THE "DARK SIDE" OF DEEP VEIN THROMBOSIS--CASE REPORT.

Venous thromboembolism (VTE) is an increasingly common cause of morbidity and mortality in cancer patients. In various malignancies the incidence of thrombosis ranges from 5% to 60%, that is four times higher in cancer patients compared to the general population. Large retrospective studies have shown that in men the tumors which are most commonly associated with VTE are lung cancer and pancreatic cancer and, in women cancer of the genital area, pancreas, colon and rectum. Thromboembolic events may often occur before the cancer diagnosis. We present the case of a 41-year-old female patient with a history of genital cancer which was surgically treated and who is now admitted for clinical signs of ileofemoral deep vein thrombosis (DVT) of the left leg. The diagnosis was confirmed by laboratory data and Doppler ultrasound and the patient received anticoagulant treatment. Given the history of the patient, abdominal and pelvic ultrasound and computer tomography (CT) were performed to detect the cause who predisposed to the thrombotic event. These confirmed the ovarian cancer, this time on the right side, and the presence of hepatic and pulmonary metastasis. This case highlights the importance of screening for a cause of the thromboembolic event in patients, especially in those who have a history of a neoplasia.

Rare Tumors, Rare Association: Ovarian Strumal Carcinoid - Retroperitoneal Cystic Lymphangioma.

INTRODUCTION: Strumal carcinoid is a rare neoplasm of the ovary containing thyroid (struma) and carcinoid component revealed by immunohistochemistry. Case present: A 55-years-old woman with hysterectomy and right oophorectomy for uterine leiomyoma and right ovarian cyst, performed 12 years ago, was referred to the First Surgical Clinic, St. Spiridon University Hospital Iasi with pain in hypogastrium present for 2 months. Laboratory tests are normal and serum testing for tumor markers is unchanged. Ultrasound and CT finds for topography of the left ovary a well-defined 63 57 71 mm cystic mass, with a non-uniform wall thickness. Exploration laparoscopy, after adhesiolysis, identifies a cystic tumor developed in mesosigmoid which was excised and auterine tube with cystic dilatation and left ovary with intactcapsule, for which we performed left adnexectomy and extracted pieces of tumors in endobag. Evolution is simple, the patient being discharged after 3 days postoperatively. Histopathological exam and immunohistochemistry reveal edovarian strumal carcinoid and cystic lymphangioma. After one year follow up the patient is disease free. CONCLUSION: This association between an ovarian strumal carcinoid with mesosigmoidian cystic lymphangioma is unusual and rare, not cited in the literature. A laparoscopic approach for the two conditions is safe with good immediate and distant postoperative course.

Life-threatening complications of impacted common bile duct lithiasis. A case report.

Impacted common bile duct (CBD) lithiasis poses therapeutical challenges and repeated attempts of removal may result in life-threatening complications. CASE REPORT. A 45 year-old female patient was admitted in emergency for right upper quadrant abdominal pain and jaundice. Clinical, lab data, abdominal ultrasound (US) and cholangio-MRI established the diagnosis of acute cholecystitis and obstructive jaundice due to distal CBD lithiasis. Endoscopic retrograde colangiopancreatography (ERCP) confirmed the presence of a distal CBD stone but extraction failed. The patient was operated on and surgical procedure consisted of cholecistectomy, intraoperative cholangiography and a side-to-side choledocho-duodenal anastomosis was performed because all attempts to extract the stone through choledocotomy or duodenotomy and enlargement of endoscopic shincterotomy failed. The postoperative course was endangered by a severe pancreatitis, a massive upper digestive bleeding and portal vein thrombosis that responded to conservative management in the intensive care unit. The patient was discharged after 34 days in good clinical condition and approximately 9 months later was readmitted electively for an incisional hernia. Apart from this, physical examination, lab tests and imagistic studies were normal; the patient was operated and rapidly discharged in good condition. In conclusion, the management of CBD lithiasis may be a serious challenge both for interventional endoscopists and surgeons and require a concerted team effort.

Rectal impalement injury: from cruelty to salvage endeavour.

Massive penetrating trauma by rectal impalement is a very rare form of injury, complicated and potentially lethal. It is even rarer for such injury to result in pelvic, abdominal and thoracic internal damages. We report the case of a 62 year-old man who was admitted in emergency after an aggression with a sharp wooden stake inserted forcibly into his rectum. Clinical examination revealed the blunt extremity of the stake outside the anus and the prominent sharp end reaching his right supraclavicular fossa. Radiographic examination showed the stake extending from the rectum to the right side of the neck.Surgery disclosed penetration through the rectum, retroperitoneum,large bowel mesentery, liver, diaphragm, right lung and right 2nd rib. The patient survived following management by a multidisciplinary surgical team. As similar reported cases are scarce, knowledge of the management of the few cases that have been successfully treated is likely to prepare the emergency teams to act rationally and efficiently in such exceptionally grave circumstances.

Fuzzy γ-hyperideals in γ-hypersemirings by using triangular norms.

The concept of Γ-semihyperrings was introduced by Dehkordi and Davvaz as a generalization of semirings, semihyperrings, and Γ-semiring. In this paper, by using the notion of triangular norms, we define the concept of triangular fuzzy sub-Γ-semihyperrings as well as triangular fuzzy Γ-hyperideals of a Γ-semihyperring, and we study a few results in this respect.

Complex utrasound study of the atherosclerotic plaque.

UNLABELLED: Carotid surgery concept is wining ground both among neurologists who recommend and vascular surgeons who perform an increased number of interventions. Regardless of the technique, we are interested in the tendency of the plaque to grow and determine stenosis. Ultrasound (US) is 91-94% sensitive and 85-99% specific in detecting a significant stenosis of the internal carotid artery. AIM: To establish a correlation between the preoperative US and intraoperative plaque characteristics in order to determine the restenosis rate. MATERIAL AND METHODS: From January 1, 2012 to December 31, 2012, 70 consecutive patients were included in this study. Two groups were formed: 35 patients with stenotic ICA and 35 patients presenting stenosis at the femoral artery bifurcation (control group). The comparison between these two groups started from the premise of a similar pattern for internal carotid artery--deep femoral artery and external carotid artery- superficial femoral artery. US scans were performed on admission in all patients. All images were normalized and Gray Scale Median (GSM) was calculated. RESULTS: Femoral plaque GSM values were higher in relation with hyperechogenicity highlighting the intensely calcified structure. Unstable plaques were more heterogenic, with higher transparency and lower GSM than stable plaques. This was the case of carotid plaques. During follow-up US revealed no restenosis. CONCLUSIONS: Femoral bifurcation plaques are calcified and determine chronic ischemic symptoms, while carotid bifurcation plaques are unstable and determine cerebral symptoms. US remain the gold standard non-invasive technique both for screening and diagnosis and set the therapeutic coordinates.

[Right colon cancer--clinicopathological findings]. / Cancerul colonului drept--particularitati anatomo-clinice.

BACKGROUND: The right colon cancer (RCC) has some particularities from point of view of epidemiology, clinical aspects, therapy and prognosis. MATERIAL AND METHODS: We retrospectively analyzed the patients operated in the First Surgical Unit Iasi during 2004 until 2009, for right colon cancer. The patients' data from the medical files were digitally encoded and included into a MS Access database, and statistically analyzed. RESULTS: 219 cases were included into the analysis, which represents 24.17% from all the patients with colorectal cancer. The median age was 66 years old. A palpable mass into the right abdominal quadrant was founded in 41.5% and anemia in 65.3%. Abdominal ultrasound exam has been performed in all the patients, with 71.3% sensitivity for primary tumor positive diagnosis. Resectability was 89.5% but without multivisceral resections. The intraoperative complication rate was 6.8%; postoperative morbidity was 19.4% with an incidence of anastomotic leak of 1.38%. The postoperative mortality rate was 2.77%. The mean overall survival was 40.13 +/- 1.93 months (median: 49.26). The prognosis factors for the survival rate were: histologic type of the tumor, stage and tumor grading, vascular and perineural invasion. The presence of metastasis in more than 3 lymphnodes as well as resection of fewer than 11 lymphnodes were found as negative prognosis factors for the survival rate. CONCLUSIONS: RCC has an increasing incidence and it is associated especially with elderly patients. The RCC resectability is about 90% with acceptable rates of morbidity and mortality. Perineural and vascular invasion as well as rate of positive lymphnodes and count of resected lymphnodes are prognosis factor for overall survival rate.

Ectopic adrenocorticotropic hormone syndrome caused by a carcinoid tumor of the thymus. A case report.

Ectopic ACTH secretion accounts for less that 10% of all causes of endogenous Cushing's syndrome. Carcinoids are rare thymic tumors, and when associated with ACTH hypersecretion display local or distant aggressive behavior. A 32-year-old woman was admitted to the Endocrinology Unit for obesity, moon face, facial hirsutism, hyperpigmentation, and secondary amenorrhea. Laboratory test confirmed the hypercortisolism and excess ACTH, while dexamethasone suppressive test was negative. Thorax computed tomography (CT) showed an antero-superior mediastinal tumor invading the pericardium and left mediastinal pleura. A complete resection through median sternotomy of the tumor, pericardium and left mediastinal pleura was performed. After a one-year symptom-free period, hypercortisolism recurred, confirmed by laboratory findings. Although no signs of local recurrence were seen on thorax CT, left internal mammary lymph nodes involvement and vertebral body metastases at C7 and LI were found. Refractory electrolyte disturbances could not be corrected resulting in severe cardiac arrhythmia and death from cardiac arrest. The reported case draws attention on the aggressiveness of ACTH-secralso due to the refractory electrolyte disturbances with fatal outcome.

[Image-guided diagnostic percutaneous puncture biopsy]. / Punctia percutana diagnostica ghidata radio-imagistic.

Percutaneous aspiration and biopsy have an increasing diagnostic role. Ultrasound and CT are the imaging methods most frequently used for guiding, but fluoroscopy and MRI are also considered. The paper reviews the indications, contraindications, method of ultrasound-guided and CT-guided punctures, and the results of needle aspiration and biopsy for cerebral, head and neck, thoracic, abdominal and musculoskeletal lesions.

[MRI in the differential diagnosis of liver focal lesions]. / Irm în diagnosticul leziunilor focale hepatice.

51 patients with focal liver abnormalities at ultrasound were examined by MRI. The cases with liver metastasis of known origin submitted for staging and cholangiocarcinomas of the external bile ducts or gall bladder with liver invasion were not included in the study. Most of the examinations were performed for suspected hepatocarcinoma. MRI studies, using 2D T1 and T2 weighted FSE sequences and T1 weighted 3D SPGRE contrast enhanced sequences were able to differentiate between different kinds of benign lesions e.g. large hemangiomas or FNH or even complicated hydatic cysts from hepatocarcinoma.

[MRI in acute pancreatitis]. / IRM in pancreatita acuta.

26 patients with clinical and biological suspicion of acute pancreatitis were examined by MRI. The general indications for pancreatic MRI were: suboptimal or equivocal CT or ultrasonography findings (e.g. focal pancreatic enlargement with no mass discernable on CT or US), contraindications to iodinated contrast administration (e.g. contrast allergy history and renal failure). Using fast scanning techniques most of them with breath holding and fat saturation MRI was able to depict the lesions involved (e.g. the presence and distribution of necrotic areas and fluid collections, the existence of subsequent chronic pancreatic changes) which are consistent with CT findings. MRCP demonstrated etiology, like cholelithiasis.

[Small size cephalo-pancreatic cancer. Demonstration of MRI/MRCP usefulness]. / Neoplasm cefalo-pancreatic de mici dimensiuni operabil. Demonstrarea utilitatii IRM/MRCP.

48 years old woman with obstructive jaundice has been examined by abdominal ultrasound followed by MRI. The suspicion of cephalic pancreatic cancer raised by ultrasound was confirmed by MRI and MRCP. Association of MRCP with axial and coronal T1 and T2 sequences successfully demonstrated a resectable tumor, confirmed at surgery. MRI/MRCP is demonstrating great potential in predicting resectability of cephalic pancreatic tumors.