Adrenalectomy for Cushing's syndrome: do's and don'ts.

Aim. To present specific aspects of adrenalectomy for Cushing's syndrome (CS) by introducing well established aspects ("do's") and less known aspects ("don'ts"). Material and Method. This is a narrative review. Results. The "do's" for laparoscopic adrenalectomy (LA) are the following: it represents the "gold standard" for secretor and non-secretor adrenal tumors and the first line therapy for CS with an improvement of cardio-metabolic co-morbidities; the success rate depending on the adequate patients' selection and the surgeon's skills. The "don'ts" are large (>6-8 centimeters), locally invasive, malignant tumors requiring open adrenalectomy (OA). Robotic adrenalectomy is a new alternative for LA, with similar safety and conversion rate and lower pain drugs use. The "don'ts" are the following: lack of randomized controlled studies including oncologic outcome, different availability at surgical centers. Related to the sub-types of CS, the "do's" are the following: adrenal adenomas which are cured by LA, while adrenocortical carcinoma (ACC) requires adrenalectomy as first line therapy and adjuvant mitotane therapy; synchronous bilateral adrenalectomy (SBA) is useful for Cushing's disease (only cases refractory to pituitary targeted therapy), for ectopic Cushing's syndrome (cases with unknown or inoperable primary site), and for bilateral cortisol producing adenomas. The less established aspects are the following: criteria of skilled surgeon to approach ACC; the timing of surgery in subclinical CS; the need for adrenal vein catheterization (which is not available in many centers) to avoid unnecessary SBA. Conclusion. Adrenalectomy for CS is a dynamic domain; LA overstepped the former OA area. The future will improve the knowledge related to RA while the cutting edge is represented by a specific frame of intervention in SCS, children and pregnant women. Abbreviations: ACC = adrenocortical carcinoma, ACTH = Adrenocorticotropic Hormone, CD = Cushing's disease, CS = Cushing's syndrome, ECS = Ectopic Cushing's syndrome, LA = laparoscopic adrenalectomy, OA = open adrenalectomy, PA = partial adrenalectomy, RA = robotic adrenalectomy, SCS = subclinical Cushing' syndrome.

Parathyroidectomy: is vitamin D a player for a good outcome?

Background: The field of parathyroidectomy (PTx) is complex and brings together many specialists. Even if the surgical approaches changed from classical to minimally invasive PTx, a good outcome is correlated with an adequate localization before and during PTx, while blood assays, such as parathormone (PTH) or 25-hydroxyvitamin D, become useful additional markers. Aim. Specific aspects related to parathyroidectomy and vitamins D (VD) were introduced. Material and Method. The article represents a PubMed-based narrative review. Results. The growing evidence regarding the high prevalence of hypovitaminosis D and early detection of primary hyperparathyroidism (HPT) requires a particular attention to the association of these two disorders, which may be incidental, but some common pathogenic links are displayed. Low VD stimulates PTH production as a secondary or even tertiary type of HPT diagnosis. VD deficiency is associated with larger parathyroid adenomas and higher levels of PTH before and after surgery for primary HPT. Asymptomatically and normocalcemic forms of primary HPT, which are not immediately referred to PTx, require a normalization of the VD levels. VD supplements are safe under some serum calcium cutoffs and offer a better outcome after PTx. However, primary HPT is cured by surgery and, if the indication is well established, this should not be delayed too long to replace VD. Up to half of PTx cases may experience increased PTH levels after surgery, but most of these are transitory if rapid VD correction is done and only a few remaining cases will eventually develop persistent / recurrent primary HPT. Conclusion. A close following of 25-hydroxivitamin D represents one of the keys for a good outcome in the field of parathyroid surgery. Abbreviations: HPT = hyperparathyroidism, MEN = Multiple Endocrine Neoplasia Syndrome, PTx = parathyroidectomy, PTH = parathormone, VD = Vitamin D.

Considerations on risk factors correlated to the occurrence of gastric stump cancer.

Gastric stump cancer (GSC) is the malignant tumor that develops in the gastric remnant after partial gastrectomy was performed both for benign and malignant lesions. This paper presents the results of the case studies from the scientific literature, which focused on GSC, and has been published in the last 10 years. The search was performed with the help of the specific tools offered by the international databases. The subject was approached because of the constant rising incidence of GSC in the past few years, now reaching values between 1% and 7%. The outcome report is consistent and similar to the period that ended approximately 25 years ago, when general surgeons dedicated a significant part of their activity to treating gastric ulcer. Statistics revealed that the main risk factors are the following: the type of reconstruction after distal gastrectomy (Billroth I or Billroth II), the presence of duodenogastric reflux, the time between gastric resections, and the moment of diagnosis of gastric stump cancer, the initial pathology for which partial gastrectomy was performed, gender, age, helicobacter pylori infection, Epstein Barr virus infection and the presence of vagotomy. All the authors have significantly contributed to the article and have been involved in the writing of the manuscript in draft and any revision stages, and have read and approved the final version.

Esophageal disorders in mixed connective tissue diseases.

Extra Musculoskeletal manifestations are a distinct clinical entity that refers to a combination of clinical features, which are found in multiple rheumatic diseases. Besides the standard manifestations, other organs can be damaged such as the vascular system, skin, gastrointestinal tract, musculoskeletal system, cardiopulmonary system, hematologic system, kidneys, and the central nervous system. Among the gastrointestinal MCTD symptoms, the most frequent are the esophageal ones. Treatment of patients with MCTD must be performed by both medical and surgical multidisciplinary teams in order to provide a management suitable for the patients' needs. All authors have contributed significantly and have been involved in the writing of the manuscript in draft and any revision stages, and have read and approved its final version.

The laparoscopic management of simple hepatic cysts.

The hepatic polycystic disease represents a hereditary condition with a reduced prevalence in the general population, sometimes associated with polycystic kidney disease. We present a retrospective observational study applied to 49 patients. The study aimed to observe the laparoscopic surgery of simple hepatic cysts. Laparoscopic approach is a simple and successful surgery management of these types of cysts.

Retrospective study minimally invasive management of postoperative lithiasis of the common bile duct.

INTRODUCTION: Postoperative common bile duct (CBD) lithiasis holds a significant place in the bilio-pancreatic pathology, both due to its high frequency as well as to the diagnostic and treatment issues it triggers. MATERIAL AND METHODS: Based on a 5-year experience (2008-2012), assessed retrospectively, totalling 51 patients with postoperative lithiasis of CBD, we tried to elaborate on several recommendations for the treatment of this pathology. The recommendations were guided by the existing alternative therapeutic options and by the ideas in the literature regarding the results achieved by every manner of treatment. RESULTS: The rate of clearance of the CBD was of 93.6%,the morbidity rate was of 10.65% and the mortality rate was of 0%, which entitles us to deem the effectiveness of the minimally invasive treatment as maximum in the treatment of this pathology. CONCLUSIONS: The endoscopic treatment of postoperative lithiasis of the CBD proved to be possible, efficient and we believe it good to be used as a principle; open surgery should be the solution in case of failures or of contraindications to minimally invasive treatment.

Minimally invasive treatment of cholecysto-choledochal lithiasis - "Rendez-vous" technique.

INTRODUCTION: In our paper we present the results of a study that was meant to provide a complex answer to the question:"Which is the most appropriate, most correct and least expensive treatment for mixt cholecysto-choledochal lithiasis(MCCL)?" MATERIAL AND METHODS: Based on a five year experience (2008-2012), analysed retrospectively, during which 143 patients with MCCL were treated, we are trying to find answers to some of the questions that we have asked ourselves from the very beginning of this period. The answers were guided by alternative therapeutic options, for a pathology that does not have a "gold standard", with respect to the solutions available. RESULTS: Given the fact that the period during which the study was conducted was chosen randomly and that the patients were included consecutively, the representativeness of the results is ensured for any other patient diagnosed with this pathology and admitted to a clinic with the same specialty, dimensions and equipment as the one presented. CONCLUSIONS: This paper compares the results of our study to those of others, in terms of different or similar approach therapeutic options, developed in other minimally invasive surgery centres in the world, the final conclusions being encouraging for the therapeutic sequence that we practice.

Is prosthetic repair of the abdominal wall in clean-contaminated surgical interventions possible?

The present study tries to provide an expressive, customized answer to the question in the title. The study relies on a ten-year experience (2000-2009), evaluated retrospectively on a group of 488 prosthetic repairs of incisional herniae, out of which 432 were performed in a clean environment and 56 cases in a clean-contaminated one. The two groups are superimposable based on the Apache score. The visceral surgical procedures associated to the surgery of the parietal defect were varied (cholecystectomy, appendectomy, enterectomy enterorrhaphy,colectomy colotomy-colorrhaphy, hysterectomy with adnexectomy). The assessment of postoperative suppurative complications showed no significant differences between the two groups (p 0.001). These results lead us to the idea of defining the indication for parietal prosthetic repair in a contaminated environment. The major factors of this decision are: the nature, the source and the amount of the septicinoculum, the duration of exposure, the intensity of the host inflammatory response (more difficult to quantify), and finally the surgical judgment. The last mentioned factor will evaluate the above-mentioned data and will take into account that not all bacterial contaminations are necessarily followed by an established infection. Thus, additional exaggerations - which would mean taking useless, ineffective precautions- as well as negative exaggerations - which would mean hazardous boldness- will be avoided.

Prognostic and predictive factors in colorectal cancer.

Colorectal cancer (CRC) is an important public health problem; it is a leading cause of cancer mortality in the industrialized world, second to lung cancer: each year there are nearly one million new cases of CRC diagnosed worldwide and half a million deaths (1). This review aims to summarise the most important currently available markers for CRC that provide prognostic or predictive information. Amongst others, it covers serum markers such as CEA and CA19-9, markers expressed by tumour tissues, such as thymidylate synthase, and also the expression/loss of expression of certain oncogenes and tumour suppressor genes such as K-ras and p53. The prognostic value of genomic instability, angiogenesis and proliferative indices, such as the apoptotic index, are discussed. The advent of new therapies created the pathway for a personalized approach of the patient. This will take into consideration the complex genetic mechanisms involved in tumorigenesis, besides the classical clinical and pathological stagings. The growing number of therapeutic agents and known molecular targets in oncology lead to a compulsory study of the clinical use of biomarkers with role in improving response and survival, as well as in reducing toxicity and establishing economic stability. The potential predictive and prognostic biomarkers which have arisen from the study of the genetic basis of colorectal cancer and their therapeutical significance are discussed.

[Certitudes and controversy regarding neural elements preservation in total mesorectal excision technique (ETM)]. / Certitudini si controverse privind conservarea elementelor nervoase în tehnica de excizie totala a mezorectului (ETM).

The total excision of the mezorect, as a technique of reference in the surgical solution of rectal cancer, is evaluated today through the view of the oncological and functional outcome. Within the functional outcome, the genito-urinary disorders which follow the damage of the pelvic vegetative nervous structures, still cause discussions and controversy among dedicated specialists in this area. The work plans to share an experience of over ten years of ETM practice, in which the technico-tactical accumulation have been realized progressively, outlining a relatively codificated attitude, centered on the "critical moments" of this intervention.

Peculiarities of diagnosis and treatment in the polyp-cancer sequence.

Colorectal cancer, a public health problem with major social implications, has attracted major economic resources and specialized centers focused in the direction of obtaining an early diagnosis from effective screening means in the last decades. It is obvious that the therapeutic results and the social costs are primarily dependent on the precocity of diagnosis. The present paper aims to bring to attention a number of orientations, which may open a new perspective in approaching the genetic and molecular level of these lesions. Out of these, the value of the molecular screening based on the detection of the APC gene located on the short arm of chromosome 5, a method that allows the selection of the subjects to be subjected to further endoscopic screening is underlined. The optimization of the costs as well as the increased compliance of the subjects to such a method is thus accomplished.