[Soft tissue reconstruction after total pelvic exenteration]. / Reconstructia defectelor tisulare dupa exenteratia pelvina totala.

Total pelvic exenteration leaves a major defect in pelvic-perineal region. Delayed healing, bowel fistulae, occlusion or protrusion and infection are frequent complications of this procedure. During 2000-2006, in General Surgery and Liver Transplantation Fundeni, 73 patients with advanced pelvic cancer and invasive recurrences were operated. For 42 patients, various procedures for pelvic and vaginal reconstruction (omental flap, muscular and musculo-cutaneous flaps--rectus abdominis and gracilis) were performed in order to fill the pelvi-perineal defects and restore form and function. Technical principles, indications, contraindications, advantages and disadvantages of these procedures are outlined. We found that complications related to total pelvic exenteration dramatically decreased and primary healing of the perineal wound was superior, facts that correlate with the literature data.

[Acute urinary retention in primary vaginal carcinoma: therapeutic approach]. / Retentie acuta de urina prin cancer de vagin: atitudine terapeutica.

Carcinoma of the vagina is a very rare disease. Primary vaginal carcinoma tends to spread by local invasion of the adjacent pelvic organs (without any kind of metastases) and secondarily through lymphatic channels. The aim of this report is to add observations concerning the surgical treatment of this rare occurrence of carcinoma. The 33-year old patient's history began with an acute urinary retention which imposed bladder catheterization. Local examination revealed a hard 3/3 cm large mass on the middle third of the anterior vaginal wall, invasive in the urinary bladder. Cystoscopic examination confirmed the tumor invasion in the trigone. Biopsy specimens of the tumor and histological examination showed carcinoma. Anterior pelvic exenteration with pelvic lymph nodes dissection and total colpectomy was performed and the patient received a continent urinary diversion to the skin (modified Indiana pouch), ovary transposition, vaginal reconstruction with gracilis myocutaneous flaps. Postoperative evolution was uneventful. Organ reconstruction surgery including continent urinary diversion, vaginal reconstruction will significantly improve the quality of life and don't change the body image of the patients after pelvic major surgical procedures such pelvic exenteration.

[Total pelvic exenteration in the treatment of advanced pelvic cancer]. / Exenteratia pelvina totala in tratamentul cancerului pelvin avansat.

Total pelvic exenteration (TPE) is a radical and aggressive procedure performed in the local advanced pelvic cancer started from any pelvic organ. The experience of 73 TPE performed for local invasive cancer and centro-pelvic recurrences with initial malignancy at the cervix (45 cases), rectum (19 cases), vagina (5 cases), endometrial (3 cases) and urinary bladder (1 case), in 61 females and 12 males with age range 27-78 years, are analysed. The procedures were performed for advanced pelvic cancer in 24 cases and also for invasive centro-pelvic recurrences in 49 cases (67.5%). In 5 cases, TPE was extended laterally. In 42 patients reconstructive procedures were added. All patients survived to surgery but 5 postoperative deaths (6.8%) were recorded. Complications occurred in 52% of cases, 38 from 73 patients had one or more than one complication with an average of 1.5 per patient. 22 among these patients (30%) requiring operative treatment. The average survival was 49.07 months, the median survival of 55 months and the estimated survival at 11 and 78 months was 66%, respectively 50%. The procedure is indicated in the absence of pelvic wall invasion and secondary distant dissemination and lengthens significantly the life span and increase the quality of life.

[Central pancreatectomy--indications, technique, outcomes]. / Pancreatectomia centrala--indicatii, tehnica, rezultate.

Central pancreatectomy is a conservative resectional procedure indicated for benign and low malignant tumors located in the neck and/or body of the pancreas. We report our experience on 5 patients and some considerations about this surgical technique from medical literature.

[Cystic dilatation of main biliary tract]. / Dilatatia chistica a caii biliare principale.

UNLABELLED: The choledochal cyst (particularly with congenital origin) is a clinical form from a complex syndrome of ecstasies of the intra-, extra-, or both situations of biliary tree. The disease has until now an unsure etiopathogeny. Very frequent to child, teen-ager and young adult the incidence decreases through the third age. During the period 1960-1998, 13 patients were operated on (annually rate 0.3). The extreme ages of our patients were 5 and 72 years; being operated six children and 7 adults (two of them being 63 and 72 years old). The clinical presentation was nonspecific. The jaundice (with or without cholangitis) (n: 7), right upper quadrant pain (n: 11), a palpable abdominal mass (n: 5) were registrated but the classic triad (Sénéque--Thailhefer) was in out series the exception rather than the rule. Concomitantly there were discovered different complications of the disease: hepatic biliary cirrhosis (n: 3--two macroscopic diagnosed and one microscopic confirmed), portal hypertension (n: 8), biliary lithiasis (including the intracystic stones) (n: 6) and cholangio-carcinoma (n: 1). The clinic and biologic preoperative diagnosis is up to date difficult and not sure like in our experience too. In our series, especially in the last 20 years, the accurate imaging diagnosis was helpful (the ultrasonography, CT, hepatic scintigrams). ERCP was not available for us until now. In concordance with Todani--Watanabe classification our patients were included in the following types: I-a (n: 6), I-b (n: 1), I-c (n: 2), II (n: 2), IV-a (n: 2). All patients were operated on: cysts-digestive derivations or partial excision of the cyst with billio-digestive reconstruction were the choice procedures at a beginning of our experience or for the very fragile patients (n: 5). The total excision of the cyst with choledochal--jejunostomy (Roux-en-Y) is the preferred method now (n: 8) when it is possible. The microscopic pathology of the disposable specimens (cystic wall) showed:--chronic intra- and perimural inflammation (n: 7);--severe displasia and metaplasia (n: 2); cholangiocarcinoma islands (n: 1); additional lesions: hepatic chirrosis (n: 1); hepatic fibrosis (n: 3). RESULTS: The postoperative morbidity--three patients--one of them died with a peritonitis. Long-term follow-up, effective for only 10 patients, reveled recurrent cholangitis in two cases treated by the reoperation of the former anastomosis; the other 8 patients had a normal evolution. CONCLUSION: The choledochal cyst is an exclusive indication for surgery as soon as it was discovered.

[Rectal hemangioma--a pseudoneoplastic form. A case report and review of the literature]. / Hemangiomul rectal--forma pseudoneoplazica. Prezentarea unui caz si revista literaturii.

A patient, 23 years old, is presented. He was admitted on in our clinic for a lower, very bleeding rectal tumor, the macroscopically characters evoking quite sure a malignant neoplasm. Three successive histopathologically examinations remained inconclusive and only the fourth suggested the diagnosis of benign glandular polyp. That conclusion strongly contrasted with all the data obtained by the macroscopically examinations. Nevertheless the therapeutically option was in favor of a sphincter-saving surgery, the practiced operation being a pull-through rectosigmoid resection (Babcock). Recovery of the patient which is in a good condition at present (two years after surgery). The histopathological examination of the operative specimen stipulated like diagnosis: rectal haemangioma with component parts of lymphangioma. Carrying on, the paper presented a review of the literature data referring to the very limited experience of others authors, regarding clinical aspects, diagnostics and therapeutically problems of the rectal haemangioma. In similar cases presenting voluminous rectal (or colonic) possibly benign tumors, haemangioma like, macroscopically diagnostic being difficult or unsure, but also without a certitude for a malignant tumor, it is recommended a sphincter-saving operation, adapted to the general status of the patient. In cases with malignant characters at the final histopathological examination, on the operative specimen, the transformation of the initial intervention in a amputation type surgery may be a possible alternative.

[Mechanical digestive system suturing devices]. / Suturile digestive mecanice.

Between 1994 (December)-1996 (May) 150 patients have been operated on using one or many stapling devices. The staplers disposable to us were the "Linear Cutter" or GIA (Gastrointestinal Anastomosis), "Linear Stapler" (TA) and "Intraluminal Circular Stapler" or EEA (end-to-end anastomosis) types, produced by ETHICON (Johnson and Johnson Ltd. Company). The principles operations performed were various digestive resections, intervisceralis anastomosis and interventions of reconstructions (in oesophagus surgery, ileal pouch etc.). The advantages of staplers applications are: a) the reduction of the time of operation, of the anesthesia, of the blood loss; b) a soft manipulation of the tissues; c) a smaller inflammatory reaction and the prevention of intraoperative septic contamination and d) a better and faster take back of the functionality of the anastomosis. There were only 4 intraoperative haemorrhages easy controllable. Postoperative complications: a) 3 haemorrhages medically treated; b) immediate leakage 1 patient after colorectoanastomosis, treated by Hartman colostomy; precocious, 7 patients and after 4-6 month, 2 patients. Corrective iterative interventions were necessary only in 5 patients. The operative mortality-1 patient, the cause of death being a bronhopneumonia after a radical oesophagectomy with oesophagoplasty (oesophageal cancer). There was not postoperative mortality depending of stapling application. We don't observed late postoperative complications like stenosis of various anastomosis, quoted in the literature, because the time of following of our 150 patients is too short (maximum 18 months). The conclusions are that the stapling devices are a real surgical progress with the conditions of a correct indication and adequate tactics and operative technique. The economical effort is justified and entirely compensated by the major benefits obtained for the patients.

[Cancer of the vulva]. / Cancerul de vulva.

UNLABELLED: Our study includes 50 patients operated on between on between 1970 - 1995 for vulvar carcinoma. The age of patients varied from 36 to 85 years old with a media of 59.4. The localisation of the lesions were: 42 (84%) on the major labia; 7 on the minor labia; 1 on the clitoris and 1 on the Bartholin's gland. Histopathologically there were 46 (92%) squamous carcinoma, 2 adenocarcinoma and 2 fibrosarcoma. The staging after FIGO classification: stage 1--7 patients (14%); II--22 (44%); III--20 (40%); IV--I (2%). Palpable lymphadenopathy in the inguino-femoral regions has been present to 24 (48%) patients, but with positive nodes (N+) only 16 (32%). Preoperative radiant therapy was applied to 21 patients (42%). All the patients were operated on: 1. total vulvectomy (vv) 15 cases (30%); 2. total vv + various lymphadenectomies 23 (46%); 3. partial vv 8 (16%); 4, different interventions 4 (8%). Iterative intervention for recurrencies: 9 cases (1 of them operated on by us 4 years anterior). Postoperative morbidity was present to 27 patients (52%): the main complication was the local infection of the wound +/- wound break-down; 5 of those patients presented also persistent lymphorrhagia. We don't noticed postoperative lymphedema of the inferior limb (limbs). Without postoperative lethality. Postoperative all the patients were submitted to a complimentary oncological treatment. The longest survival after the combined treatment was available specially for "N-"patients (but not exclusive). We verified 29 (58%) patients from the total of 50 (the rest being lost of evidence or having a short postoperative interval of time). The index of survival was: 1 year: 29 (100%); 3 years: 23 (79%); 5 years 16% (56%); and between 6 and 25 years 9 (31%). CONCLUSIONS: a) early diagnosis + therapy = good results; b) complex therapy is mandatory; c) optimal operation total vv + inguinal-femoral lymphadenectomy; d) the optimal prognosis is available for "N-" cases.