[The efficiency of lumbar transperitoneal laparoscopic sympathectomy--100 cases revue]. / Eficacitatea simpatectomiei lombare laparoscopice pe cale transperitoneala--analiza a 100 cazuri.

Lumbar sympathectomy, classical surgical technique applied in conventional arteriopathy treatment, has acquired new valence by the development of laparoscopic technique. In a period of ten years (2000-2009), a number of 100 patients with different cause of arteriopathy have been operated by transperitoneal lumbar sympathectomy. Mean age was 62 years. Indication establishment has been achieved by an investigation protocol taking into account clinical and Para clinical criteria and methods. Postop evolution has been simple with very low morbidity and mortality zero. Particularly good evolution had patients in stages II and III of the disease, with missing effort claudication and repaos pain. Unfavourably results were recorded in advanced stages of disease, at diabetic patients with plenty of associated disease, therefore 9 patients suffering amputations of limbs. Results immediate and late were coordinated with stage and age of patients. Lumbar laparoscopic transperitoneal sympathectomy represents a viable alternative in artheriopathy treatment because of reduced morbidity--representing a chance for these very delicate patients.

[Giant parathyroid adenoma with hypersecretion and severe clinical course--clinical case]. / Adenom paratiroidian gigant hipersecretant cu evolutie severa--prezentare de caz.

Primary hyperparathyroidism is an uncommon disease, with late diagnosis due to insidious and various symptoms. Parathyroid adenoma is the most frequent cause of primary hyperparathyroidism. This paper presents the clinic of disease, the necessary exams to perform in order to obtain a positive diagnosis also the case of young man with long evolution period prior to diagnosis and with severe complications at bones. Surgery represents the only valid option resulting complete healing.

[Three centuries of surgery at Coltea Hospital]. / Trei secole de chirurgie la Spitalul Coltea.

The authors present the evolution of surgery at Coltea Hospital during the last three centuries. After a brief history of the Coltea hospital and its masters surgeons, the attention is drawn on the masters efforts to optimize the care, equipment and surgery techniques, things that became of national and world-wide importance.

[Umbilical hernia in adults: laparoscopic approach with prolene mesh--is it a safe procedure?]. / Hernia ombilicala (HO) la adult: plasa de prolene montata laparoscopic este un procedeu eficace?

INTRODUCTION: The laparoscopic approach for umbilical hernia is more and more used, but few results are reported. The aim is to evaluate the efficacy and safety of using the Prolene mesh placed laparoscopically in umbilical hernia treatment. MATERIAL AND METHOD: Between 2004-2006, 21 patients with umbilical hernia, aged of 34 to 77 years, were submitted to intraperitoneal application of a Prolene mesh to cover the umbilical ring. The mesh was sewed by Protack staples or transfascial stitches. Before deflating the patients, the greater omentum was interposed between the mesh and the bowel. It is notice that 8 patients were obese, 6 patients had omental or bowel adhesions to the peritoneal sac and 5 patients had ascites due to liver cirrhosis. The patients were discharged 24 to 48 hours after the operation and followed up for 6 to 12 months. RESULTS: All patients were alive at the end of follow-up, without hernia recurrence or complications due to the Prolene mesh in the abdominal cavity. In 3 patients we registered subcutaneous seromas for 1 to 3 weeks (imposing evacuation by punction) and 5 patients kept a mildly deformed umbilical scar after the cure of large hernias. DISCUSSIONS: In the literature are mentioned the techniques using composite or two-layers meshes. Prolene meshes are not agreed by some authors, for the supposed risk of bowel lesions. In our trial were no such complications. CONCLUSION: Laparoscopic repair using Prolene intraperitoneal mesh in umbilical hernia is a safe, efficient and rapid method, avoiding infections complications in obese or cirrhotic patients.

[The sentinel lymph node technique in colorectal cancer using in vivo dye--utility and limits]. / Ganglionul santinela in cancerul colorectal folosind colorant intravital--utilitate, limite.

The aim of this work is to analyze the importance of sentinel lymph node technique in the treatment of colorectal cancer. There are presented data from literature concerning sentinel lymph node, especially papers about the place of sentinel lymph node method in the treatment of colorectal cancer. This work also shows the experience of Surgical Clinical Department of Coltea Hospital in the use of sentinel lymph node method in colorectal cancer (8 patients with colon cancer and 9 with rectal cancer). There are presented the criteria for inclusion in the study group (26 patients initially proposed for the study) and the exclusion criteria, the diagnostic method using an in vivo dye and the pathology study. The study of the literature and our experience leads to the conclusion that the identification of the sentinel lymph node in colorectal cancer doesn't modify the dissection of the lymphatic area. This procedure may change the adjuvant treatment for colorectal cancer. The discussion is still open concerning the importance of lymphatic micro metastases found by RT-PCR and immunohistochemistry methods. More studies are necessary to clarify these problems.

[Learning curve and his consequences in laparoscopic antireflux surgery]. / Curba de invatare si consecintele ei in interventiile laparoscopice antireflux.

The laparoscopic fundoplication became the gold standard of the laparoscopic antireflux surgery (LARS). Our aim is to indicate the evolution of the learning curve as well as its consequences on the patient's outcome. We studied the gastro-esophageal reflux (GER) cases treated laparoscopically in Coltea University Hospital throughout 6 years. We gathered a group of 40 patients with an average age of 54, 57 years and a sex ratio F:M = 1.67. The patients had either a simple GER disease, small and medium hiatal hernias (21 cases) or giant hiatal hernias (GHH--19 cases). Two equal groups resulted: group 1 consisted of the first 20 patients operated from 1999 to 2002, group 2 consisted of the rest of the patients. Operating time, hospital time, complication rate and postoperatory endoscopy were compared. The average of the operating time was calculated. For giant hiatal hernias, a separate average was also taken into account. The total operating time for GER, small and medium hiatal hernias was 115 min in group 1 and 80 min in group 2 meanwhile for GHH it was 143 min vs. 130 min. The average operatory time was 129 min vs. 105 min. All these differences were statistically significant but there were no differences concerning complication rate and post-operatory endoscopy. Although the learning of the laparoscopic fundoplication requires practice, the learning curve does not have influence on the patients' outcome.

[The complications of colostomies]. / Complicatii ale colostomelor.

The evaluation of the frequency of complications that arise after colostomies performed for colorectal and genital neoplasm, and also the treatment possibilities for these complications. In Coltea Hospital, Surgical Department during 1984-2002 there have been admitted and surgically treated 891 patients with colorectal cancers, among which, 484 had rectosigmoidal neoplasm. We have treated 25 patients with complicated genital neoplasm (19 rectovaginal and recto-bladder-vaginal fistulas following cervical cancers, 5 pelvic tumoral blocks following ovarian cancers and a vulvar cancer with local invasion). For all these patients we performed: 25 Hartmann resections, 75 Reybard resections, 73 Dixon resections and 147 rectal amputations, with 294 colostomies (30 iliac anus in continuity-Audrey, 18 on a stick, 232 terminal and 14 cecostomies for protection or decompression). There were 48 complications following the colostomies: 10 cases of stenosis, 14 prolapses, 7 intestinal loop necroses and 17 parastomal hernias, all of them surgically managed. Terminal colostomies and colostomies for protection are still frequently used in surgical departments, having strict indications. Because they are frequently performed as emergencies, at patients with poor biological status they are often enough followed by complications, most of them with little gravity. The complications can be avoided by a proper therapeutic choice and in most cases can be managed with a surgical intervention.

[The rectal cancer--between resection and amputation. Surgeon's decalogue]. / Cancerul rectal--între rezectie si amputatie. Decalogul chirurgului.

The surgeon has the opportunity to use a lot of treatment choices taking into account the site, the progression and the aggressiveness of the rectal tumors. If the treatment of anal cancer have been the same over the last years there are a few problems regarding the rectal cancer, especially for the one, which is distal and locally advanced. The therapeutic choice must take into account the following factors: the site of the tumor, the circumferential invasion, the local and distant spread, the complications and loco-regional recurrences, the anatomical shape of the pelvis, the possibility of developing tumor implants on the residual rectum, the equipment of the hospital, the experience of the surgical team, the accuracy of stoma technique, and the previous results in patients survival. In a trial of 381 patients with recto-sigmoidian and anal cancers we performed 171 rectal amputations, 29 Hartmann procedures and 76 laparotomies and colostomies. From the 276 patients with colostomy 172 (62.31%) were followed. The survival rate was: 6-10 months for the patients with laparotomy and colostomy, 16-24 months for those with palliative procedures (55.8%) and 5-17 years for those with radical procedures. From the point of view of the authors the rectal amputation with colostomy it is an alternative between oncological safety and patients comfort. This kind of surgical procedure must be done in specialized centers excepting the emergencies.

[Conversion in laparoscopic surgery]. / Conversia în chirurgia laparoscopica.

AIM: The conversion causes evaluation in dynamics. METHODOLOGY: The study is a retrospective analysis of the conversion to open surgery in 1993-2001 period, indifferently of the moment and the determinant cause. The yearly dynamics of the conversions was divided by operation types and surgeons. There were also analysed the moment and the cause of the conversion. RESULTS: There were realised 3961 laparoscopic operations (by 7 experienced surgeons and a lot of young surgeons), with 244 conversions (6.2%), percentage variable depending of the operation (3.3% in hernioraphies, 5.3% in cholecystectomies, 8.2% in gynecologic procedures, 12.1% in appendectomies, 33% in abdominal esophagus procedures, 33% in splenectomies) and on surgeon (until 0% and 8%); the differences until the surgeons don't depend on their experience and for the same surgeon, the experience accumulation doesn't reduce the conversion rate. The most conversions happen after a simple inspection or a minimal dissection (73.1% in cholecystectomy) caused by the existence of plastron, the discovery of a difficult anatomic situation or of another pathology; more rarely, the conversion happens in the principal time (23.4% in cholecystectomy), doing to hemorrhage, impossible dissection, visceral injury or even at the end of the operation (3.5% in cholecystectomy), doing to hemorrhage, loss piece or calculs. CONCLUSIONS: The conversion rate depends especially on the correctness of the indication of laparoscopic approach and not on the surgeon experience, what proves that it is a moment of surgical maturity. Decide from the beginning, in the moment of the recognition of a difficult situation and not after the occurrence of a complication, modifies neither the morbidity, nor the much discussed hospital stay.

[The laparoscopic procedures on abdomen with adhesions]. / Interventii chirurgicale laparoscopice pe abdomen cicatricial.

The scar abdomen is more and more seldom a contraindication of the laparoscopic approach. According to Rohr it is classified in scar abdomen after Mac Burney, suprapubic or supraumbilical approach and of the polyoperated patients. Our trial consists in 452 patients with laparoscopic operations consecutive open abdominal surgery (out of the 3900 patients undergoing celioscopic procedures between 1995-2001). The laparoscopic procedure was performed distant to the previous operation in 95.1%, on a neighboring organ to that initially conventionally operated in 4.1% or on the same organ in 3 patients (0.8%). We lead no preoperative fatalities, but the conversational rate was 12% (54 patients), due to the high-risk dissection or to the unsolvable bleedings by laparoscopic means (2 cases). The operative accidents consisted in visceral injuries soloed by laparotomy. Postoperatively we registered 5 port site seronas, 1 deep vein thrombosis and 1 pneumonia. The evolution and the mean hospitalization was the same for the scar abdomen patients with the operative procedure accomplished laparoscopically as for non previously operated patients. The data support the feasibility of the laparoscopic procedures on scar abdomen, using the "open laparoscopy" with a reasonably increased conversational rate.

[The therapeutical strategy for locally advanced breast cancer]. / Strategia terapeutica în cancerul mamar local avansat (C.M.L.A.).

As for the other cancers, the strategy of therapy of breast cancers is going to a unitary standardization. In our department between 1984-1999 we are operated 1040 patients with breast cancers, which means 25.3% of all cancers treated. 688 (64.3%) were CMLA, 646 (96.7%) of them were in patients women and 22 (3.3%) men. The mean age was 52.4 years (3-84 years). All patients were divided into two trials and analyzed: retrospectively (A) 312 (46.7%) and prospectively (B) 356 (53.3%) patients, 51.2% of patients was in III and IV TNM stage. The patients from trial B were treated concerning with specific therapeutically protocol, adapted by age, anatomopathological form, volume of tumor, skin or thoracic wall invasion, inflammatory lesions, lymph node invasion and physiological period. The results were: the increase of number of radical surgical interventions, the decrease of the morbidity, the increase of survival and a better quality of life.

[The capacity of preoperative ultrasonography in predicting technical challenges in laparoscopic cholecystectomy]. / Ecografia preoperatorie ca factor de predictie al dificultatilor tehnice intraoperatorii în colecistectomia laparoscopica.

UNLABELLED: Ultrasonography is a nonsophisticated, cheap and safe exploration, that makes it the most used non-invasive method in the diagnosis of biliary diseases. Present study aims to evaluate preoperative ultrasonography's capacity of predicting technical challanges in laparoscopic cholecystectomy (LC). MATERIAL AND METHOD: The trial is represented by a sequence of 100 patients undergoing LC in 2001. The conversions to open procedure were excluded. Patients with certified lithaisis were re-examined by ultrasonography the day before surgery. The sonographic features as size, volume (scleroatrophic gallbladder), function (distension, contraction), wall thickness, hydrops, number and size of stones, infundibular position (impactation) of the stones, perivesicular liquid collections hepatic and pancreatic aspects, main bile duct caliber were registered. During LC, the difficulty in performing the procedure was measured using a 10 points-score of following parameters: 1 peritoneal and perivesicular adhesions; 2. Difficult grasping of the gallbladder; 3. Cystic duct's dissection; 4. Cystic artery; 5. Liver bed; 6. Difficult cystic stappling; 7. Gallbladder's wall efraction; 8. Need for intraoperative cholangiography; 9. operative bleeding; 10. Operative time. RESULTS: Gallbladder's and the number, the size and infundibular impactation of the stones was significantly associated to ultraoperative difficulties (p < 0.05), the other parameters having not a sensitive influence upon LC procedure. CONCLUSION: Preoperative ultrasonography is able to furnish valuable data in predicting LC challenges.

[Strategy and tactic in the treatment of local advanced rectal cancer]. / Strategie si tactica în tratamentul cancerului rectal local avansat.

In local advanced rectal cancer (LARC) was defined at the work group in rectal cancer as a tumour what invade the serosa or neighbouring organs, associated with invaded perirectal or mezorectal nodes, with internal fistulae, peritoneal carcinomatosis and locoregional recidives. On a trial of 97 patients, the authors present personal experience, in comparison with literature data regarding therapeutic strategy and tactic of parameters: operability and the moment of operation, indication of preoperative radiotherapy, the type of operation, excision of the metastasis, adjuvant therapy and attitude of locoregional recidives. The survival of the patients was 21.6% at 3 years and 15.4% at 5 years.

[Analysis of 3100 laparoscopic cholecystectomies]. / Analiza a 3100 colecistectomii laparoscopice.

AIM: To evaluate the results of laparoscopic cholecystectomy (LC) in the 8 years period. PATIENTS AND METHODS: First LC in Coltea Hospital was performed in September 1993 and introduced for treatment of patients with gallbladder disease. From September 1993 to February 2001 LC was performed in 3100 patients. Mean age 51.2 years (ranged from 8 to 87 years) among 2512 women and 588 men. 232 (7.48%) of the cases were patients with acute cholecystitis. Intraoperative cholangiography was performed in 112 cases (3.6%). RESULTS: Conversion to open cholecystectomy (OC) was necessary in 111 patients (3.58%). Operative complications occurred in 16 (0.5%) patients: CBD lesions in 4 (0.12%) patients, bleeding from cystic artery--12 (0.38%) patients. In one patient CBD injuries was recognized at the time of operation and after conversion to OC primary ductal repair was performed. Postoperative complications occurred in 44 (1.41%) patients: a) local infection--in 15 (0.48%) patients (subhepatic abcess-3, wound infection-9. b) bile leakage--in 21 (0.67%) patients. c) haemoperitoneum because of the bleeding: from the abdominal wall at the trocar insertion site--in 2 patients, from a. cystica-one patient. d) obstructive jaundice due to stone in CBD--in 5 patients (endoscopic papillosphincterotomy and stone extraction was performed). There 21 reoperations due to complications: 13 laparatomies and 8 relaparascopies. Two patients (52 and 64 years old) died after LC-mortality 0.06 per cent. Mean hospitalisation day was 3.8. CONCLUSIONS: To prevent iatrogenic CBD injuries correct preparation with a clear identification of the anatomic structures is essential. Relaparascopy and endoscopic retrograde cholangyopancreatography can be successfully used in the treatment of complications after LC.

[ Epidemiological and clinical-therapeutical considerations on 500 operated cases of uterine cervix cancer]. / Consideratii epidemiologice si clinico-terapeutice asupra a 500 cancere col uterin operate.

AIM: Optimization of the treatment on uterine-cervix neoplasia, in a general surgery department. MATERIAL AND METHOD: Between 1984-1999, in Coltea Surgical Department were operated 746 uterine-cervix cancers. We selected two trials of 250 females, similarly regarding age and stadium. The A trial (250 females) were treated and operated 1984-1989, the study being retrospectively, and the B trial (250 females) treated and operated between 1990-1995, the study being prospectively by introduction of cisplatyn and carboplatyne chemotherapy in the advanced steadies. In the B trial, on registrated many mutations with negative epidemiological implications as: the grow the number of new cases, the diminution of immunity, the abandon of the screening, a possible grow of irradiations (Cernobâl accident), and the belated of presentation to medical consultation. RESULTS: The complex treatment, comparative in two trials, show a grow of lifetime, at 5 years in B trial from 82.1-93.4% in the 1st and 2nd steadies, 50.7-60.4% in the II B study and 12.9-28.5% in the III study. In the IV study the grow of lifetime was under 24 month. CONCLUSIONS: The resumption of the screening. Complexes therapeutical protocols for each study. Widely introduction of polichemotherapy in the advanced steadies.

[Ultrasonically activated scalpel in laparoscopic surgery advantages and limits]. / Bisturiul cu ultrasunete în chirurgia laparoscopica: avantaje si limite.

UNLABELLED: The disadvantage of monopolar coagulation, the limits of the bipolar coagulation and the frequent changes of instruments during laparoscopic procedures, are three elements that make the harmonic dissectors very useful in laparoscopic surgery. MATERIAL AND METHOD: In Surgery Clinic were operated with anatomic scalpel (HS), in the last month: 50 cholecystectomies, 25 appendectomies, 12 partial ovarectomies, 10 anexectomies and 2 splenectomies. We used 5 and 10 mm instruments, especially the ETICON scissors. RESULTS AND CONCLUSIONS: After our short experience with HS and in concordance with literature, we consider that: The advantages are: the features to coagulate nearest delicate anatomic structures (biliary tree, large bowel, blood vessels) the absence of the smog and the slag; the scissors is a versatile device which allow the dissection and the coagulation without changes the instruments. The limits are: hemorrhages after insufficient coagulation or prehension, the necessity of the learning curve, high costs of the disposable materials. The HS device represent a real progress, especially for that laparoscopic surgery which requires the coagulation of blood vessels placed in thick and fat structures.

[Incidents, accidents and complications in laparoscopic surgery]. / Incidente, accidente si complicatii în chirurgia laparoscopica.

Between 1995-1999 in Coltea Surgical Clinic were performed 2498 laparoscopic operations (1957 cholecystectomies, 541 other procedures). The laparoscopic approach consisted in 1 to 6 ports of 5 to 12 mm. Conversional rate was, 176% and reintervention was required in 0.76% of cases. In 4 cases (0.10%) parietal bleeding imposed conversion or early reintervention. Parietal emphysema was not significant in our trial. Wound infection or chondritis occurred in 0.72% of cases; only one patient had to be reoperated. Post-incisional hernia developed in 0.08% of patients. We don't treat patients with cancer by laparoscopic approach, but the 4 patients with unknown neoplasia in our trial didn't develop port metastases. Our trial suggests the real benefit of the laparoscopic approach also concerning parietal morbidity.

[Considerations on 988 breast cancers]. / Consideratii pe 988 cancere de sân.

AIM: Therapy schedule improvement. MATERIAL & METHOD: The study includes 988 patients (which 16 men) with breast cancer who underwent surgery between 1984-1998. Out of them 63.2% were in advanced stages. The patients were divided in 2 homogenous groups: trial A = 520 patients treated between 1984-1991 (in stade: I = 2, II = 240, III = 246, IV = 32) studied retrospectively, and trial B = 468 patients treated between 1992-1998 (in stade I = 3, II = 212, III = 235, IV = 18) studied prospectively. In trial B the complex therapy schedule was improved according to disease's stade, local breast aspect and patient's biological status, straining on neoadjuvant therapy. To the entire group 945 radical mastectomies (95.6%) were performed. Only 628 (63.5%) could be properly followed up. RESULTS: Global 5 years survival rate was 72% (improved from 69% in trial A to 72% in trial B). The survival rate varied according the stage from 100% (stade I), 88% (stade II), to 22% (stade III) and 2% (stade IV). In the advanced states, the local recurrencies at 5 years were of 22% and the methastases of 17%. CONCLUSIONS: The neoadjuvant therapy, selectively applied upon stade and patient improves the 5 year survival rate. Every patient with an advanced breast cancer can benefit of a complex, differentiated and well guided treatment. The adequate operation earn the important role in powering the neoadjuvant and adjuvant therapies. Further results improvement requires restarting the collectivities and high risk persons screening.

[Technical solving variants of external biliary and pancreatic fistulas]. / Variante tehnice de rezolvare a fistulelor externe biliare si pancreatice.

Two cutaneous postoperative fistulas--pancreatic and biliary--was solved by an anastomosis of maturate fistulas traject with duodenum and respectively an Y jejuno loop (Roux) with good results.