Impact on Long-term Survival of a Standardized Histopathological Protocol on the R1 Incidence in Pancreatoduodenectomy for Pancreatic Ductal Adenocarcinoma.

Background: Pancreatic Ductal Adenocarcinoma (PDAC) is a pathology with a very poor prognostic, the only curative treatment option being surgery, in association with chemotherapy. This study aims to assess the influence that the use of a standardized pathology report after a pancreaticoduodenectomy (PD) has on the R1 margins rate and the impact that this has on long term survival. Material and Methods: We included 116 patients admitted to the Regional Institute of Gastroenterology and Hepatology Prof. Dr. O. Fodor Cluj Napoca, who underwent PD for PDAC (Pancreatic Ductal Adenocarcinoma) between January 2012 and May 2017. We divided them in two groups: 59 patients for which a nonstandardized histopathological protocol was used and 57 patients for which a standardized protocol was implemented. We considered a margin to be R1 when there were tumor cells at ¤ 1 mm from the resection margin. Results: The R1 percentage in the first group of patients was of 39%, while the R1 resection rate in the second group was of 68.4%. The median survival rate was similar in the two groups, with no statistically significant difference between them, but in the prospective study when comparing R0 vs R1 margins there was a statistically differences in 5 year OS with a p-value = 0.03. Conclusion: The use of a standardized pathology report reveals a significant increase in R1 resection rates. Also study revealed not only increasing R1 incidence when using a standardized histopathology report, but also that those margins (R1) playing a determinant role in 5-year OS. The mesopancreas is the most frequently R1 resection margin.

Inflammatory Ratios as Predictors for Tumor Invasiveness, Metastasis, Resectability and Early Postoperative Evolution in Gastric Cancer.

Our study aimed to evaluate the baseline neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), lymphocyte-to-monocyte ratio (LMR), and systemic immune-inflammation index (SII) in relation to invasion, metastasis, and resectability for patients with gastric cancer, respectively, as predictors of death during hospitalization or surgical complications. A retrospective cohort study was conducted on 657 gastric cancer subjects. Inflammatory biomarkers were computed. The associations with tumor stage, metastasis, optimal procedure, in-hospital mortality, and surgical complications were evaluated. Subjects who underwent curative-intent surgery presented lower median NLRs (2.9 vs. 3.79), PLRs (166.15 vs. 196.76), and SIIs (783.61 vs. 1122.25), and higher LMRs (3.34 vs. 2.9) than those who underwent palliative surgery. Significantly higher NLRs (3.3 vs. 2.64), PLRs (179.68 vs. 141.83), and SIIs (920.01 vs. 612.93) were observed for those with T3- and T4-stage cancer, in comparison with those with T1- and T2-stage cancer. Values were significantly higher in the case of metastasis for the NLR (3.96 vs. 2.93), PLR (205.22 vs. 167.17), and SII (1179 vs. 788.37) and significantly lower for the LMR (2.74 vs. 3.35). After the intervention, the NLR, PLR, and SII values were higher (p < 0.01) for patients with surgical complications, and the NLR and SII values were higher for those who died during hospitalization. Higher NLRs, PLRs, SIIs, and lower LMRs were associated with a more aggressive tumor; during early follow-up, these were related to post-operative complications and death during hospitalization.

Klatskin Tumor: A Survival Analysis According to Tumor Characteristics and Inflammatory Ratios.

Background and Objectives: The aim was to evaluate the association of inflammatory biomarkers with resectability and overall survival in hilar cholangiocarcinoma. Materials and Methods: We conducted a retrospective cohort study over 72 consecutive surgical cases of Klatskin tumor over an 11-year period. The sample was divided into two groups: 42 surgical resection cases and 30 unresectable tumors. Values of inflammatory ratios were compared according to the resectability. Log-rank test, univariate, and multivariate Cox proportional hazards models were used to evaluate the overall survival. Results: Subjects were between 42−87 years old (average age of 64.91 ± 9.15 years). According to the procedure: 58.33% benefited from resection (with a 30.95% R0 resection rate) and 41.66% had palliative surgery. Elevated NLR (neutrophil to lymphocyte ratio), PLR (platelet to lymphocyte ratio), and SII (systemic immune-inflammation index), and lower LMR (lymphocyte to monocyte ratio) at admission were associated with unresectable tumors (p < 0.01). For the multivariate Cox proportional hazard models, increased absolute values of NLR, PLR, and SII were associated with lower survival; no differences were observed for LMR absolute value. The cut-off value of NLR ≥ 6 was associated with lower survival. The median survival time for all subjects was 442 days, with 774 days for the resection group and 147 days for the group with palliative surgery. Conclusions: In hilar cholangiocarcinoma, inflammatory ratios are associated with tumor resectability. Tumor excision conferred an important advantage in survival. Elevated NLR, PLR, and SII values at admission significantly increased the hazard ratio. LMR had no influence on survival.

Trends in Minimally Invasive Approaches for Liver Resections-A Systematic Review.

BACKGROUND: SILS (single incision laparoscopic surgery) and NOTES (natural orifice transluminal endoscopic surgery) are considered breakthroughs in minimally invasive surgery, the first consisting in the surgeon working via a single entrance site and the second via a natural orifice (e.g., oral cavity). METHODS: Since 2000 until 2022, the original articles published in the online databases were analyzed. Eligible studies included information about the current therapy of patients with liver surgical pathology and how the two new techniques improve the surgical approach. RESULTS: A total of 798 studies were identified. By applying the exclusion criteria, nine studies remained to be included in the review. Two out of nine studies examined the NOTES approach in liver surgery, whereas the other seven focused on the SILS technique. The age of the patients ranged between 24 and 83 years. Liver resections for hepatocellular carcinoma or colorectal metastases were undertaken and biliary or hydatid cysts were removed. The mean procedure time was 95 to 205 min and the average diameter of the lesions was 5 cm. CONCLUSIONS: When practiced by multidisciplinary teams, transvaginal liver resection is feasible and safe. The goals of SILS and NOTES are to be less intrusive, more easily tolerated and aesthetic.

An Attempt to Build a National Prospective Electronic Database for Pancreaticoduodenectomies in Romania - Preliminary Results of the First Year Enrollment.

Introduction: National databases for pancreaticoduodenectomies (PD) have contributed to better postoperative outcomes after such complex surgical procedure because the multicentre collection of data allowed more reliable analyses with quality assessment and further improvement of technical issues and perioperative management. The current practice and outcomes after PD are poorly known in Romania because there was no national database for these patients. Thus, in 2016 a national-intent electronic registry for PD was proposed for all Romanian surgical centers. The study aims to present the preliminary results of this national-intent registry for PD after one-year enrollment. Patients Methods: The database was started on October 1st, 2016. Data were prospectively collected with an electronic online form including 102 items for each patient. The registry was opened to all the Departments of Surgery from Romania performing PD, with no restriction. Results: During the first year of enrollment were collected the data of 181 patients with PD performed by 24 surgeons from four surgical centers. The age of patients was 64 years (28 - 81 years), with slightly male predominance (61.3%). Computed tomography was the main preoperative imaging investigation (84.5%). All the PDs were performed by an open approach. The Whipple technique was used in 53% of patients, and a venous resection was required in 14.3% of cases. A posterior approach PD was considered in 16.6% of patients. The stomach was used to treat the distal remnant pancreas in 50.1% of patients. The operative time was 285 min (110 - 615 min), and the estimated blood loss was 400 ml (80 - 3000 ml). The overall morbidity rate was 55.8%, with severe (i.e., grade III-IV Dindo-Clavien) morbidity rate of 10%, and 3.9% in-hospital mortality rate. The overall pancreatic fistula, delayed gastric emptying and hemorrhage rates were 19.9%, 39.8% and 15.5%. Periampullary malignancies were the main indications for PD (78.9%), with pancreatic cancer on the top (48%). Conclusions: To build a prospective electronic online database for PD in Romania appears to be a feasible project and a useful tool to know the current practice and outcomes after PD in our country. However, improvements are still required to encourage a larger number of surgical centers to introduce the data of patients with PD.

Malignant endometriosis of the abdominal wall.

Endometriosis is a disease represented by the presence of extra uterine endometrial tissue. It is a rare condition, and malignant transformation is seldom. We report a case with clear cell adenocarcinoma oncogenesis on abdominal wall scar that appeared after years of a caesarian section. After diagnosis, surgical treatment was performed twice, due to the fact that the margins were infiltrated with tumor cells, with replacement of the defect with a polypropylene mesh. The patient was cured and discharged with a favorable prognostic. To the best of our knowledge, there are few reported cases of clear cell adenocarcinoma arising from abdominal wall endometriosis. It is a rare condition that appears mostly after abdominal surgical interventions that clinicians must be aware. KEY WORDS: Abdominal wall, Endometriosis, Cesarean section, Clear cell adenocarcinoma, Malignant transformation.

Analysis of p53 Protein Expression in Hepatocellular Carcinoma.

BACKGROUND AND AIMS: Hepatocellular carcinoma (HCC) has a growing incidence and studies regarding the risk factors or pathogenesis for this type of carcinoma benefit special interest. This study evaluates the correlations between p53 protein expression and clinical and laboratory factors in patients with HCC. METHODS: The study group included 76 patients diagnosed with HCC, either by biopsy or after surgical resection (with curative intent). Immunohistochemistry for p53 protein assessment was performed in all patients. Correlations between the protein 53 expression and age, tumour size, viral infection, liver cirrhosis were performed using the chi-square test (Pearson's chi-square) together with the contingency coefficient Kendall's coefficient in the tau-b form. RESULTS: In the study group, 51 patients were male (67%) and 25 female (33%). Cirrhosis due to hepatitis virus B or C infection (in a proportion of 63% of the study group) was not significantly associated with the presence of HCC. Altered expression of p53 protein was observed in 69 patients (91%). The relationship between p53 protein expression and patient sex (p=0.067), age (p=0.531), tumour size (p=0.270), presence of hepatitis B and C viral infections (p=0.7), and of liver cirrhosis (p=0.511) was not statistically significant. CONCLUSION: The p53 protein expression was not significantly associated with the demographic characteristics of the patients, tumour size, presence of viral B and C infections or liver cirrhosis.

Endoscopic ultrasound for the characterization and staging of rectal cancer. Current state of the method. Technological advances and perspectives.

Endoscopic ultrasound is the most accurate type of examination for the assessment of rectal tumors. Over the years, the method has advanced from gray-scale examination to intravenous contrast media administration and to different types of elastography. The multimodal approach of tumors (transrectal, transvaginal) is adapted to each case. 3D ultrasound is useful for spatial representation and precise measurement of tumor formations, using CT/MR image reconstruction; color elastography is useful for tumor characterization and staging; endoscopic ultrasound using intravenous contrast agents can help study the amount of contrast agent targeted at the level of the tumor formations and contrast wash-in/wash-out time, based on the curves displayed on the device. The transvaginal approach often allows better visualization of the tumor than the transrectal approach. Performing the procedure with the rectal ampulla distended with contrast agent may be seen as an optimization of the examination methodology. All these aspects are additional methods for gray-scale endoscopic ultrasound, capable of increasing diagnostic accuracy. This paper aims at reviewing the progress of transrectal and transvaginal ultrasound, generically called endoscopic ultrasound, for rectal tumor diagnosis and staging, with emphasis on the current state of the method and its development trends.

Characterization and staging of rectal tumors: endoscopic ultrasound versus MRI / CT. Pictorial essay.

Endoscopic ultrasound is recommended for rectal cancer staging. Transrectal ultrasound approach is able to overcome one of the limitations of this technique regarding circumferential rectal stenosis. Prior intrarectal administration of a small amount of fluid contrast agent optimizes the method, making it easier to distinguish the layers of the rectal wall and tumor formation. Endoscopic ultrasound focuses on the gray-scale mode. Additional procedures provide useful information for tumor assessment: Doppler ultrasound helps identify chaotic intratumoral vascularization; 3D ultrasound allows the assessment and accurate measurement of the tumor; elastography can identify focal tumor dysplasia within adenomas; contrast-enhanced ultrasound allows characterization of tumor microvasculature. Even if they are not as accurate in distinguishing rectal wall layers, cross-sectional imaging techniques (CT, MRI) can identify the anatomical relationships of advanced locoregional cancers, as well as possible distant metastasis. This paper aims at illustrating the main pathological aspects of endoscopic ultrasound multimodal examination useful for cancer staging.

[Clinical aspects with prognostic value in gastric cancer--analysis of 468 cases with gastric adenocarcinoma]. / Aspecte clinice cu implicatie prognostica în cancerul gastric--analiza a 468 cazuri de adenocarcinom gastric.

The aim of this study is to assess clinico-pathological parameters and find out the correlation between them and their possible prognostic value. We made a retrospective analysis of a group of 468 patients with gastric adenocarcinoma which were operated in the 3rd Surgical Clinic--Cluj Napoca--01.01.1998-31.12.2003. The median age was 62 years. Patients in pTNM 0 stage were significantly younger than the rest of patients, with an average of 7.5 years. The male/female ratio was 1.7:1, this ratio being significantly higher in cases with proximal gastric cancers. There was not found any significant correlation between the interval : onset of symptoms and surgery, and pTNM stage. The most frequent signs and symptoms were epigastric pain, weight loss, indigestion, fatigue, pallor and loss of appetite, each of them were found in more than 40% patients. Multivariate analysis of symptoms showed that weight loss (p=0.00638) was independently correlated to advanced pTNM stages. The number of signs and symptoms was significantly correlated to advanced pTNM stages (p=0.000026). This significant group of patients studied has maintained characteristics encountered in populations with higher incidence of gastric adenocarcinoma, men being more frequently affected, distal localization and intestinal histologic type being encountered more frequently.

[Morbidity and mortality in gastric cancer surgery--analysis of 468 cases with gastric adenocarcinoma]. / Morbiditate si mortalitate în chirurgia cancerului gastric--analiza a 468 cazuri de adenocarcinom gastric.

The aim of this study is to evaluate the morbidity and mortality in the surgical treatment of gastric cancer and the factors that could influencing them. We made a retrospective analysis of a group of 468 patients with gastric adenocarcinoma which have been operated in the 3RD Surgical Clinic-Cluj Napoca--01.01.1998-31.12.2003. We analyzed parameters related to patient, pTNM stage and type of treatment. Morbidity was significantly higher in these circumstances: elder patients, cases with lower serum levels of hemoglobin and total proteins, after Billroth II procedures; we found no significant differences of morbidity depending on gender, pTNM stage, type of intervention: simple or multiorgan resection, subtotal or total gastrectomy, radical or palliative procedure or only exploratory laparotomy, presence or absence of splenectomy or caudal pancreatectomy, D1 or D2 lymphadenectomy (in radical procedures), palliative resection or gastrojejunal bypass. Elder patients and male patients have had a mortality significantly higher; we found no significant differences of mortality depending on serum levels of hemoglobin and total proteins, pTNM stage, type of intervention: simple or multiorgan resection, subtotal or total gastrectomy, radical or palliative procedure or only exploratory laparotomy, presence or absence of splenectomy or caudal pancreatectomy, D1 or D2 lymphadenectomy (in radical procedures), type of restoring of the digestive continuity after subtotal gastrectomy, palliative resection or gastrojejunal bypass.

[Laparoscopic surgery of hepatic hydatid cyst at the 3rd Surgical Clinic, Cluj-Napoca]. / Chirurgia laparoscopica a chistului hidatic hepatic--experienta Clinicii Chirurgie III Cluj-Napoca.

In the III-rd Surgical Clinic Cluj-Napoca, during 1996-2005, there was operated laparoscopic 33 patients with hepatic hydatid cyst. The sex ratio was M10/F23, with a mean age of 34 years and with ages between 10 and 66 years. Hepatic echography was used in preoperative diagnosis. The hepatic hydatid cysts were situated in 9 cases in the left liver (II-III-IV Couinaud segments) and in 24 cases in the right liver (15 cases in the V-VI segments and 9 cases in the VII-VIII Couinaud segments). The laparoscopic treatment was performed by Lagrot pericystectomy at 31 patients and by ideal cystectomy at 2 patients. Around the cyst there were put switches impregnated with formalin 2% or hypertonic saline 20% to prevent peritoneal insemination. The cyst sterilization was done in most cases with hypertonic saline solution. The mean postoperative hospitalization was 5,6 days, with the range 1-21 days. Laparoscopic surgery with the well known advantages offers a good alternative to classic surgery in the treatment of hepatic hydatid cyst.

[Radiofrequency ablation of liver tumors: technique and preliminary results]. / Ablatia cu radiofrecventa a tumorilor hepatice: tehnica si rezultate preliminare.

Radiofrequency ablation is a therapeutic method more and more applied for unresectable liver tumors; the purpose of this study is to evaluate its advantages and disadvantages. A series of 14 cases with liver tumors was treated by radiofrequency ablation; in 5 cases (35.7%) a hepatic resection was associated. Laboratory data, complications, morbidity, mortality and survival were noted. Mean age was 57.4 years (40-70) for this series consisting of 8 women and 6 men. The mean number of tumors treated per patient was 2.2; the mean total tumoral diameter was 7.2 cm. There were no major technique related complications, nor perioperative mortality. Mean global survival was 507.4 days; one year mean global survival was 64.2% (9 cases) and two years mean global survival was 28.5% (4 cases). We presented the technique of radiofrequency ablation applied for liver tumors and our experience because it is less known and used in our country and there is a tendency to treat liver tumors by this mean.

Gallbladder carcinoma. A clinical study of a series of 38 cases.

We analyse a series of 38 cases of gallbladder carcinoma. All cases presented gallbladder stones and IVB was the most frequent TNM stage--29 cases (76.31%). Preoperative diagnosis was made in 9 cases (23.69%), all of them by ultrasound examination. Resective procedures was possible in 8 cases (21%), whereas radical cholecystectomy was possible only in 3 cases (7.9%). The histological findings were: adenocarcinoma in 28 cases (73.67%), papillary adenocarcinoma in 3 cases (7.89%) and undifferentiated carcinoma in 7 cases (18.4%). We conclude that the late presentation due to the absence of specific symptoms and the poor diagnosis performance were responsible for the failure of detection in early stages and therefore for the poor prognosis of gallbladder carcinoma.

Radiofrequency by open surgical approach in the treatment of hepatic tumours: early experience with 14 cases.

The aim of the study was the evaluation of radiofrequency in the treatment of hepatic tumours during laparotomy performed for hepatic tumours. The initial experience with 14 patients operated for hepatic tumours (5 primary and 9 metastatic) is presented. The paper also presents the technique concerning the intensity and duration of the power applied, the association with the surgical resection, the immediate postoperative evolution and the dynamics of the hepatic enzymes as well as the postoperative results of ultrasound and CT examinations performed within the first 6 weeks. The indications of RF during laparotomy and the place of RF ablation in the treatment of liver tumours in comparison with other ablation techniques are discussed

In situ thermal ablation of focal liver neoplasms, with a special emphasis on the intraoperative ultrasound-guided radio frequency ablation method.

In the last two decades an important number of image-guided procedures have been developed in order to treat focal liver tumors through ablation in a similar way with the surgical procedure, which is still considered as the curative method for patients with resectable hepatic tumours. Unfortunately this criteria does not apply to all patients and in those cases (nonsurgical patients), the techniques are becoming frequently used as standard independent or adjuvant therapies. Tumour ablation using thermal procedures is now considered as one of the most promising among these alternative ablation therapies. It is the goal of these techniques together with the continuous improvement in technology and increasing clinical experience, to become the treatment of choice for limited liver tumours, challenging surgical resection