[Upside-down stomach and hiatal hernia]. / Upside-down stomach si hernia hiatala.

Hiatal hernias represent a special variant of diaphragmatic hernia in which there is a transdiaphragmatic migration of the stomach through the esophageal hiatus. There are 4 types admitted--sliding (type I), paraesophageal (type II), mixt-combining elements for both previous types (type III) and complex (type IV) and represents at most 5-15% from all hiatal hernias. Upside-down stomach is a special form of organoaxial volvulus of the entire stomach in a sac of mixt hiatal hernia (type III) or complex (type IV). There are asymptomatic forms, but the majority of the patients present signs of gastroesophageal reflux and up to one third may show complications such as bleeding, acute volvulus with obstruction or perforation. Surgical intervention is the only treatment option for the gastric volvulus and offers a durable resolution. The ideal surgical technique, the gold standard, consists in reduction of the stomach in the gastric lodge, resection of the sac and calibration of the hiatus adding a gastropexy or antireflux procedure.

[Surgical management of acute pancreatitis. One hundred years of evolution]. / Managementul chirurgical al pancreatitei acute. 100 de ani de evolutie.

The aim of the paperwork is to present the evolution of surgical management of acute pancreatitis for a period of more than a century, by using the literature data that reveal the important moments in the knowledge of patho-etiology, in clarifying the definition and classification and, last but not least, in the progress of biological and image exploration, the right timing and the permanent development of surgical procedures so that the general mortality should decrease up to 10-15%, as it nowadays. The need for surgical intervention in acute pancreatitis is the controversy that appeared during this period. Until the mid of the 20th century, mainly on the basis of the clinic diagnosis, only the severe cases were recognized and became subjects of surgical exploration, with disastrous results. A great step forward was the dosage of urinary and serum amylase that allowed the non-surgical diagnosis of the disease, so that some patients could be treated successfully without surgery. Introduction of prognosis criteria by Ranson, the dosage of C-reactive protein together with CT scanning of the injury: interstitial - edematous or necrosis,the fine needle aspiration for bacteriology and the adoption of a definition and unitary classification resulted in a major change in therapy, in general, and in the surgical procedures. Necrosectomy combined with a drainage method, practised and developed by Beger since 1982, becomes a surgical dogma. Minimally invasive procedures became a reliable alternative to classic procedures due to the diversity and permanent development of laparoscopic, endoscopic and radiologic techniques.

[Pseudo-Meigs syndrome, a rare variant]. / Varianta rara de sindrom pseudo-Meigs.

The pseudo- Meigs syndrome is defined as a pelvic tumour, other than the ovarian fibroma complicated with ascites and hydrothorax that can be recovered after the tumour is surgically extirpated. The uterine leiomyoma is an extremely rare cause of this syndrome, only 24 cases have been recorded so far, most of them presenting hydropic degeneration or necrosis. The case exposed by us, a 50- year old obese,with nanism woman, presented clinical, biological and imaging characteristics of the syndrome; moreover, she had arterial high blood pressure for more than five years, fact that didn't need postoperative treatment. She was sent to the ER because she had severe respiratory insufficiency, arterial high blood pressure, tachycardia and, at the clinical examination, she presented massive right hydrothorax, ascites, and pelvic tumour. The biologic explorations (the benign cytology in the pleural liquid and ascites, CA-125 with ten times the normal value) and the imagery completed the picture of a Meigs/ pseudo-Meigs syndrome that implied the laparotomy. The H-P examination and the postoperative evolution confirmed the diagnosis. We presented this case in order to emphasize both its rarity and its real positive and differential diagnosis problems.

Intussusception of efferent intragastric loop after gastrojejunostomy--an exceptional cause of high occlusion and hematemesis.

Jejunogastric intussusception (GI) is an extremely rare complication of gastrojejunostomy (GJS) that may appear any time after surgical intervention. Less than 200 cases have been reported so far, on very small series. Young female, 32, who 12 years ago was operated for a gastroduodenal disease that she doesn't know many details about. She presented severe pain in the superior abdominal segment posteriorly irradiated, incoercible biliary nausea followed by hematemesis. The endoscopic, imaging and biological explorations suggested a huge gastric tumor that occupied the whole stomach and was bleeding diffusely. The rapid acute evolution asked for the urgent laparotomy that emphasized: soft tumour mass, intragastrically mobile without any scar at the stomach or duodenum level; adherent to the posterior of the stomach we discovered a ball of jejunal loops that couldn't be undone. The anterior gastrotomy sets the diagnosis: JGI of the efferent loops of a GJS. We hardly managed to reduce the intussusception, without resection, the loop being absolutely viable. In order to prevent a relapse, and because the anastomosis was not justified it was taken down. JGI in a patient presenting GJS must be taken into consideration in the presence of epigastric pain that would not cease, biliary nausea followed by hematemesis and rapid deterioration of general health status.

[The great omentum in surgical pathology]. / Marele epiploon in patologia chirurgicala.

The aim of the survey is to bring forward the relationship structure-function-pathology of the great omentum from the surgical point of view. The common origin (similar) with that of the spleen and the structural particularities give the great omentum distinct responding potentialities in pathology and these have challenged the anatomists, anatomo-pathologists and surgeons to a more careful and deep research for the last one hundred years. The study corroborates data from literature with the authors' experimental, clinical and microscopic research regarding the vascularization, the lymphoreticular component and the innervation, with the aim of emphasizing the functions of the great omentum in pathological conditions: plasticity, adherence to traumatized and swollen areas, neo-vascularization, absorption of fluids and phagocytosis. Concerning the innervation, by using special techniques, we have managed to emphasize neurofibres in interlobular spaces. By using clinical observation and microscopic study, we can notice dynamically the changes of the great omentum in the inflammatory pathology and in front of the malignant tumour invasion. Last but not least, this survey pays our respects to professor Ion Kiricuta, the first who used the great omentum in plastic surgery and whose studies stimulated the research concerning the great omentum that has been a subject for the international conferences for the last 20 years.

[Rare case of retroperitoneal malignant Schwannoma]. / Caz rar de Schwannom malign retroperitoneal.

UNLABELLED: Malignant Schwannoma, recently renamed malignant peripheral nerve sheat tumor retroperitoneally localized, represents 0.01 of retroperitoneal tumours. A 41-year old woman, without pathological record--and without cutaneous neurofibromatosis--hospitalized for increased volume of the abdomen, without symptomatology, is diagnosed after the imaging and biological tests--without CT and RMN--with retroperitoneal tumour. The unusual size of tumour--6000 gr.--the macroscopic aspect suggesting malignancy (histopathologically and immunohistochemically confirmed), the relatively easy extirpation which, nevertheless, required caudal spleen- and pancreatectomy as well as transvers colectomy, the absence of proximity adenopathy and remote secondary determinations, the simple postoperative evolution represent overwhelming elements in this case. Two years after the operation, during which the patient was under chemotherapy, on a routine control we found a relapse at a distance from the initial tumour (primitive tumour ?), totally operable. For the time being, after almost five years from the first operation, there are no clinical, biological and imaging changes. CONCLUSIONS: the retroperitoneal space is quite enough for the development of large tumour masses, without symptomatology. The present case combines most characteristics of retroperitoneal neoplasms: large or very large size, quasi-absent symptomatology, difficulty in preoperative diagnosis, surgical tactics and techniques--quite often, the total extirpation of tumour mass led to the sacrifice of other organs within the limits of a justified risk--and unforeseeable evolution with relapses having the same characteristics.