PELVIC ACTINOMYCOSIS MIMICKING A LOCALLY ADVANCED PELVIC MALIGNANCY--CASE REPORT.

We present the case of a former user of an intrauterine contraceptive device (IUD) for 10 years, diagnosed with a bulky, fixed pelvic tumor involving the internal genital organs and the recto sigmoid, causing luminal narrowing of the rectum, interpreted as locally advanced pelvic malignancy, probably of genital origin. Intraoperatively, a high index of suspicion made us collect a sample from the fibrous wall of the tumor mass, large Actinomyces colonies were thus identified. Surgery consisted in debridement, removal of a small amount of pus and appendectomy, thus avoiding a mutilating and useless surgery. Specific antibiotic therapy was administered for 3 months, with favorable postoperative and long-term outcomes. Pelvic actinomycosis should always be considered in the differential diagnosis of pelvic tumors in women using an IUD. The association of long-term antibiotic treatment is essential to eradicate the infection and prevent relapses.

PALLIATIVE TREATMENT OF MALIGNANT ESOPHAGOPULMONARY FISTULAS WITH COVERED SELF-EXPANDABLE METALLIC STENTS (SEMSS). A SINGLE CENTER EXPERIENCE.

AIM: The aim of our study was to determine the efficiency of SEMSs in patients with esophagopulmonary fistulas, regarding fistula closure, enhancement of dysphagia scores and survival rates. MATERIALS AND METHODS: Between January 2004 and June 2014, from a total of 133 patients who underwent stent placement procedures, 26 were diagnosed with esophagopulmonary fistulas. In 19 cases the fistulas were caused by esophageal carcinomas and in 7 cases by bronchogenic ones. 16 patients developed aspiration pneumonia, 3 lung abscess and 7 subclinical fistulas. RESULTS: Complete fistula sealing occurred in 26 patients (100%). There were no immediate procedural complications except chest pain in 5 cases. After sealing of the fistulas and antibiotic treatment, pneumonia has regressed. After stent insertion, the dysphagic syndrome improved significantly (mean dysphagia scores decrease from 3.28 to 1.3 after stent insertion). The main goal of palliative therapy in patients with unresectable cancer and esophago-pulmonary fistulas is to close the fistulas, thus preventing the aspiration of saliva and food into the bronchus. Other goals include amelioration of dysphagia symptoms, maintenance of oral intake and improvement of quality of life. Ultimately covered expandable metal stents may increase survival rate as compared with other therapies. CONCLUSIONS: The endoscopic placement of covered SEMSs is the treatment of choice for malignant esophago-pulmonary fistulas.

Transarticular approach and retrograde plate osteosynthesis (TARPO) using implants with angular stability -- a series of 17 cases of complex distal femoral fractures type C3/AO.

AIM: The aim of this retrospective study was to evaluate the outcome of distal femoral fractures type C3 AO, using TARPO technique and plates with angular stability. MATERIAL AND METHODS: The study included 17 fractures type C3 AO, with 4 open fractures: 1 type I, 1 type II, and 2 type IIIA with bone loss Gustilo. All patients were operated by TARPO technique using Less Invasive Stabilization System-LISS (4 cases), Locked Compression Plates-LCP (8 cases) and plates with polyaxial stability (5 cases). The excellent stability of the construct allowed fast knee rehabilitation. The follow-up period included at least 12 months. RESULTS: 15 fractures healed within a mean time of 12.6 weeks,while 2 cases with open fractures and bone loss required secondary bone grafting. We recorded no infection or implant failures. The outcome using Neer scale was excellent in 9 cases and satisfactory in 7 cases (1 patient with discontinued follow-up). CONCLUSIONS: This demanding TARPO technique has the advantage of a faster rate of union and improved exposure of the knee joint. The locked plates provide a unique alternative in distal femoral fractures type C3 AO, as well as in osteoporotic and open fractures.

Corelation of lymphocytic infiltrates with the prognosis of recurrent colo-rectal cancer.

BACKGROUND: Recent studies are focusing on complementary prognostic and predictive markers that could complete the predictive TNM staging and one of the most promising directions is the study of tumor immune infiltrates. MATERIALS AND METHODS: Our 2-year retrospective study includes resection specimens from the primary tumors of 23 patients presenting to our clinic for a local or a distant relapse after colon or rectal cancer. From every primary tumor specimen we obtained immunohistochemically stained slides in order to assess cd3, cd4, cd8, cd45ro and cd68 infiltrates. Digital analysis assessed the density and percentage of positively stained cells in the normal peritumoral tissue, invasive margin and center of the tumor. RESULTS: A small density of cd8 positive cells in the peritumoral region was strongly correlated with a longer disease-free interval (p=0.009) and the Kaplan-Meier survival analysis showed that the percentage of cd8+ T cells could be used to stratify patients in terms of relapse risk (p=0.006). We found no correlation between invasion front infiltrates and intra tumoral infiltrates and the disease-free interval. CONCLUSION: Our study concludes that cytotoxic T-cell infiltrates in the normal peritumoral tissue could be used to predict a more aggressive tumor in terms of the relapse risk.

Results of surgical treatment of acetabular fractures using Kocher-Langenbeck approach.

AIM OF THE STUDY: To evaluate the results of acetabular fractures surgically treated using posterior Kocher-Langenbeck approach for internal fixation. METHODS: A series of 42 consecutive cases treated during a 4 year period was analysed. The mean age of the patients was 41 years. According to the Letournel classification 9 posterior wall fractures, 3 posterior column fractures, 11 transverse fractures,4 posterior column and posterior wall fractures, 10 transverse and posterior wall fractures and 5 T-shaped fractures were noted. RESULTS: Quality of reduction based on Matta's criteria shows anatomical reduction in 25 cases (59.5%), imperfect in 11 cases(26.2%) and poor in 6 cases (14.3%). Neurological injury represented by peroneal nerve palsies occurred in 3 patients(7.1%). Acute infection was noted in one case (2.4%). Clinical results (for 38 patients) was excellent in 9 cases (23.7%), good in 23 cases (60.5%), fair in 4 cases (10.5%) and poor in 2 cases(5.3%). There was a statistically significant correlation between quality of reduction and clinical results with r = 0.68 (Pearson coefficient). Heterotopic ossifications were recorded in 14 cases and osteonecrosis of the femoral head was recorded in 2 cases. CONCLUSIONS: Despite the relatively large number of complications,surgery treatment for acetabular fractures offers better results than conservative treatment, in which the complication rate is much higher.

[Regeneration capacity of the peripheral nerve: experimental study--final results]. / Regenerarea nervului periferic. Studiu experimental--rezultate definitive.

Any injury affecting peripheral nerve continuity is followed by a degenerative reaction from nerve itself and its muscle. Nerve regeneration is possible when the two ends are put in direct contact (direct suture), proximity (autologous or artificial grafts), or through muscle neurotization. The aim of this experimental study was to evaluate sciatic nerve degeneration and regeneration in rats after no suture (group 1), direct suture (group 2), nerve grafting (group 3) and muscle neurotization (group 4). Nerve samples were analyzed by optical microscopy at 8 and 16 weeks after surgery, and nerve degeneration (group 1), axonal growth (group 2) and neuromuscular regeneration (group 4) were assessed. Optical microscopy and different staining techniques confirmed nerve degeneration, regeneration, and axonal growth in different moments. Cholinesterase test after direct muscle neurotization showed enzymatic activity at the level of muscle implantation of nerve fibers, indirectly confirming the presence of neuromuscular synapse.

[Surgery in advanced cervical cancer]. / Consideratii asupra tratamentului chirurgical în cancerul de col uterin avansat.

UNLABELLED: The aim of this study was to highlight the importance of surgical treatment in advanced cervical cancer (IIB-IIIB). MATERIAL AND METHOD: Data from 179 patients with cervical cancer, admitted in the Clinic of Emergency Surgery, "Sf. Ioan" Hospital, Iasi, between January, 1st, 2003 and December, 31st, 2009, were collected. RESULTS: A number of 11 cases (6.1%) cases were without any clinical response, so that they benefit by radical radiotherapy; a radical surgical intervention was performed in the other 168 cases (93.7%), in 4-6 weeks after chemotherapy. No intraoperative complications were evidenced, but after surgical intervention we recorded: urinary troubles--10 (6.5%); lymphedema--3 (1.9%); posttoperative intestinal occlusions--2 (1.3%); extended dynamic ileus--2 (1.3%); phlebitis--2 (1.3%).

[Therapeutic approach in kidney trauma. Assessments of 49 patients treated at surgical emergencies clinics]. / Orientari terapeutice în traumatismul renal. Evaluari pe un lot de 49 pacienti asistati în clinica de urgente chirurgicale.

UNLABELLED: The aim of this study is to contribute to efficiency of therapeutical interventions, using an optimal stadialisation followed by a maximum preservation of renal function. MATERIAL AND METHODS: A number of 49 cases with polytrauma, included urinary lesions, were studied between January, 2002 and December, 2009. Demographical, clinical, paraclinical data were collected, as well as those regarding therapeutical measures. RESULTS: From a number of 1436 cases with polytrauma, 49 (3.41%) suffered from urinary tract prejudices and 36 (73.46%) with major kidney lesions--11 (30.55%) severe at admission; 5 (13.89%) patients with multiple lesions and hypovolemic shock. The conservative treatment was applied in 24 (66.64%) cases and other types of surgical interventions for the other patients. CONCLUSIONS: The urinary apparatus is affected in aproximately 10% of cases of abdominal trauma due to road and falls from heights accidents, especially in patients of 26-50 age groups: 30.5% with severe lesions, 13.89% with hypovolemic shock at admission, and 1 death. The treatment was conservative in 66.64% of cases and various types of surgical interventions for the others patients.

[Capacity for peripheral nerve regeneration. Experimental study--preliminary results]. / Capacitatea de regenerare a nervului periferic. Studii experimentale--rezultate preliminare.

Any injury affecting peripheral nerve continuity is followed by a degenerative reaction from nerve itself and its muscule. Nerve regeneration is possibly when the two ends are put in direct contact (direct suture), proximity (autologus or artificial grafts) or through muscle neurotization. The aim of this experimental study was to evaluate sciatic nerve degeneration and regeneration in rat after no suture (group 1), direct suture (group 2), nerve grafting (group 3) and muscle neurotization (group 4). Nerve samples were analyzed in optical microscopy at 8 and 16 weeks after surgery and nerve degeneration (group 1), axonal growth (group 2) and neuromuscular regeneration (group 4) were evaluated. Neuromuscular synapses after direct muscular neurotization are to be searched using the cholinesterase test.

[Postmastectomy breast reconstruction--outcome on 33 consecutive cases]. / Reconstructia mamara postmastectomie rezultate pe 33 cazuri consecutive.

UNLABELLED: Nowadays postmastectomy breast reconstruction for breast cancer, seems to receive greater acceptance than in the past due to three important reasons: the improvement of the methods and techniques of plastic surgery; the new improved materials used as breast prosthesis; the better informed patients. The aim of this study is to review the outcomes of breast reconstruction performed for patients with mastectomy for breast cancer. MATERIAL AND METHOD: The medical records of 33 consecutive patients who underwent breast reconstruction, during a one year period, at a large municipal hospital were reviewed retrospectively. The main parameters studied were type of reconstruction, morbidity rate and type and number of reoperations. RESULTS: Among 33 patients , a number of 30 patient (90.9%) had theirs breasts reconstructed using a prostesis material and for 3 patients (9.1%) a flap type reconstruction was used. Immediate breast reconstruction was the preferred method of reconstruction. No major complications were noted. Minor complications were present in 4 patients (12.5%): infection (1 case), haematoma (1 case), skin necrosis (1 case), device extrusion due to local infection (1 case). CONCLUSIONS: Immediate breast reconstruction using expander and implant technique offers very good outcomes with low morbidity rate, excellent cosmetic results and consists in small, reliable and perfect reproductible operations.

[Urinary tract trauma: anatomo-lesional, etiological and clinical considerations]. / Consideratii anatomo-lezionale, etiologice si clinice in traumatismele aparatului urinar.

UNLABELLED: Urinary tract injuries are rare lesions and account for about 3%, of all injuries and 10% of abdominal trauma injuries. The aim of this study is to review retrospectively a series of patients with urinary tract injuries treated in a general surgery clinic. MATERIAL AND METHODS: A series of 41 consecutive patients with urinary tract trauma who hospitalized in Surgery Clinic of "St. John" Hospital of Iasi during a 7 years period (January 2002 - December 2008). The main analyzed variable was age, mechanism of injury, anatomical site of injury, associated injuries, and methods of treatment, morbidity and mortality. RESULTS: Urinary tract injuries accounted for 3.2% of all abdominal trauma injuries. Adults males were more affected with 90.2% of cases. Traffic road accident and falls represented over 50% of cases. Renal trauma were present in 73.7% of cases, and associated lesions were present in all cases. Conservative treatment was applied for 24 patients (58.5%), nephrectomy (total or partial) was performed in 9 cases, suture of the urethra 1 case, suture of the urinary bladder 5 cases and cystostomy in 3 cases. Conservative treatment failed in 24 cases (58.5%), urinary complications were present in 8 patients (19.5%) and one patient died due to associated lesions. CONCLUSIONS: Urinary tract injuries are rarely encountered in trauma settings, to a high index of suspicion is necessary to establish the diagnosis. Renal trauma is the most fervently lesions and conservative treatment represent feasible solution for these.

[Considering risk factors and prevention in uterine cervical cancer]. / Consideratii asupra factorilor de risc si a preventiei in cancerul de col uterin.

UNLABELLED: Cervical cancer is a disease with important medical and social involvements and a severe evolution in advanced stage. Its high incidence in Romania situated this country on the first place in Europe. MATERIAL AND METHOD: The paper analyzed retrospectively a sample of 51 cases suffering from cervical cancer in advanced stage. The most important risk factors, depending on environment, genetic and lifestyle peculiarities of patients, were quantified. RESULTS: Age groups of 35-65 were involved in 70% of cases, those of maximum genital activity in 50.9% of cases and after the menopause in 45% of cases. The sample features: medium level of education, low socioeconomic standards, precarious health education in 45.9% of women, over 50% never seing controlled with a Papanicolaou test or cytohormonal smear. Diagnosis was carried out in advanced stadium (IIB-IIIB) for 75% of cases. CONCLUSIONS: Though the cancer of uterine cervix is committed oneself to a precocious diagnosis, due to a low level of sanitary education, the absence of the prevention testing concerning cells of the vaginal-cervix, the deficit hygiene, the smoking, the cases are diagnosed tardily, in advanced loco regional stages.

[Anatomo-clinical considerations regarding the celiac-mesenteric junction]. / Consideratii anatomo-clinice asupra butonului celio-mezenteric.

AIM: This work points out the access ways - both the classical ones and the ones less known and used - to the origin and the first centimeters of the superior mesenteric artery (SMA), underlining the advantages and disadvantages of each of them. MATERIAL AND METHOD: Our work is based on dissection of 30 human bodies and 200 selective arteriographies. RESULTS: There are two classical ways to access the first part of SMA: inter-duodeno-pancreatic and the left thoraco-abdominal ways. CONCLUSIONS: An access way to the origin of the SMA is necessary for the revascularisation through different techniques of the visceral territory depending on the SMA, taking into account the fact that at this level we have the most frequent localization of the atheroma plaques, which leads to acute or chronic intestinal ischemia (manifest in the form of postprandial abdominal 'angor').

[Splenic infarction in endocarditis: case report]. / Infarctul splenic in endocardita. Prezentare de caz.

Splenic infarction is a very rare event though it can occur in a multitude of conditions with general or local manifestations. Splenic involvement in infectious endocarditis can be either infarction or abscess formation. The clinical picture is usually nonspecific and the diagnosis is often not initially suspected. We present a case of a 67 year-old male patient with infectious endocarditis who has been diagnosed with a splenic infarction by abdominal CT scan. The infarction was a result of septic embolization from the infected endocardium. The patient was initially managed conservatively with triple antibiotic therapy and regular follow-up ultrasound scan. The persistence of abdominal symptoms and the suspicion of splenic abscess formation led to the decision of performing splenectomy. Although imaging can characterize the nature of a splenic lesion, it is sometimes impossible to differentiate between infarction and abscess without histopathological confirmation. Splenic infarction should be suspected in all patients with a past history of thromboembolic disease who complain of left upper quadrant pain and present with localized or systemic inflammatory signs. Unfavorable clinical course and suspicion of abscess formation are indications for surgery. The characteristic features of splenic infarction are discussed together with a review of the recent literature.

[True posttraumatic femoral artery aneurysm: a rare clinical entity]. / Anevrism adevarat posttraumatic de artera femurala. Entitate clinica rara.

Traumatic etiology in aneurysms is very rare. After arterial trauma we usually find pseudo aneurysms. True aneurysms are due to deterioration of the arterial wall in small and long-term repetitive trauma. Pseudo aneurysms are usually described on radial and cubital artery in patients who work with vibrating tools ("hypothenar and thenar hammer syndrome") and on axilar artery in those who use axilar crutches. We present a case of a woman with a true aneurysm of the femoral artery developed due to repetitive trauma of the femoral region at the work place. The patient presented as an emergency, with ruptured aneurysm and she underwent an emergency operation. The diagnosis was established late by histopathological examination. This is the first case of posttraumatic true aneurysm with this location. True aneurysms should be considered in repetitive trauma regardless of anatomical region.

[Axillary wound with complete vasculo-nervous section. Functional outcomes]. / Plaga axilara cu sectiune completa nervoasa si vasculara. Rezultate functionale. Caz clinic.

Axillary wound with complete vasculonervous section are rare in adults, males between 20 and 30 years being more affected. In children these lesions are even more rarely encountered. Immediate surgical repair of vascular and nervous sections is recommended. Neurological impalement may be severe when all nervous trunks in the axilla are affected. Recovery of the motor and sensitive deficit is a long process and is often partial, good functional outcome being rare. Recovery in children is supposed to be better due to a more rapid regenerative capacity of the nerves. We present the case of a 9-year-old boy with axillary wound and complete section of axillary artery, median, ulnar, radial and musculocutaneous nerves and medial cutaneous nerve of arm. Vascular reconstruction with venous graft and epiperineural nerve reconstruction was done. Kinetotherapy and physiotherapy was part of recovery treatment. Follow up at 15 months confirmed very good functional outcomes with almost complete motor and sensitive function of the limb.

[Traumatic rupture of the diaphragm: diagnostic considerations, prognostic factors, outcomes]. / Traumatismele diafragmului: consideratii diagnostice, factori prognostici, rezultate.

UNLABELLED: Diaphragmatic rupture remains a diagnostic challenge because of the lack of an accurate test demonstrating the injury. AIM: To analyze our experience with the management of these injuries, diagnosis problems, and to identify predictors of outcomes. MATERIAL AND METHOD: Sixty-one patients were treated for diaphragmatic rupture in our hospital, between January 1992 and August 2003. RESULTS: Blunt trauma accounted for 15 injuries (24.6%) and penetrating trauma for the rest of 46 injuries (75.4%). The preoperative diagnostic was established for 17 patients (27.8%), 7 blunt and 10 penetrating. Twenty-nine patients (47.5%) presented with hemorrhagic shock upon admission and 48 patients (78.6%) had associated injury with an average Injury Severity Score of 24 (range 6-75). All cases but 4 were operated on the first 12 hours upon admission. Two right penetrating lesions were treated conservatively and two cases presented after 11 and 23 years respectively from the trauma episode. Intraoperatively, 15 right lesions (24.6%), 45 left (73.7%) and one bilateral (1.6%) were identified. There were 9 deaths (14.7%) and 14 patients (22.9%) developed complications. CONCLUSIONS: Hemorrhagic shock upon admission, Injury Severity Score, mechanism of the injury and age strongly influenced the outcome (p < 0.05). In emergency trauma settings the diagnostic for diaphragmatic lesions is mainly established by laparotomy. A high index of suspicion and a thorough examination of both diaphragms during laparotomy is mandatory in order to avoid missing traumatic diaphragmatic injuries.

[Traumatic injuries to the spleen in adults]. / Traumatismele splinei la adult.

The management of splenic injuries is still controversial, with an increasing trend toward non-operative treatment. The aim of this study was to assess for patients with splenic traumatic injuries, the treatment methods, the factors contributing in selecting appropriate management and the patients outcomes. Between 1994 and 2003, 77 patients were admitted and treated in our hospital for splenic traumatic injuries. There were 69 blunt (89.61%) and 8 penetrating injuries (10.38%). Nineteen patients were initially proposed for non-operative treatment, eventually only 5 patients (16.49%) were successfully treated (success rate 26.31%). Splenic conservation was used in 6 patients (7.79%; success rate 100%) and splenectomy on 66 patients (85.71%). Indications for laparotomy were: hemodynamic instability (35 patients), peritonitis (9 patients) and the presence of hemoperitoneum and splenic injury (22 patients). Overall mortality was 7.79%, with 4 deaths in splenectomy group and 2 deaths in proposed non-operative group. In conclusion, conservative treatment of splenic injuries can be performed with good results and an increasing number of patients can be treated in this way. For this purpose are necessary a perfect selection of the patients, a surgeon skilled in conservative splenic techniques and good techniques facilities.

Abdominal wall actinomycosis associated with prolonged use of an intrauterine device: a case report and review of the literature.

The relationship between pelvic actinomycosis and the presence of an intrauterine device is well known. Abdominal wall actinomycosis with no involvement of pelvic organs in the presence of an intrauterine device is extremely rare. We report a case of a 32-year-old woman with a long-standing intrauterine device who developed abdominal wall actinomycosis. The diagnosis was established late by histopathological examination after an initial surgical procedure during which the abscess was evacuated and all the necrotic tissue was excised. Postoperatively, the patient developed two intra-abdominal abscesses, which were treated by surgical drainage. The combination of long-term high-dose antibiotic therapy with surgery led to successful management of the condition. We highlight the difficulty in diagnosis, necessity for an early postoperative diagnosis, and the importance of high-dose intravenous antibiotic therapy to prevent recurrence. Abdominal wall actinomycosis should be considered in intrauterine device users who present with abdominal abscesses of unknown origin.

[Laparoscopic splenectomy for epithelial cyst of the spleen]. / Splenectomia laparoscopica in tratamentul chistului splenic epitelial. Caz clinic.

Splenic cysts of all types are a relatively rare entity. The origin of epithelial cysts of the spleen is controversial, most probably congenital in origin. Generally, epithelial cysts of the spleen are asymptomatic and discovered incidentally. We present the case of a 40-year-old woman with a 3.5 cm splenic cyst diagnosed four years before. The cyst raised progressively in dimension, the actual size being of 6.5 cm. Computed tomography scan and magnetic resonance showed a central splenic cyst in close relations with main splenic vessels. An initial indication of partial splenectomy was established, eventually a total splenectomy being performed by laparoscopy due to close relations of the cyst with the main hilar splenic vessels. The hemostasis was assured with the aid of Ligasure Atlas 10 mm instrument. The pathology examination revealed a multilocular splenic cyst with a cuboidal epithelial lining. Central localization of splenic cysts represents an indication for total splenectomy. Laparoscopy provides a minimal access method of obtaining pathological confirmation of diagnosis, reduction of cyst complications, and a short hospital stay. This article discusses different aspects of epithelial cysts related to pathology, diagnostic and indications for operative treatment, a review of the literature being also presented.