients with RHPT operated on in our clinic between 1994 and 2009 evaluating the diagnosis methods, surgical indications, techniques and results together with the evolution of our own therapeutical concept. The study included 22 men and 21 women of median age of 48 (range 15-67) years, performing hemodialysis (n=41) or peritoneal dialysis (n=2) from 7,7 (range 3-13) years respectively. Three patients received an unsuccessful renal graft. The diagnosis was established by anamnesis, clinical complaints (mainly osteoarticular pains, osteoporosis, fractures and skeletal deformities, muscle weakness, severe itching and mental troubles), completed by abnormal values of calcemia, phosphatemia alkaline phosphatasis and intact PTH. Ultrasonography and parathyroid scan were useful in "adenomised" parathyroids and coexistent thyroid pathology. RESULTS: All the patients were operated on. Twentyfour sub-total parathyroidectomies and 19 total parathyroidectomies (6 with autotransplantation), were performed (two video-assisted). There were no deaths and the operative morbidity was 20,9% (vocal cord hemiparesis and postoperative bleeding--each one case, mild transitory hypocalcemia three cases and recurrences four cases). Pathology revealed that RHTP was due to four gland diffuse hyperplasia (n = 23) or nodular hyperplasia (n = 19). One parathyroid carcinoma (in the fourth parathyroid gland), one thymoma and two papillary thyroid microcarcinoma was identified. Clinical and biochemical cure was achieved at median term control of 38 (range 6-165) months in 79.0% (n = 34) of cases. CONCLUSION: Parathyroidectomy is effective for long intervals as symptomatic therapy in cases of RHPT appearing in uremic patients on hemodialysis or after renal transplant but the optimal technique must be individualized on each case and still to be debated.

[Pancreaticoduodenectomy in surgical treatment of malignant tumors of Vater's region]. / Duodenopancreatectomia cefalica in tratamentul tumorilor maligne ale regiunii vateriene.

BACKGROUND: The optimal treatment of tumors of Vater's region represents a permanent interest of every physician involved in the treating of malignant diseases with such localization. AIM: This presentation proposes a pancreaticoduodenectomy (DPC) evaluation in the surgical treatment of tumors of Vater's ampulla. MATERIALS AND METHODS: Between 1999 - 2009 our clinic has treated a number of 37 cases with mechanic jaundice by malignant diseases (JMN). Out of these, 5 cases (13.5%) have been hospitalized with JMN (preoperative diagnose) by malignant tumors of Vater' region: 4 men and a woman, aged 46 to 72, from rural medium, who represent the aim of this paper. RESULTS. DISCUSSION: In 4 cases (10,.8%), intra-operatory exploration confirms the existence of tumors of Vater's ampulla or duodenal papilla (diagnosis having been established by preoperatory duodenoscopy) using DPC (Child Procedure). Postoperative evolution, either immediate or distanced, was favorable, implying no deaths. The microscopic exam of the extirpated piece confirms Vater's Ampulloma in two cases (5.4%); in the other two cases, the above mentioned exam reveals the small bowel's carcinoma at duodenal papilla. In the last 2.7% cases intra-operatory lymph node and visceral metastases have been observed, choledochoscopy revealing cholangiocarcinoma (confirmed by microscopic exam), the patient having suffered only a choledochoduodenostomy. CONCLUSIONS: Without being endowed with great experience in the field, the results of DPC treatment in these first cases of malignant tumors of Vater's region allow us to found the reasoning of the righteousness of surgical indication. DPC draws the hope of radical healing intention in the cancer with this localization.

Laparoscopic hand-assisted splenectomy for hydatid cyst.

Hydatid cyst of the spleen is a rare location even in endemic areas. From classical splenectomy, surgical treatment has evolved to more conservative and even minimal invasive techniques. The authors report a 44 year old male with a palpable but asymptomatic mass in the left hypochondrium. Ultrasonography and computed tomography confirmed a large round unilocular cystic imagine of 12.5 cm in diameter with a thin regular wall. A total splenectomy was performed laparoscopic, the dissection being directed upward from the lower peritoneal attachments continuing with delivery of the anterior aspect of the hilum and splenorenal ligament, interception of main splenic vessels and finally detachment of the superior pole of the spleen where the cyst is adherent to the diaphragm muscle. The all delivered spleen was partial evacuated of hydatid content and the extraction was done via a mini-laparatomy with a digital lever manoeuvre. The 200 minutes operation has an uneventful postoperative course and the patient is still well 12 and 24 months after surgery without recurrence. The laparoscopic approach of hydatid cyst of the spleen constituted a challenging therapeutic perspective in selected cases and a good expertise of the surgeons.

[Cystic mucinous tumors of the pancreas]. / Tumorile chistice mucinoase ale pancreasului.

Mucinous cystic tumors (MCTP) are uncommon borderline lesions of the pancreas that may often be misdiagnosed as pseudocysts and have unknown propensity to malignity. During the last two decades in our clinic of 38 patients with cystic lesions of the pancreas two presented MCTP: a 48-year-old woman with a cyst located in the body and tail of the pancreas and a 59-year-old man with a tumor situated in the head of the gland producing an obstructive jaundice. Ultrasonography and computer tomography confirmed the presence of the cystic mass in both patients but the precise diagnosis was made only after the histologic examination of the removed lesions. With an attempted curative resection: distal pancreatectomy with preservation of the spleen in the first case and a Whipple procedure in the second one, both cases were cured. Pathology do not reveal malignant transformations. Both patients were alive, had no complaints or recurrences at 12 and 24 month after surgery. The treatment of choice in such cystic tumors is surgical removal as untreated these lesions may progress to neoplastic degeneration.

[Reoperations of the thyroid gland]. / Reinterventii în chirurgia tiroidei.

Reoperative thyroid surgery may be necessary in recurrent simple goiters, thyrotoxicosis and especially cancers of the thyroid gland. The present series reviewed 33 cases representing 7.3 % from our experience consisting of 440 thyroid operations. Five patients had undergone two prior operation. Details of original procedures were available only for 26 patients, the first operations being carried "extra muros" in 20 cases. There were 25 women and 8 men with mean patient age 44.5 (range 22-75) years, which had undergone one prior operations. The interval between the primary operation and the second one varies between 5 days and 44 years. Eleven cases had benign lesions: eight with uni or bilateral nodular goiters and three thyrotoxicosis (two with Basedow-Graves'disease and one with toxic adenoma) for which nodulectomy, subtotal lobectomies or thyroidectomies were performed. In twenty one cases the surgical indication was done for persistent or recurrent thyroid carcinomas (16 papillary, two follicular and one case each of medullary, anaplastic and malignant lymphoma). Among these 6 patients underwent completion total thyroidectomies associated in 9 another patients with radical or modified neck dissection and in the 6 remaining cases conservative procedures (lobectomies, tumoral excision) of the gland or nodes were done. Complications, includes two recurrent laryngeal nerve palsy, two spontaneously healed esophageal fistulas and one case each of permanent hypothyroidism and hypoparathyroidism. Reoperative thyroid surgery constitute a valuable surgical procedure for persistence or recurrence of benign and especially malignant thyroid lesions but is associated with significant increased risk of functional and anatomic complications rate than those of the initial surgery.

[Gastrocolic fistulas. Review of three cases]. / Fistulele gastrocolice. Consideratii în legatura cu trei observatii.

Gastrocolic fistula (GCF) is a rare and severe lesion appearing traditionally as a complication of inadequate gastric surgery or in the context of stomach or colon malignancy, but actually arising from many different gastrointestinal conditions. Three patients with GCF, admitted and operated in our clinic, are presented. The first case, a man aged 36 years, was a classical one, with a G(jejuno)CF appearing three years after a gastrectomy with Reichel-Polya reconstruction for duodenal ulcer, resolved by a "revision gastrectomy" en block with segmental resection of the jejunum and transverse colon. The second case, also a man aged 43 years, presented a spontaneous GCF determined by a gastric carcinoma, that required an en block enlarged gastro-colectomy. The last case, a 61 year-old woman, presented three weeks after an emergency concomitant cholecystectomy and appendicectomy, with clinical manifestation suggesting a subphrenic abscess. Although a contrast-enhanced CT revealed a communication between the great curvature of the stomach and the splenic flexure of the colon, no fistula was found at laparotomy (spontaneous healing?). However, the terminal ileum and ascending colon had a suggestive appearance of Crohn's disease (confirmed by pathology) and a right colectomy was done. Excepting the rare situation of spontaneous or after medical treatment healing, the mainstay therapy of GCF is the case-adapted surgery.

[Parathyroid carcinoma in a patient on hemodialysis for renal failure]. / Cancer paratiroidian la un bolnav cu insuficienta renala cronica în regim de hemodializa.

Parathyroid carcinoma is a rare endocrine neoplasm with difficult histological diagnostic and unpredictable evolution. More unusual are the cases appearing in the course of end-stage renal disease on maintenance dialysis (22 observations in medical literature). A 46-year-old man suffering of chronic glomerulonephritis and renal failure for 13 years, having been on hemodialysis for three years, complains of asthenia, adynamia, muscle weakness, progressive osteoarticular pains, itching. The preoperative iPTH was 71/ng/ml, seric Ca2+/1.23 mmol/l, seric Ca/2.6/mmoli/l, seric P/2.02 mmol/l. Clinical and ultrasonographical examinations revealed a left "thyroid nodule" of 44 x 37 mm but no images of the parathyroid. Upon surgery, three parathyroid glands (two from the right side and the superior left one) were identified and excised after the frozen section. The fourth gland was not found but the resected "nodule" together with the adjacent thyroid lobe proved a parathyroid carcinoma upon paraffin examination. The clinical course after operation was uneventful. The authors underlined the criteria and difficulties in the pathologic diagnosis of parathyroid carcinoma and also the principles of surgical treatment based on their experience of three cases.

[Hyperthyroidism and coexistent thyroid carcinoma]. / Hipertiroidismul coexistent cu cancerul tiroidian. Consideratii în legatura cu 11 observatii.

The association between thyrotoxicosis and thyroid cancer is a classical, rare and controversial entity. Within their series of eleven such cases the authors dissociate two distinct groups from clinical and pathological viewpoint. The first category is represented by one case of follicular thyroid cancer with clinically and biologically confirmed hyperthyroidism. The second group includes ten patients with thyrotoxicosis (three cases with Graves' disease, four with toxic multinodular goiter and three with toxic adenoma) and associated unsuspected occult or nodular carcinoma. None of these patients had received previous treatment with radioiodine. In all cases the diagnosis was established by pathological examination of the surgical specimen. Surgery is the treatment of choice in these lesions, the presence of carcinoma imposing the extent of operation. Five near total thyroidectomies and three near total lobectomies with ablation of the isthmus was performed in our cases associated with appropriate additional measures: TSH suppression or 131I treatment. Post surgical results were satisfactory without morbidity or mortality. The long-term survey was good (seven cases alive after 5 years).

[Minimally invasive approach of the cervical endocrine glands]. / Abordul minim-invaziv al glandelor endocrine cervicale.

Improved preoperative functional and topographic diagnostic techniques and availability of intra-operative hormone monitoring, stimulated the introduction of video-assisted minimally invasive operations in parathyroid and thyroid surgical pathology. The first cases of such pathology operated on in our clinic are presented. The first one is a 62 year old man with renal hyperparathyroidism consecutive to a chronic renal insufficiency and hemodialysis from five and three years respectively. The technique of a minimally invasive gapless resection of all four "adenomised" parathyroid glands using laparoscopic and classic instruments is described. Fragments of one gland are implanted in the left forearm musculature. The second case was a 48 year old woman with a three cm diameter right toxic adenoma. With a lateral 15 mm incision, dissociation of the musculature and adequate moving of the retractors the excision of the thyroid nodule was done in 25'. The video-assisted minimally invasive approach allows magnification and adequate identification and removal of endocrine secreting tissues in thyroid and parathyroid pathology. The authors believe that these techniques represent a feasible and attractive alternative to conventional surgery.

[Bulbantrectomy with truncal vagotomy in the surgical treatment of duodenal ulcer]. / Bulbantrectomia asociata vagotomiei tronculare in tratamentul chirurgical al ulcerului duodenal.

Duodenal ulcer benefits of very efficient medical treatment. In currently medical practice exist many cases with complicated duodenal ulcer (by stenosis or penetration in neighbor organs like pancreas or biliary tract or painful forms etc.) to which surgical treatment is necessary. Based on the retrospective study of 116 patients operated between 1991-2002 years for gastric or duodenal ulcer, this paper demonstrates that bulbantrectomy associated with bilateral truncal vagotomy (63.7% of cases) is the best surgery in the treatment of duodenal complicated ulcer or resistant to the medical procedures. Provided by correct indication, the intervention is the most pathogenic, offering the best immediate and long term postoperative results. If the bulbantrectomy is contraindicated (critical general status, etc.), the alternative is a bilateral truncal vagotomy associated with a drainage procedure: pyloroplasty (6.9% of cases) or gastroenterostomy. When the vagotomy are contraindicated or cannot be correctly performed, a large gastrectomy (29.3% of cases) followed by gastroduodenal (preferable) or gastrojejunal anastomosis are practiced.

[Total parathyroidectomy with forearm graft in tertiary hyperparathyroidism]. / Paratiroidectomia totala cu autogrefon glandular la antebrat în hiperparatiroidismul tertiar.

Autonomic and persistent hypersecretion of PTH is a frequent and tormenting complication of the patients with chronic renal dialysis for end stage renal disease (ESRD). In these cases, surgery remains a therapy option with real effects on clinical status of patients, especially in perspective of a renal transplant. The authors present the case of a patient with tertiary hyperparathyroidism for which a total parathyroidectomy followed by autotransplantation of small glandular fragments in forearm muscles was performed. The postoperative clinical and immunological statuses were favorable with the disappearance of pruritus and osteoartralgia with improvement of psychic behavior and normalization of calcium blood level. Considering the parathyroidectomy as a palliative stage in the treatment of ESRD, the authors discussed a hierarchy system of both indications and surgical alternatives to be considered in this condition. In well selected cases this surgical method represents an attractive and easy possibility to control and later adjustment of the hyperfunction of remained parathyroid tissue, avoiding in this way a very risky intervention.