[Surgical treatment of hyperparathyroidism]. / Tratamentul chirurgical al hiperparatiroidismului.

BACKGROUND: Hyperparathyroidism (HPT), the result of excessive secretion of the parathormone, is one of the most common endocrine disorders. In most forms of HPT, surgical parathyroidectomy is the best choice. AIM: This paper aims to examine patients with hyperparathyroidism operated in First Surgical Unit Iasi, in terms of indications, surgical technique and postoperative results. MATERIAL AND METHOD: We performed a retrospective study, in First Surgical Unit Iasi, during 2000-2008. Clinical, laboratory, intraoperative and histopathological data were included in a MS Access Office XP database. Statistical analysis was performed with the SPSS ver. 15.0 for Windows (Statistical Package for the Social Sciences, Chicago, Ilinois). RESULTS: There were examined 34 patients with HPT: 32 cases were primary HPT (94.12%), and two cases with secondary HPT (patients with renal failure). The men/women ratio was 6/28 and mean age was 50.09 +/- 2.23 years old. Clinical presentation was variable: the dominant symptoms were osteoarticular (67.6%) followed by neuropsychological (64.7%), digestive (17.6%) and renal (11.8%). Associated diseases were recorded at 47.06% of patients: arterial hypertension--32.4%, coronary heart disease--23.5%, heart rhythm disorders--17.6%, diabetes--11.8%, biliary lithiasis--5.9%, renal lithiasis--8.8% and thyroid hypertrophy--55.9%. In 8 cases, primary hyperparathyroidism was associated with other diseases of the endocrine glands: 4 cases with Multiple Endocrine Neoplasia (MEN) type 1; a patient with von Recklinghausen disease; a patient with associated hypothyroidism and diabetes; two cases that with papillary thyroid carcinoma. Positive diagnosis was supported by determining serum calcium, phosphorus and serum concentration of the parathormone (PTH). All patients were evaluated by ultrasound exam; the sensitivity of the investigation was 88.23%. 99Tc-sestamibi scintigraphy was performed in 32.35% of patients with a sensitivity of 72.72%. Parathyroidectomy was performed by Kocher's incision in 88.23% and minimally-invasive open approach in 11.76%. The following types of interventions have been performed: tumor resections (73.53%), subtotal parathyroidectomies (17.6%), total parathyroidectomies (8.82%). In patients with associated thyroid disease total thyroidectomies (26.5%) and subtotal thyroidectomies were done (11.8%). The postoperative morbidity rate was 2.9% (transient hypocalcemia). Histopathological examination revealed the presence of parathyroidian adenoma in 67.6% of patients (N=23), parathyroidian hyperplasia in 26.5% (N=9) and parathyroidian carcinoma in the others 5.9% (N=2). CONCLUSIONS: The diagnosis of HPT involves positive determination of calcium and PTH. The most useful imaging techniques, are 99Tc-sestamibi scintigraphy and ultrasonography, which locates in most cases, the parathyroid pathological glands. Surgical treatment is the only curative treatment of HPT, with medical treatment only role in preoperative preparation. The precise site of the parathyroidian lesion facilitates minimally-invasive approach. The postoperative follow-up is mandatory because of the increased potential for recurrence and for diagnosis of other endocrine tumors (in patients with MEN).

[Pancreaticoduodenectomy for pancreatic head cancer, 54 cases]. / Duodenopancreatectomia cefalica in cancerul de cap de pancreas--consideratii asupra 54 cazuri.

UNLABELLED: Pancreatic cancer has an increase rate in western countries. From the first pancreaticoduodenectomy (PD) performed by Kausch in 1909, the value of the resection in the treatment of pancreatic head cancer was disputed. AIM: To assess the PD with or without pylorus preservation as surgical treatment for pancreatic cancer. METHODS: Retrospective review of the clinical records of patients undergoing PD for pancreatic cancer. RESULTS: From January 1995 till December 2005, in the First and Third Surgical Units, "St. Spiridon" University Hospital Iasi, Romania, were performed 137 PD. From these, 54 cases were histologic diagnosed with pancreatic cancer; 23 cases underwent pylorus preserving pancreatico-duodenectomy (PPPD) and 31 patients, classical Whipple procedure (PDW). Mean age was 59.07 +/- 1.42 years old (26-75 years old), and male to female ratio was 29 to 25. Jaundice was presented in 51 cases (94.4%), abdominal pain at 39 patients (72.2%) and Curvoisier-Terrier sign at 37 cases (68.7%). Fever was observe only in 4 cases (7.4%). Other biological and imaging parameters (e.g. main diameter of the biliary duct, tumor and wirsung ) were also discussed, but no significant difference was found between PPPD and PDW. Pancreatico-jejunostomy was performed in 41 cases (28 during the PDW and 13 in PPPD) and 13 pancreatico-gastrostomy (3 during PDW and 10 during PPPD). Mean operating time and mean blood loss in the PDW group were 358.22 +/- 10.53 minutes and 587.74 +/- 60.87 mL. After PPPD, these figures were 326.08 +/- 15.04 minutes and 571.74 +/- 90.50 mL, but no significant difference was noted. Delayed Gastric Emptying (DGE) was presented at 15 patients: 8 in PPPD group and 7 in PDW group (p=0.322). Postoperative morbidity rate (excluding DGE) was 33.33% (8 cases in PDW group and 10 in PPPD group). Pancreatic leak has a rate of 5.55% (3 cases--one in PPPD group vs two in PDW group), biliary leak has a rate of 12.96% (4 in PPPD group vs 3 in PDW group)and duodeno-jejunal anastomotic fistula appeared in one cases (PPPD). Acute postoperative pancreatitis is presented in one case (PPPD group) and postoperative hemorrhage appeared in 4 cases (2 in PPPD and 2 after PDW). Hospital stay was 19.91 +/- 2.28 days in PPPD group vs 18.87 +/- 2.24 days in PDW group (p = 0.751). Postoperative mortality rate was 5.5% (one case after PPD and 3 cases after PDW). Histological exam diagnosed ductal pancreatic adenocarcinoma in 51 cases (94.44%). Mean long-term survival rate was 20.98 months (10.52-31.45 months; 95 CI) and no difference was revealed between PPPD and PDW (log rank test - p = 0.796). CONCLUSION: PD should be performed for any pancreatic tumor even without preoperative histologic confirmation. The results after PPPD (postoperative morbidity and mortality, long-term survival) are similar to that following conventional Whipple procedure, if the principles of viable and tumor free margins are observed.

[Pancreaticoduodenectomy with or without pylorus preservation: a retrospective analysis of 137 patients]. / Duodenopancreatectomia cefalica cu sau fara prezervarea pilorului: analiza retrospectiva a 137 pacienti.

OBJECTIVE: We performed a retrospective study to assess the postoperative results, long-term survival and quality of life after pylorus preserving pancreaticoduodenectomy (PPPD) versus standard Whipple pancreaticoduodenectomy (WPD). METHODS: A retrospective study was performed in a nonselected series of 137 patients who were operated in the Surgical Clinics of "St. Spiridon" University Hospital Iasi, Romania, from January 1st, 1995 till December 31, 2005. Demographics, preoperative and intraoperative data, as well as postoperative morbidity, mortality and follow-up were analyzed. Quality of life, after to at least six months after discharge, was also studied. RESULTS: There were no significant differences noted in demographics data. Jaundice was more frequent in the PPPD group as for WPD patients (p=0.047). For the most patients the digestive reconstruction after resection were performed as in Child technique: the first anastomosis was pancreaticojejunostomy (end-to-end or end-to-side), the second anastomosis was hepaticojejunostomy (end-to-side) and the last anastomosis was gastrojejunostomy end-to-side (duodenojejunostomy in PPPD group). For 31 cases a pancreatico-gastrostomy were performed. We also noted 14 cases with pancreatico-gastrostomy and duodenojejunostomy end-to-end, and a Roux jejunal loop for 3 patients with previous gastrectomy and gastrojejunostomy (Reichel-Polya). The operating time was shorter in the PPPD group as in WPD (p < 10-3), but the mean blood loss was the same. Postoperative morbidity rate was 46.8% in PPPD group vs 39.2% in WPD (p > 0.05), but the reintervention rate was significant higher in PPPD group (30.6% vs 15%; p = 0.027). We also noted no significant differences of Delayed Gastric Emptying, postoperative mortality rate (14.5% in PPPD group vs 10.1% in WPD group) and mean survival time (42.42 months (24.94 - 59.89; 95% CI) in PPPD group vs 46.78 months (28.07 - 61.50; 95% CI) in WPD group; log rank test p = 0.643). Pathological exam diagnosed a malignancy in 109 cases (54 cases with pancreatic cancer); we noted chronic pancreatitis in 22 cases. Quality of life was also the same in the two groups. CONCLUSIONS: PPPD and WPD were associated with comparable results, but, there is a tendency of increase rate of postoperative morbidity and mortality for PPPD patients. We also noted that postoperative quality of life is the same for both procedures.

[Laparoscopic assisted vaginal hysterectomy (LAVH). Overview on 25 case series]. / Histerectomia vaginala asistata laparoscopic (HVAL). Experienta preliminara pe 25 de cazuri.

The aim of the study is to evaluate the laparoscopically assisted vaginal hysterectomy (LAVH) in terms of indications, uterine size, surgical procedures and their safety, intraoperative complications and blood loss, operative time, concomitant surgical procedures and postoperative period of complications. A total of 25 patients underwent LAVH between 1998 and 1993, in our surgical unit. The mean age of our patients was 44.2 years (range 36-66). The most common indication was fibromyoma. The mean size of the removed uterus was 11.5 cm. The mean weight was about 242 g. The mean estimated blood loss was 155 ml and the mean operative time 150 min. Intraoperative complications included one case of bladder injury due to thick adhesions. Postoperative complications included 2 cases of cystitis, and 3 cases of ileus. The hospital stay was 2 to 7 days.

[Minimal invasive treatment of the adnexal surgical pathology]. / Tratamentul minim invaziv al afectiunilor chirurgicale ale anexelor.

Laparoscopic approach has become the "golden standard" in managing a wide range of adnexial sufferings. Most laparoscopic cases allow patients to recover quickly. Conventional ultrasonography appears to be useful in the preoperative selection for this surgery. Conventional pulsed Doppler and colour Doppler sonography proved their importance in the diagnosis of malignancy. The aim of the study is to evaluate the advantages and the limits of the minimal invasive approach in managing surgical adnexial sufferings. A retrospective study was carried on 75 operative laparoscopy cases performed between 1998-2002. Surgical procedures were performed mainly for ovarian cysts (69 cases, 92%), but there were also treated other types of adnexial pathology such as: hydrosalpinx (2), piosalpinx (1), tubal cysts (2), ectopic pregnancy (7), pelvic adherences (7) and one case of hydatid tubal cyst. Types of surgery performed were cystectomy (36), ooforectomy (11), salpingo-ooforectomy (10), fenestration (10), salpingectomy (6), lysis of adhesions (7). The mean operation time ranged between 50 and 80 minutes and the mean postoperative stay was of 3.65 days.

[Minimally invasive treatment of pulmonary and pleural hydatid cyst]. / Tratamentul minim invaziv al chistului hidatic pulmonar si pleural.

The incidence of hydatid disease is increased in Balkan region and Eastern Europe. The global incidence in Romania is 5-6 cases of 100,000 populations. The etiological agent is Taenia echinococcus. The pulmonary localization is about 30% from all cases with hydatic disease. The only efficient treatment is represented by surgical intervention with minimal visceral and parietal destruction. We will present 4 cases with pulmonary and pleural hydatic cysts that were treated with minimally invasive techniques. New minimally invasive approaches are developed to reduce physical discomfort, to offer a better intraoperative visibility, for the esthetic aspect of incisions, shorten hospitalization and quick socio-professional reintegration. The mean duration of hospitalization in these 4 cases was 8.5 days (limits between 7-12 days). The rate of complication and the necessary of analgesics were reduced. The medical treatment with Albendazole 10 mg/kg/day, 14 days in preoperative and 3 months postoperative period was followed in all patients. After discharge, imaging evaluation in the first 24 months is very important. The obtained results were excellent and we conclude that minimally invasive surgery in pulmonary hydatid disease represent a better method of surgical treatment.

[Jejunoileal bypass]. / By-pass-ul jejunoileal.

Obesity is a condition which can be found very frequently today, both in developed and 3rd world countries. The incidence of obesity in adult population of Romania is about 35%, and most of these patients are females. We'll present the case of a 54 years old woman with BMI = 57 kg/m2, who was hospitalized for the treatment of a postoperative eventration after an umbilical hernia. Her nocturnal breathing troubles, knee pains and walking difficulties made us consider the idea of a digestive by-pass. The surgical intervention consisted of jejunoileal by-pass, abdominoplasty and dermolipectomy with bipolar drainage. Many complications occurred in the postoperative period (renal failure due to severe diarrhea). The weight loss after 18 months was 37%, which means 66% of the weight surplus (similar results can be found in professional statistics--around 70%). After 18 mounts her weight is 95 kg and she allowed to consume any food. 18 mounts after the operation, the number of stools decreased to normal (1-2 per day). In conclusion the morbid obesity can and must be treated surgically. Jejunoileal by-pass is a highly effective procedure, but surgeons must be aware of the pact that severe complications which may occur anytime and must be treated immediately. After this kind of operation, weight stabilization can be achieved within 2 years, no diet being necessary as an additional treatment.