Gastroduodenal Surgery in Cirrhotic Patients - Case Series and Literature Review.

Specific risk factors for gastroduodenal surgery in cirrhotic patients have been identified, which dictates for a more personalized management. The retrospective study was conducted between 2012-2019 on twelve patients (7 cases of duodenal ulcer, 2 cases of gastric ulcer and 3 patients with gastric cancer). We took into account a number of possible factors involved in the unfavorable evolution of patients, based on data published in the literature so far. In order to follow the involvement of each factor we compared two groups of patients, one with unfavorable evolutions, exitus and another with favorable evolutions. Emergency surgery, the presence of ascites at the time of intervention, a higher than 30 MELD score, alcoholic cirrhosis, liver encephalopathy and liver failure are common factors that are found in a high percentage (between 75% and 100%) in patients who have had an unfavorable evolution, exitus. The same risk factors are found in much lower percentages in patients who have evolved favorably postoperatively, most between 12.5% and 25%. We analyzed preoperative aspects, surgical approach, complications and risk factors for these patients, compared them with the results of our study and identified future therapeutic possibilities. For CHILD B or C patients, the indication for surgery should be discussed in advance with a multidisciplinary team. Endoscopic submucosal dissection or discontinuation of D2 dissection should be considered in these patients.

Colorectal Cancer Biomarkers - A New Trend in Early Diagnosis.

Colorectal cancer (CRC) is one of the most widespread malignancy, posing as a great challenge due to its high incidence and mortality in both genders. Yet, it also stands as one of the most preventable diseases because of its known malignant transformation mostly from tubular adenomas or serrated polyps, therefore offering a strong incentive to the screening programs that are being developed for this disease. Current diagnosis of CRC has surely evolved along with the evolutionary step in gastrointestinal technology of flexible endoscopy. These innovations have promoted colonoscopy as a primary choice for screening programs of colonic lesions, proving to be of great benefit for patient's well-being. In this review, we present the current status of CRC screening methods from the non-invasive options to the long developed colonoscopic and imaging techniques. We search through PubMed and Medline databases and chose relevant articles on CRC with focus on blood based biomarkers and stool based tests. Additional relevant publications were also according to the reference lists of firstly identified articles.

Correlations between CD34 Immunolabelled Blood Vessels and CD34 mRNA Expression in Colorectal Cancer.

PURPOSE: This study aims to determine the correlation between microvessel density of CD34 immunolabelled blood vessels and CD34 mRNA gene expression in colorectal cancer tissue. MATERIAL/METHODS: Standard immunohistochemistry and gene expression was perform on samples collected from 76 patients with colorectal cancer in order to determinate the number of CD34 immunolabelled blood vessels and the relative quantity of CD34 mRNA. RESULTS: For the study group, the mean CD34 immunolabelled microvascular density (MVD) was of 307/mm2, and the mean CD34 gene expression value for colon cancer was 2.303. The low p value (<0.001) of the Spearman correlation test showed a significant direct correlation between CD34 MVD and CD34 gene expression for the entire study group. CONCLUSIONS: CD34 gene`s expression can be looked at as a prognostic factor in colorectal cancer.

Endomicroscopy with Fluorescent CD105 Antibodies for "In Vivo" Imaging of Colorectal Cancer Angiogenesis.

The aim of this case report was to evaluate the feasibility of in vivo acquisition of microscopic images using fluorescent CD105 antibodies for molecular imaging in human colorectal cancer. After excluding the presence of tissue autofluorescence, the antibody solution was topically administered through a spray-catheter. The targeted area was analyzed by eCLE and images were recorded. The fractal dimension of tumor vessels and the vessel density were determined using ImageJ software. Immunohistochemistry was used as a gold standard. In vivo CLE analysis of CD105 expression enabled the study of tumor vascular network, revealing a chaotic structure.

Prognostic factors in resectable pancreatic cancer.

The pancreatic cancer is a disease with exponentially increased incidence, especially over the last decades, being the sixth or even fifth cause of death by cancer in most of the modern societies. Moreover, it is estimated that almost 95% of the patients with this disease are presenting to the doctor in the advanced and unresectable stages. Also, over the past few decades the development and advance of the surgical methods and techniques have improved only morbidity and hospital postoperative mortality, without significant impact on survival. In this way, in the present mini-review we want it to make a short description for some modern aspects regarding the factors implicated in pancreatic cancer survival.

Therapeutic management of massive subcutaneous emphysema, bilateral pneumothorax and pneumomediastinum after anterior cordectomy for in situ vocal cord carcinoma - case report.

We present the case of a 70 year-old smoker patient, who was admitted in hospital for removal of a tumour located on the left vocal cord. After direct suspension laryngoscopy (with tumorbiopsy sampling), preliminary histopathological exam revealed an in situ carcinoma. At 2 weeks after histopathological confirmation, the left vocal cord was removed by anterior approach, under general anesthesia. In the first 24 hours after surgery, the patient presented an ischaemic stroke, with a deep coma and left hemiplegia, which necessitated mechanical ventilation and specific neurological treatment. Under mechanical ventilation, the patient developed massive subcutaneous emphysema, bilateral pneumothorax and pneumomediastinum,which required tracheostomy and bilateralpleural drainage, in order to limit suddenly installed respiratory insufficiency. After an 18-day interval of intensive care therapy,the patient was released at home, considered to be surgically cured and had a moderate remaining left brachial monoplegia,which was almost totally cured in the next six months.

Importance of Laparoscopic Assessment of the Uterine Adnexa in a Mayer-Rokitansky-Kuster-Hauser Syndrome Type II Case.

In the case reported, diagnosed with Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome, the presence of normal ovaries proved to be challenging to confirm due to unusual high positioned (ectopic) ovaries. MRKH syndrome is a rare pathological condition characterized by a spectrum of the Mullerian duct abnormalities resulting in congenital aplasia of the uterus and of the upper part (2/3) of the vagina, developed during embryogenesis. At the same time, the mullerian development is interdependent with the Wolffian (mesonephric) duct and this explains the associated renal abnormalities (MRKH type II). Laparoscopic assessment was of great importance in defining the exact anatomic characteristics of MRKH syndrome.

Hysterectomy for benign uterine pathology: comparison between robotic assisted laparoscopy, classic laparoscopy and laparotomy.

OBJECTIVE: Hysterectomy is one of the most important surgeries in gynecology and requires a lot of care and skill. In this study we attempt to make a comparison between laparoscopic hysterectomy, robotic assisted hysterectomy and abdominal hysterectomy for treatment of uterine pathology. MATERIALS AND METHODS: We conducted a study comparing 29 patients who were treated by robotic assisted laparoscopic hysterectomy in Cisanello Hospital, Pisa, Italy, 30 patients who were treated by laparoscopy in General Surgery Clinic, Craiova and 30 patients who were treated by abdominal hysterectomy in General Surgery Clinic, Craiova. RESULTS: Comparing the surgeries, it was noticed that the operative time of a robotic assisted interventions is the largest, 183.9 minutes. Even if the duration was greater, the time needed to perform vaginal suture was lower, 17.75 minutes to 22.79 minutes by classic laparoscopic approach. In terms of blood loss we concluded that intraoperative blood loss was lowest during a robotic surgery, 199.3 ml versus 285 ml in the laparoscopic group and 417 ml in the laparotomic group. CONCLUSIONS: Robotic assisted laparoscopic hysterectomy is a feasible method that can be used very successfully to treat patients diagnosed with benign uterine pathology.

The importance of full tests of incidentally detected premalignant lesions.

Early detection of asymptomatic phase or paraneoplastic manifestations in precancerous lesions and an early, correct and accurate diagnosis in terms of pathology of the lesion in question, makes important chances of healing and prolonged patient's life expectations. We present the case of a young patient who came to the emergency room and then admitted in the cardiology department with a heart rhythm disorder. The medical investigations that followed (gastric endoscopy, biopsy, histological and IHC exams), finds gastric polyps, which proved to be gastrointestinal stromal tumors (GIST).

Current issues in gastric cancer epidemiology.

Gastric cancer, one of the most common malignant tumors of digestive tract continues to be a major health problem by frequency, aggressiveness and low rate of cure in symptomatic stage. Although its incidence is decreasing (especially in the West), globally the gastric cancer is ranked fourth in incidence among cancers at various sites. Despite these developments, the gastric cancer mortality, overall declining globally, is high. especially in the West where even if diagnosed fewer cases of gastric cancer, TNM stages are advanced and have a poor prognosis. In contrast, in Japan, where the incidence is still high, the percentage of cases diagnosed at the stage of "early gastric cancer" has greatly increased, thus improving prognosis. Gastric neoplasia affects more men, age range 50-70 years, disadvantaged social classes and black race. In Romania the gastric cancer incidence is increasing over recent years, presenting variations across the country being more common in men compared with women, reaching a peak of incidence around age 60. Gastric cancer mortality in the world places Romania among the countries with average mortality. Gastric cancer prognosis remains extremely reserved, in close correlation with tumor stage at diagnosis, surgical treatment being the only possibility to provide improved survival, especially in the early stages. Improvement of survival rate in recent years is due to increased gastric resectability result of an earlier diagnosis, a more complex treatment and a closer monitoring of the population at risk.

Role of innate immune receptors TLR2 and TLR4 as mediators of the inflammatory reaction in human visceral adipose tissue.

White adipose tissue from different locations is characterized by significant differences in the structure of adipocyte "secretoma". Fat accumulation in the central-visceral depots is usually associated with a chronic inflammatory state, which is complicated by the metabolic syndrome. Recently, the adipose tissue was emerged to have an essential role in the innate immunity, adipocytes being considered effector cells due to the presence of the Toll-like receptors (TLRs). In this study, we compared the expression of TNF-α, TLR2 and TLR4 in peripheral-subcutaneous and central-peritoneal adipose depots in three different conditions - lean, obese and obese diabetic - using immunohistochemistry. Our results suggest a correlation between the incidence of the stromal vascular cells and adipocytes TNF-α and TLR4 in the visceral depots in strong correlation with adipose tissue expansion. TLR2 positive cells were seen in the peripheral depots from all groups without any association with fat accumulation. These results focus on the existence of a new pathogenic pathway, the activation of TLR4, for the involvement of visceral adipose tissue in the activation and maintenance of the inflammatory cascade in obesity.

Correlations between colposcopy and histologic results from colposcopically directed biopsy in cervical precancerous lesions.

INTRODUCTION: Cervical cancer develops from well-defined precursor lesions in a varied period of time. Detected in early or pre-invasive stages, cervical cancer is preventable and curable, so detection of precancerous lesions is very important. Colposcopy with directed biopsy is used in the evaluation and management of patients with cervical lesions, and described as the 'gold standard' for the diagnosis of cervical precancer. AIM: The aim of this study is to assess the accuracy of colposcopic examination and cervical punch biopsy, to determine the correlation between these two methods. MATERIALS AND METHODS: We examined 245 patients who present malignant findings at colposcopy and biopsy. Colposcopic findings in our study group: 28 (11.4%) cases were CIN I, 50 (20.4%) cases were CIN II, 150 (61.2%) cases were CIN III, 13 (5.3%) cases were micro-invasive carcinoma and four (1.6%) cases were CIS. Histological results in the 245 examined cases were: four (1.6%) cases normal, 26 (10.6%) cases CIN I, 55 (22.4%) cases CIN II, 138 (56.3%) cases CIN III, 15 (6.1%) cases micro-invasive carcinoma and seven (2.8%) cases of CIS. RESULTS: The correlation was 78.5% in the CIN I category, 84% in the CIN II category, 88.6% (133 out of 150 patients) in the CIN III category, 46.1% for micro-invasive carcinoma and 50% for CIS. The colposcopy method incurred fewer false negatives (four patients), giving a general accuracy rate of 98.3%. Sensitivity of colposcopic examination was 83.6%. CONCLUSIONS: This study demonstrated high accuracy and correlation between colposcopy and histology, comparable with results from similar studies in the literature. Sensitivity is lower, probably because biopsies were done in all cases, during diagnostic work-up. We also demonstrated the usefulness of these two diagnostic procedures as screening tests in preclinical cervical cancer. In our study, there were cases of under or over diagnose; the benefit of colposcopy and directed biopsy is to avoid over treatment of low-grade lesion, and under treatment of high-grade lesion.

[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.

Prognosis of colorectal cancer: clinical, pathological and therapeutic correlation.

INTRODUCTION: Significant progress in the knowledge of carcinogenesis and natural history of colorectal carcinoma (CRC), especially in polyp-cancer sequention and time for transition, are important prerequisites for a new approach to diagnosis. Surgical resection is the mainstay therapy for colorectal cancer, and pathologic assessment of the resected specimen provides data for assessment of outcome and rationale for adjuvant therapy. A pathology report includes TNM stage, tumor type, histologic grade, status of resection margins, and vascular invasion. AIM: The purpose of this paper was to highlight the pathological features and their correlations with postoperative evolution and prognosis of this cancer. PATIENTS AND METHODS: Data was collected using the database system of the Emergency County Hospital of Craiova, Romania. A total of 302 patients from January 2003 to December 2005 were included. RESULTS: The average survival for the entire group was 44.35 ± 28.94 months, and the D'Agostino-Pearson test for batch distribution showed abnormal distribution with two peaks, separated by a group of five patients who survived between 37 and 8 months. Fifty-one (38.05%) patients presented a median survival of 73.54 ± 10.47 months. CONCLUSIONS: Factors that contribute to a favorable prognosis in CRC are vegetant gross tumors and papillary microscopic forms, G1 and G2 degree of differentiation and disease diagnosed in stages I and II.

Histological evaluation of pure NOTES - related complications in a survival animal study.

Considered as an extension of both laparoscopic surgery and interventional endoscopy, natural orifice transluminal endoscopic surgery (NOTES) is emerging as a new alternative of minimal invasive surgery. Literature on the gastrointestinal complications of this novel technique is sparse. The goal of this study was the histopathologic evaluation of postoperative complications in a NOTES experimental animal group. Ten female pigs (Sus scrofus domesticus) underwent transgastric endoscopic oophorectomy and tubectomy followed by gastric closure using OTSC clips. Fourteen days after surgery, the animals were sacrificed. Based on the gross examination during necropsy focused excisional biopsies were performed. Gross and microscopic evidence of gastric ulcer distal to the puncture site and perigastric lymph node abscess were found on one animal. Histological evaluation plays a determinant role in the correct evaluation of postoperative complications of pure NOTES procedures.

Genetic patterns of metalloproteinases and their tissular inhibitors - clinicopathologic and prognostic significance in colorectal cancer.

Colorectal cancer (CRC) is the third most common cancer in men and second in women. Progression and invasion of colorectal cancer is a multistep process involving multiple interactions between the tumor and the surrounding stroma mediated by many proteins, among them metalloproteinases (MMPs) and tissular inhibitors of metalloproteinases (TIMPs). We aimed to review the correlations between the expression of the MMPs and TIMPs genes and the clinicopathologic variables of the CRC. Levels of MMPs genes expression in colorectal cancer correlate with the depth of invasion, hematogenous and lymphatic metastasis, poor differentiation, Duke's stage and prognosis. Levels of TIMP's genes expression correlate with better prognosis and longer survival. There are also some controversial data explained by the fact that most of the studies addressed one or few MMPs and÷or TIMPs. The methods to assess the variance in gene expression were not always the same. The promoter regions of metalloproteinases present many polymorphisms and all have allele-specific effects on regulation of MMP gene transcription. Numerous studies on the association of these polymorphisms with cancer susceptibility have been carried out. Most of the studies addressed one or two polymorphisms and their implications. A meta-analysis is necessary to confirm significant correlations. The heterogenicity of the MMPs and TIMPs genetic patterns generated by different studies on colorectal cancer does not allow us to have an overall correlation with clinicopathologic variables and the prognosis of the disease. Studies that involve many MMPs, TIMPs polymorphisms and their tissular expression would be more valuable to better assess the role of those enzymes in the progression of the disease and may serve as a starting point for selective therapeutic approaches.

Study of clinical-morphological correlations in carcinoid tumors of the colon.

INTRODUCTION: The incidence of carcinoid tumors of the digestive tract increased in the last 30 years. The aim of the study is to find clinical and morphologic correlations in cases with digestive carcinoid tumors. MATERIALS AND METHODS: A retrospective study on 76 cases with digestive carcinoid tumors divided in five groups according to their location on the segments of the digestive tract. RESULTS: The subgroup of colon carcinoid is analyzed and clinical-morphological correlations are obtained between the demographic data of the patients (age, gender and environment), tumor location, clinical expression and morphologic features. CONCLUSIONS: Due to the newly discovered techniques of investigation, the incidence of digestive carcinoid tumors has risen in association with other pathologies for which we make these investigations.

Retropancreatic cystic lymphangioma - considerations upon a case.

UNLABELLED: Cystic lymphangiomas are benign tumors developing as an anomaly of the lymphatic channels. Most of them are discovered in children and are located mostly in the head and neck with no differences between sexes. Retroperitoneal locations are rare, clinical symptoms not specific and are discovered incidentally. We report the case of a 32-year-old female sex patient with a cystic tumor situated in the retroperitoneum, behind the pancreas, discovered by abdominal ultrasound during a diagnostic work-out for urinary infection and hypertension. Anamnesis, physical examination and CT-scan could not indicate the nature of the cyst. The cystic tumor had a shape of a butterfly, crossing the midline in front of the aorta and vena cava. A laparotomy was indicated and established the diagnosis of a cystic lymphagioma based on its macroscopic appearance. The tumor was approached from its right side by a generous Kocher maneuver and then from the left by disinsertion of the Treitz ligament and elevating the pancreatic body and splenic vessels. It was completely removed. Postoperative course was uneventful. Histopathologic examination confirmed the diagnosis of benign cystic lymphangioma. At 2 years of follow-up the patient was free of recidive. CONCLUSIONS: Retropancreatic cystic lymphangioma are rarely seen in adults. Precise diagnosis is made at laparotomy, imagistic test give details about walls, content, relationship with the surrounding structures and major blood vessels. Complete surgical resection represents the treatment of choice avoiding recurrence.

Considerations upon a case of synchronous primary malignancies: adenocarcinoma of the sigmoid and clear cell carcinoma of the right kidney.

Synchronous primary colon and renal cancer is a rare but real clinical entity reported with variable incidence. An 81-year-old man admitted for abdominal pain and melena is diagnosed with right colic tumor by colonoscopy and with simultaneous right kidney tumor by CT-scan. The patient is adequately prepared and scheduled for laparotomy. Both tumors are resected in the same surgical session with curative intent - right hemicolectomy and right radical nephrectomy. The patient recovered well and was discharged after 10 postoperative days. The microscopic examination indicated an adenocarcinoma in the sigmoid and a clear cell renal carcinoma in the kidney. Immunohistochemical staining did not find any compatibility between those tumors. The patient started chemotherapy and is under appropriate oncologic follow-up. Modern investigations allow detection of simultaneous malignancies making possible the planned simultaneous resection of both. Histopathologic examination will proof the diagnosis of primary different malignancies.

Ileal iterative spontaneous perforation from foreign body granuloma: problems of histopathologic diagnosis.

Spontaneous ileal perforation is a very rare cause of peritonitis. It occurs, in most of the cases, as a complication of Crohn's disease or intestinal tuberculosis. We present the case of a 23-year-old female patient with multiple surgical interventions during the last year, for iterative ileal spontaneous perforation with generalized peritonitis of which cause was initially assigned to intestinal tuberculosis. Actual episode of generalized peritonitis was determined once again by an ileal perforation of 5 mm at 70 cm from the ileo-cecal valve situated on a suture scar. Distally, a bowel stricture and a non-complicated Meckel's diverticulum were also noted. We performed an enterectomy including all three aforementioned lesions with end-to-end anastomosis. The histopathologic report revealed granulomatous giant-cellular inflammation in the margins of the perforation. The tuberculous etiology was questioned because of the negativity of the PCR-test and multiple recidives of perforation under specific anti-tuberculous medical therapy. The discovery of some rests of non-resorbable suturing material in a granuloma on an ancient enterorraphy scar in the resected specimen, finally established the cause. The granulomatous giant-cellular inflammation of foreign body is a rare cause of ileal perforation. The histopathologic differential diagnosis is difficult needing correlation with clinical data. Usage of resorbable suture material avoids that risk.