Repetitive Self-Inflicted Craniocerebral Injury in a Patient with Antisocial Personality Disorder.

Self-inflicted penetrating injuries in patients with mental disorders are a rare phenomenon. The authors report the case of a prisoner who recurrently presented to the emergency department over a period of four years for self-insertion of six metal foreign bodies into the skull. Computed tomography each time revealed the presence of a metal foreign body (screw, nail, metal rod, and wire) passing through the frontal bone into the frontal lobe. In each situation, the foreign body was safely extracted with a favorable outcome. Despite the use of the latest imaging modalities, metal artifacts can limit the assessment of vascular involvement, and special attention must be given to preoperative planning. Surgical extraction of the foreign body can be safely performed when appropriate preoperative planning is carried out to consider all possible complications.

The multimodal treatment of central and peripheral cholangiocarcinoma - analysis based on a single center experience.

UNLABELLED: The hilar and intrahepatic location represents the most frequent positioning of cholangiocarcinoma. Late diagnosis, tumour resection - as the sole method of radical treatment require a multimodal approach of this form of malignancy. MATERIAL AND METHODS: The paper is based on a retrospective study conducted on a series of 56 patients diagnosed with hilar and peripheral cholangiocarcinoma admitted and treated in the 3rd Surgical Clinic Cluj-Napoca between September 2004 - December 2010. The series included patients treated with radical or palliative surgical treatment, or patients who underwent minimally invasive treatment of biliary endoscopic or percutaneous drainage followed or not by surgery. We analyzed the data on the postoperative morbidity and mortality, surgical re-interventions, the percentage of patients who received curative resection with radical intention or palliative treatment. CONCLUSIONS: Cholangiocarcinoma is an aggressive form of cancer and commonly diagnosed late. The cholangiocarcinoma resectability results are comparable to those in literature and may be improved by increasing the number of tumor resections with negative resection margins. The main goal of the palliative procedures is the improvement and remission of the obstructive jaundice, in most cases being successful. The multimodality of the cholangiocarcinoma treatment is a reality, but also a goal in the group of patients studied, the number of patients in which the sequential treatment biliary drainage - surgical treatment were applied being still low.

Determinants of survival after liver resection for metastatic colorectal carcinoma.

PURPOSE: Prognostic factors for survival after liver resection for metastatic colorectal cancer identified up to date are quite inconsistent with a great inter-study variability. In this study we aimed to identify predictors of outcome in our patient population. METHODS: A series of 70 consecutive patients from the oncological hepatobiliary database, who had undergone curative hepatic surgical resection for hepatic metastases of colorectal origin, operated between 2006 and 2011, were identified. At 44.6 months (range 13.7-73), 30 of 70 patients (42.85%) were alive. Patient demographics, primary tumor and liver tumor factors, operative factors, pathologic findings, recurrence patterns, disease-free survival (DFS), overall survival (OS) and cancer-specific survival (CSS) were analyzed. Clinicopathologic variables were tested using univariate and multivariate analyses. RESULTS: The 3-year CSS after first hepatic resection was 54%. Median CSS survival after first hepatic resection was 40.2 months. Median CSS after second hepatic resection was 24.2 months. The 3-year DFS after first hepatic resection was 14%. Median disease free survival after first hepatic resection was 18 months. The 3-year DFS after second hepatic resection was 27% and median DFS after second hepatic resection 12 months. The 30-day mortality and morbidity rate after first hepatic resection was 5.71% and 12.78%, respectively. In univariate analysis CSS was significantly reduced for the following factors: age >53 years, advanced T stage of primary tumor, moderately- poorly differentiated tumor, positive and narrow resection margin, preoperative CEA level >30 ng/ml, DFS <18 months. Perioperative chemotherapy related to metastasectomy showed a trend in improving CSS (p=0.07). Perioperative chemotherapy improved DFS in a statistically significant way (p=0.03). Perioperative chemotherapy and achievement of resection margins beyond 1 mm were the major determinants of both CSS and DFS after first liver resection in multivariate analysis. CONCLUSIONS: In our series predictors of outcome in multivariate analysis were resection margins beyond 1mm and perioperative chemotherapy. Studies on larger population and analyses of additional clinicopathologic factors like genetic markers could contribute to development of clinical scoring models to assess the risk of relapse and survival.

Selective ex-vivo photothermal ablation of human pancreatic cancer with albumin functionalized multiwalled carbon nanotubes.

The process of laser-mediated ablation of cancer cells marked with biofunctionalized carbon nanotubes is frequently called "nanophotothermolysis". We herein present a method of selective nanophotothermolisys of pancreatic cancer (PC) using multiwalled carbon nanotubes (MWCNTs) functionalized with human serum albumin (HSA). With the purpose of testing the therapeutic value of these nanobioconjugates, we have developed an ex-vivo experimental platform. Surgically resected specimens from patients with PC were preserved in a cold medium and kept alive via intra-arterial perfusion. Additionally, the HSA-MWCNTs have been intra-arterially administered in the greater pancreatic artery under ultrasound guidance. Confocal and transmission electron microscopy combined with immunohistochemical staining have confirmed the selective accumulation of HSA-MWCNTs inside the human PC tissue. The external laser irradiation of the specimen has significantly produced extensive necrosis of the malign tissue after the intra-arterial administration of HSA-MWCNTs, without any harmful effects on the surrounding healthy parenchyma. We have obtained a selective photothermal ablation of the malign tissue based on the selective internalization of MWCNTs with HSA cargo inside the pancreatic adenocarcinoma after the ex-vivo intra-arterial perfusion.

NAT2 polymorphisms and sporadic colorectal cancer survival.

BACKGROUND AND AIM: NAT2 gene polymorphisms can influence colorectal cancer (CRC) risk. We aimed to determine the extent to which NAT2 gene polymorphisms influence the survival of patients with sporadic colorectal cancer. METHODS: Seventy patients with sporadic colorectal cancer that underwent surgery at the 3rd Surgical Department of Cluj-Napoca between October 2003-May 2005 were randomly selected. Correlations between NAT2*5C(T341C), NAT2*5A(C481T), NAT2*6B(G590A), NAT2*7B(G857A) polymorphisms and survival of patients with different Dukes-MAC stages of CRC were analyzed. We compared patients with a slow acetylator genotype with those having an intermediate or rapid acetylator genotype. RESULTS: The slow acetylator 341CC genotype is a negative prognostic factor, 20% vs. 30.8%, as compared to rapid acetylator 341TT/TC genotypes (p=0.02) in the patients diagnosed with stage C CRC. For the same stage patients, the slow acetylator 481CC was a positive prognostic factor, 33% vs. 25% (p=0.03). The slow acetylator 590AA was a negative prognostic factor for the survival of patients with stages B and C, 0% vs. 31% (p=0.02). The slow acetylator 857AA genotype was a negative prognostic factor for the patients in stage B, survival rate 0.69% vs. 50%, and positive for patients with stage C, survival rate 50% vs. 21% (p=0.0101). The rapid acetylator 341TT/TC represented a good prognostic factor, while the slow 341CC a negative one for stage D patients (p= 0.04, survival of 18.9%) HR=0.30 with 95%, CI[0.025- 0.9810]. CONCLUSION: The NAT2 gene may be considered as a prognostic factor for the survival of patients with CRC.

C677T and A1298C mutations in the MTHFR gene and survival in colorectal cancer.

BACKGROUND AND AIMS: Our preliminary results laboratory have shown some association between C677T and A1298C MTHFR mutations and factors influencing survival in colorectal cancer. We studied the survival of patients with colorectal cancer depending on the initial Dukes-MAC stage of the disease at the time of diagnosis and the MTHFR mutation present. METHODS: We randomly selected 69 patients with sporadic colorectal cancer who underwent surgery at the Surgical Clinic III Cluj between October 2003 and May 2005. The study ended on 15 March 2008. Survival data was verified in 48 cases. Survival analyses were performed using Kaplan-Mayer survival curves and median survival time was calculated. The comparison of two or more categories was performed using the Logrank test, considering the threshold value p less or equal to 0.05. RESULTS: In both stage B and C patients with the CT/TT mutation have a poorer survival rate than those with the wild CC genotype (p less than 0.05). The presence of the C677T mutation (CT or TT genotype) in patients diagnosed in stage D did not result as a significant survival risk factor (HR=0.537, 95% CI 0.128-2.184) p>0.05. Patients diagnosed with stage C colorectal cancer, who have the 1298C allele, have significantly better survival than those without this allele, 60% vs. 15.4%, (p=0.0016). CONCLUSIONS: In our study in both stage B and C, patients with the CT/TT mutation have poorer survival than the wild CC genotype. In stage B patients, the A1298C mutation is a negative prognostic factor. The presence of the A1298C mutation in a hetero- or homozygous form plays a protective role in stage C.

MTHFR polymorphisms as prognostic factors in sporadic colorectal cancer.

AIM: Theoretically, individuals having at least one mutant allele present a modified activity of the MTHFR enzyme and low methylation, DNA synthesis-repair respectively, which could imply a higher risk of colorectal cancer. The purpose of this study was to investigate the relations of these mutations with the clinico-pathological aspects of colorectal cancer. MATERIAL AND METHOD: The study included 69 patients with sporadic colorectal cancer. The relative risk in homozygous patients with a normal allele and for mutations C667T and A1298C, in heterozygous patients with one normal and one mutant allele, and for homozygous patients for the mutant allele was calculated. RESULTS: C667T and A1298C mutations represent a risk factor for colorectal cancer with an OR (odds ratio) = 2.13 (CI (0.51-8.91)) and 3 (CI(0.3-29.58), respectively, in homozygous patients. These mutations are associated with a more frequent location of lesions at the colon level, OR=2.3 and 2.15 respectively. The incidence of the A1298C mutation was more frequent in stage N0 than N+ (p<0.05), pT2 vs. pT3 (p<0.05), as well as in Dukes stages B and D vs. A or C (p<0.05). CONCLUSIONS: The results obtained support the hypothesis of an increased colorectal cancer prevalence in patients with one of the MTHFR gene mutations. These patients develop colon cancer more frequently, they present lymph node invasion more rarely, and develop more often distant metastases.

NAT2 gene polymorphism and sporadic colorectal cancer. Prevalence, tumor stage and prognosis. A preliminary study in 70 patients.

AIM: Theoretically, individuals with a NAT2 rapid acetylator genotype are exposed to a higher risk of developing colorectal cancer. We attempted to study this relationship. MATERIAL AND METHODS: We evaluated a group of 70 patients with sporadic colorectal cancer and 40 controls. We calculated the relative risk for patients homozygous for the normal allele NAT2*5C, NAT2*5A, NAT2*6B, NAT2*7B, for heterozygous patients and for patients homozygous for the mutant allele. RESULTS: We found an increased risk for patients with a rapid acetylator genotype to develop colorectal cancer. Rapid acetylators, homozygous negative or heterozygous for the NAT2*5C, NAT2*5A and NAT2*6B mutations have an increased risk of colorectal cancer compared to homozygous positive patients.The analysis of the NAT2*5C genotype shows that the majority of the cases are at stage pT3 for rapid acetylators, 41 cases (74.54%), compared to slow acetylators, where the majority of cases are at stage pT4, 10 cases (66.66%) (p<0.05). The genotype with a rapid acetylator phenotype of the NAT2*5C, NAT2*5A and NAT2*7B variants was most frequently associated with Dukes stage B. The NAT2*5C, NAT2*5A and NAT2*7B gene variants with a slow acetylator pheno-type were most frequently associated with Dukes stage C. CONCLUSIONS: Rapid acetylators, homozygous negative or heterozygous for the NAT2*5C, NAT2*5A and NAT2*6B mutations have a higher risk of colorectal cancer compared to positive homozygotes. Rapid acetylators have earlier stages of colorectal cancer and a better prognosis than slow acetylators, who are diagnosed in more advanced stages.

Laparoscopic resection of duodenal diverticulum. A case report.

We report the case of a laparoscopic resection of a symptomatic duodenal diverticulum. A 35 year old female with history of pain in the upper abdomen, nausea and regurgitation was diagnosed with a diverticulum of the second portion of the duodenum on the external border at upper gastrointestinal radiography. The diverticulum size was medium (2 cm in diameter). Under general anesthesia, a pneumoperitoneum was created. Four trocars were inserted into the peritoneal cavity for this intervention. After the sectioning of posterior parietal peritoneum on the external border of the second portion of duodenum, the diverticulum was dissected. The resection was performed with an endo-GIA linear stapler at the base of the diverticulum. One subhepatic drain was inserted. The operative time was 30 min. There were no intra- or postoperative complications. Postoperative gastrointestinal series revealed no signs of diverticulum or stenosis on the second portion of the duodenum. The patient was discharged in the fifth postoperative day after a normal course. The follow-up evaluation was normal.

Gallbladder carcinoma. A clinical study of a series of 38 cases.

We analyse a series of 38 cases of gallbladder carcinoma. All cases presented gallbladder stones and IVB was the most frequent TNM stage--29 cases (76.31%). Preoperative diagnosis was made in 9 cases (23.69%), all of them by ultrasound examination. Resective procedures was possible in 8 cases (21%), whereas radical cholecystectomy was possible only in 3 cases (7.9%). The histological findings were: adenocarcinoma in 28 cases (73.67%), papillary adenocarcinoma in 3 cases (7.89%) and undifferentiated carcinoma in 7 cases (18.4%). We conclude that the late presentation due to the absence of specific symptoms and the poor diagnosis performance were responsible for the failure of detection in early stages and therefore for the poor prognosis of gallbladder carcinoma.

Radiofrequency by open surgical approach in the treatment of hepatic tumours: early experience with 14 cases.

The aim of the study was the evaluation of radiofrequency in the treatment of hepatic tumours during laparotomy performed for hepatic tumours. The initial experience with 14 patients operated for hepatic tumours (5 primary and 9 metastatic) is presented. The paper also presents the technique concerning the intensity and duration of the power applied, the association with the surgical resection, the immediate postoperative evolution and the dynamics of the hepatic enzymes as well as the postoperative results of ultrasound and CT examinations performed within the first 6 weeks. The indications of RF during laparotomy and the place of RF ablation in the treatment of liver tumours in comparison with other ablation techniques are discussed

In situ thermal ablation of focal liver neoplasms, with a special emphasis on the intraoperative ultrasound-guided radio frequency ablation method.

In the last two decades an important number of image-guided procedures have been developed in order to treat focal liver tumors through ablation in a similar way with the surgical procedure, which is still considered as the curative method for patients with resectable hepatic tumours. Unfortunately this criteria does not apply to all patients and in those cases (nonsurgical patients), the techniques are becoming frequently used as standard independent or adjuvant therapies. Tumour ablation using thermal procedures is now considered as one of the most promising among these alternative ablation therapies. It is the goal of these techniques together with the continuous improvement in technology and increasing clinical experience, to become the treatment of choice for limited liver tumours, challenging surgical resection

[Comparative study of accidents and complications of laparoscopic cholecystectomy in cirrhotic and non cirrhotic patients]. / Etude comparative des accidents et des complications de la cholécystectomie laparoscopique chez les cirrhotiques et les non cirrhotiques.

Among a total of 9000 laparoscopic cholecystectomies, 60 (0.66%) were performed in cirrhotics patients. We have analyzed the presence of intra- and postoperative complications and have made a statistical comparison between cirrhotics and the group of 8940 non-cirrhotics. Cirrhosis was associated with a higher rate of conversions, of intra- and postoperative complications and mortality. The particularities of the intervention in cirrhotic patients are evaluated. Data analysis shows that cirrhotic patients have special problems regarding operation indication, surgical technique and pre- and postoperative treatment.

Metastasis of malignant melanoma in the small intestine. A case report.

Malignant melanoma is the most common metastatic tumor of the gastrointestinal tract and can present with fairly non-specific symptoms. A 63-year old man with previous enucleation of the left eye for a malignant coroidian melanoma presented signs of intestinal subocclusion. Weight loss and a palpable mass deep on the paraumbilical left region were the significant physical signs. Because the state of the patient had worsened, the diagnosis was made by ultrasonography examination. Segmental intestinal resection with regional lymph node dissection was performed. Surgical resection can be performed safely as patients for whom all sites of disease are completely resected experience significant improvements in survival times, compared with patients who undergo an incomplete resection. For selected patients, surgical treatment of metastatic melanoma involving the gastrointestinal tract is appropriate therapy.