Rectal impalement injury: from cruelty to salvage endeavour.

Massive penetrating trauma by rectal impalement is a very rare form of injury, complicated and potentially lethal. It is even rarer for such injury to result in pelvic, abdominal and thoracic internal damages. We report the case of a 62 year-old man who was admitted in emergency after an aggression with a sharp wooden stake inserted forcibly into his rectum. Clinical examination revealed the blunt extremity of the stake outside the anus and the prominent sharp end reaching his right supraclavicular fossa. Radiographic examination showed the stake extending from the rectum to the right side of the neck.Surgery disclosed penetration through the rectum, retroperitoneum,large bowel mesentery, liver, diaphragm, right lung and right 2nd rib. The patient survived following management by a multidisciplinary surgical team. As similar reported cases are scarce, knowledge of the management of the few cases that have been successfully treated is likely to prepare the emergency teams to act rationally and efficiently in such exceptionally grave circumstances.

Rare complication of the cervical spine trauma--traumatic esophageal fistula: case report and review of the literature.

BACKGROUND AND STUDY AIMS: Esophageal fistula due to cervical spine trauma is a rare, potentially fatal complication, which changes significantly the treatment and the prognosis of the trauma patient. There is scarce data regarding this associated pathology of cervical trauma and it consists only of isolated cases, most of them being reported as a complication of the surgical treatment. We present the case of a female patient who suffered a fall from a wagon and who was diagnosed at presentation with cervical fracture and esophageal fistula. Patient: A 65 years old female who suffered a fall from a train wagon presented for intense neck pain and bilateral brachial paresis. The MRI exam showed a C6-C7 fracture with bilateral facet dislocation in the context of a degenerative, spondylotic cervical spine. It also showed an anterior fragment from the C7 body, in contact with esophageal adventitia. The patient underwent surgery. RESULTS: A C6 corpectomy was performed, with arthrodesis with bone graft and cervical plate fixation. 24 hours after the procedure, the clinical signs of an esophageal fistula appeared and a CT-scan revealed the typical aspects of that complication. The patient underwent a second surgery in collaboration with the general surgeon with a good outcome and complete neurological recovery. CONCLUSION: In the case of cervical spine trauma the imaging exploration has to look for potential signs of lesions to the neighboring vital structures. Although a rare complication of cervical trauma, esophageal fistula represents a formidable complication and requires immediate surgical sanction, the only factor decisive for a good prognosis.

Emergency pancreaticoduodenectomy for bleeding pancreatic pseudoaneurysm in patient with common mesentery and replaced right hepatic artery.

Pancreaticoduodenectomy is infrequently performed in emergency, so much the less in lack of traumatic evidence.A rare vascular complication of the pancreatic pseudocyst,the pseudoaneurysm, presents as a pulsating malformation which may lead to life-threatening bleeding if left untreated.Its optimal treatment remains controversial. Most authors agree that angioembolization is the first step to stabilize the patient's condition, with further surgery if such be the case.We herein report an unusual case of pancreatic head pseudocyst complicated with a bleeding pseudoaneurysm arising from the inferior pancreaticoduodenal artery, in a patient with multiple comorbid conditions, common mesentery,hepatic artery variant and hemodynamic instability. An emergency early retropancreatic approach pancreaticoduodenectomy was performed with uneventful immediate and long-term outcome. We highlight that emergency surgery allowed both rapid control over the bleeding with hemostasis and removal of the pseudocyst. This is particularly relevant in high-risk patients in whom selective angioembolization is no more of choice.

Early retropancreatic lamina dissection during pancreaticoduodenectomy: how, when and why?

UNLABELLED: Pancreaticoduodenectomy is the procedure of choice for tumors of the pancreatic head and periampullary region. During pancreaticoduodenectomy, early neck division may be inadequate in case of hepatic artery anatomic variants, suspected involvement of the superior mesenteric vessels or intraductal papillary mucinous neoplasms. MATERIAL AND METHODS: We describe our early approach to the superior mesenteric vessels during pancreaticoduodenectomy, by retroportal lamina dissection before pancreatic transection. RESULTS: We used this approach in 41 patients. There were 28 patients with abnormal hepatic artery, which was spared in 26 cases. Hepatic artery reconstruction was required in 2 cases. Nine patients with intraductal papillary mucinous neoplasms underwent 6 pancreaticoduodenectomies extented to the body and 3 total pancreaticoduodenectomies. Four patients with adenocarcinoma involving the portomesenteric vein required pancreaticoduodenectomy with venous resection and reconstruction. CONCLUSIONS: Early retropancreatic lamina dissection is useful way to tailor a pancreaticoduodenectomy which is recommended in selective indications.

Laparoscopic adrenalectomy for large solid cortical tumours--is it appropriate?

BACKGROUND: Laparoscopic adrenalectomy, the procedure of choice for small benign adrenal tumours, is also used for large tumours. Our study aims to assess the outcome of large adrenal tumours laparoscopically resected. METHODS: All patients with laparoscopic adrenalectomy performed in between 2002 and 2009, without preoperative or intraoperative malignant characteristics, were reviewed. Clinical, biochemical and CT follow-up data were reviewed for evidence of recurrent disease. RESULTS: Fifty patients underwent laparoscopic adrenalectomies in our unit, 18 of them having solid cortical tumours > or = 7 cm without preoperative or intraoperative malignant features: 6 Cushing's syndrome tumours, 8 non-secreting tumours, 4 aldosteronomas. The mean age of the patients was 46.89 years (range 22-64 years), and the mean tumour size 7.57 cm (range 7-9.1 cm). Histology identified 10 cortical adenomas, 4 malignant tumours, and 4 indeterminate tumours. The mean - follow-up was 28.94 months (range 4-58 months). Three patients died of systemic recurrent disease (liver and lung metastases) at 12, 19 and 21 month, respectively, after operation. One patient underwent a left hepatectomy for liver metastases, 33 months postoperatively. Fourteen patients have no evidence of recurrence. CONCLUSIONS: Adrenal tumours > or = 7 cm without pre- or intraoperative evidence of malignancy are resectable laparoscopically. This approach is unlikely to worsen the long-term outcome. The mortality is related to the malignancy.

Laparoscopic surgical education--the experience of the first surgical unit Iasi.

The classic apprenticeship model for surgical training takes place into the operating theater under the strict coordination of a senior surgeon. During the time and especially after the introduction of minimally invasive techniques as gold standard treatment for many diseases, other methods were developed to successful fulfill the well known three stages of training: skill-based behavior, rule-based behavior and knowledge-based behavior. The skills needed for minimally invasive surgery aren't easily obtained using classical apprenticeship model due to ethical, medico-legal and economic considerations. In this way several types of simulators have been developed. Nowadays simulators are worldwide accepted for laparoscopic surgical training and provide formative feedback which allows an improvement of the performances of the young surgeons. The simulators currently used allow assimilating only skill based behavior and rule-based behavior. However, the training using animal models as well as new virtual reality simulators and augmented reality offer the possibility to achieve knowledge-based behavior. However it isn't a worldwide accepted laparoscopic training curriculum. We present our experience with different types of simulators and teaching methods used along the time in our surgical unit. We also performed a review of the literature data.

Treatment of gastrointestinal stromal tumors--initial experience.

BACKGROUND: Gastrointestinal Stromal Tumors (GIST) offered the first opportunity of a specific treatment in neoplasms (tyrosine-kinase inhibitors) and also a new perspective of management of other neoplasms. METHODS: We have prospectively recorded the clinical characteristics, type of surgery, pathologic findings, adjuvant treatment, and recurrence of the patients with confirmed GISTs admitted between January 2004 and December 2008. RESULTS: There were 18 patients. Location of the tumor was gastric (44.44%), duodenal (11.11%), jejunal (16.67%), right colon (5.55%) and rectal (22.22%). None of our patients had clinical, imagistic or macroscopic metastases. All the patients had R0 resections, except a patient with local excision and another with R1 anterior resection for rectal GISTs. Postoperatively, 4 patients received Imatinib therapy. The mean follow-up period is 32 months (range 8-58 months); 2 recurrences, both after rectal GISTs. The rest of patients are tumor-free and subjects of prospective follow-up. CONCLUSION: We present the first 5 years experience of a prospective study of GIST started in 2004. The complete resection and the malignant potential according to Fletcher index are the most significant prognostic factors. Imatinib treatment may improve outcome in incomplete resected or high risk GISTs.

Palliative gastrectomy in patients with stage IV gastric cancer--our recent experience.

BACKGROUND: Patients with metastatic gastric cancer are usually not good operative candidates. Recent improvements in surgical techniques allowed palliative gastric resection and other surgical procedures. METHOD: We have examined the place of palliative gastrectomy and its impact on survival in stage IV gastric cancer patients admitted in 2003-2008 period. RESULTS: From a total of 295 patients with gastric cancer, we found 140 patients with stage IV disease; 85 of them had no resection (45 received only chemotherapy) and 55 underwent palliative gastric resection with or without postoperative chemotherapy. Mean survival in non-operated patients with chemotherapy alone was 6.4 months, not significantly different to that of the patients with palliative surgery alone (8.9 months). The group with palliative surgery and adjuvant therapy had a significantly better mean survival (17.8 months). Mortality and morbidity rates associated with palliative surgery were 9% and 34.5%, respectively. CONCLUSIONS: These data suggest that palliative surgery associated with adjuvant chemotherapy can improve survival in patients with stage IV gastric cancer.

[Gossypiboma--retained textile foreign body]. / Corpi straini textili restanti postoperator.

UNLABELLED: INTRODUCTION, HISTORY: Increasing complexity of modem surgery is accompanied by the emergence of very different possibility of errors; one of the oldest and most obvious errors is the foreign body forgotten inside the patient. Surgeons worldwide have reported this incident since the first record by Wilson in 1884. DEFINITIONS: Over time, different terms have been used for retained textile foreign body (RTFB), with various etymologies, sometimes controversial: gossypiboma is the latest in this line. EPIDEMIOLOGY: Various studies indicate the incidence of RTFB in range of 1:833-1:32.672; this expresses the difficulty to determine precisely due to complex causes. In our unit the incidence is 1:15.047. RTFB occur after operations on any cavity or organ (operations on the abdomen 56%, pelvis 18%, thorax 11%, orthopedic, neurosurgical, cardiovascular, etc.), at all ages and both sexes. DIAGNOSIS IS VARIABLE: from a loud postoperative evolution, with fever, suppuration of the wound, fistula tracks, spontaneous erosion into various hollow organs to a long asymptomatic period. Imaging diagnosis is difficult and requires RTFB inclusion in the differential diagnosis of patients with a history of surgery. Treatment involves a patient's informed consent and an adjustment to a case: removal of RTFB and individualized treatment of any associated injuries (abscess, fistulas, adhesions, remaining cavity, foci of bone lysis) or just monitoring. PREVENTION: From the theory of "bad apple" (mistake of an incompetent doctor) we moved forward to address systems that often contain latent errors whose summation results in the unfortunate incident. Various national authorities have issued regulations to prevent RTFB, based on counting compresses, intra-/postoperative radiography, marking compresses with two-dimensional matrix label or radio frequency identification. CONCLUSIONS: RTFB, no matter how exotic we name it, remains an unfortunate incident with serious consequences for patient and surgeon alike. The introduction of new technologies can help create a safer environment in the operating room, but beyond that the human factor implies the presence of variables difficult or impossible to control.

[Present trends in abdominal actinomycosis]. / Tendinte actuale în actinomicoza abdominala.

BACKGROUND: Actinomycosis is a chronic infectious disease caused by bacteria in the Actinomyces genus. The pathologic, clinic and imagistic polymorphism and the rare incidence of this disease make it so frequent misdiagnosed. MATERIAL AND METHOD: Single unit retrospective nonrandomized clinical study on over 40 years of experience in diagnosing and treating abdominal actinomycosis. RESULTS: First case of abdominal actinomycosis was diagnosed in our clinic in 1968. During the next 36 years, between 1968 and 2004, there were registered only 3 cases, all ileo-cecal actinomycosis. In the next 3 years interval, 5 more cases were diagnosed: 4 associated with intrauterine devices (IUDs) and 1 associated with intraperitoneal remnant calculi after laparoscopic cholecystectomy. We present these last 5 cases, the first 3 having been reported elsewhere. CONCLUSIONS: Abdominal actinomycosis is a rare disease, with variable and deceiving clinical and imagistic characters. In Romania we witness a shift in the epidemiology of this disease as a result of the introducing of the IUDs for the first time after 1990. Confronted with a female patient carrying an IUD that has an inflammatory and a pelvic tumoral syndrome of variable intensity, one should consider also the diagnosis of abdominal actinomycosis. Preoperative establishing of this diagnosis may allow, by a long antibiotic therapy, the elimination of the need for surgery or at least the decrease of its limits. A very rare cause of intraperitoneal actinomycosis is intraperitoneal gallstones remnant after laparoscopic cholecystectomy. To our knowledge, our case is the first reported in the medical literature.

[Tendencies and results in rectal cancer treatment]. / Tendinte si rezultate în tratamentul actual al cancerului rectal.

UNLABELLED: Rectal cancer is one of the leading cause of cancer-related death worldwide despite of multimodal treatment. OBJECTIVE: The aim of this study is to review the management strategies for rectal cancer and to determine morbidity after multimodal therapy. METHOD: Retrospective study about 276 patients with rectal cancer surgically treated in 1st Surgical Clinic of "St. Spiridon" Hospital Iasi, Romania, between 1998-September 2003. RESULTS: There were 166 men (60.14%) and 110 women (38.86%) with mean age 63.6 years (extreme 20-81 years). The tumor's staging was: stage I--12 cases (4.5%); stage II--59 cases (21.3%); stage III--134 cases (48.2%), stage IV--71 cases (25.7%). 37 patients (13.4%) received preoperative radiotherapy (20 Gy). The tumor was resectable in 204 cases (74%) with curative purpose in 190 cases (68.8%). The postoperative therapy was performed in 198 cases (71.7%). The postoperative morbidity was documented in 32 cases and 24 patients died during hospitalisation (8.7%). Long-term results are also exposed with a review of literature. CONCLUSIONS: Rectal cancer has been notoriously difficult to treat successfully but there are numerous attempts modifying existing therapeutic regimens or designing new ones.

[Stapled esophago-jejunal anastomosis after total gastrectomy in gastric neoplasm]. / Sutura mecanica în anastomoza eso-jejunala dupa gastrectomia totala în cancerul gastric.

A number of 1031 patients with gastric cancer have been admitted in the First Surgical Clinic of Iasi between 1986-2001. The operability index was 86%, 52% being resectable and 36% having potential curative resection. In this group, 222 patients benefited from total gastrectomies. We consider the introduction of stapled eso-jejunal anastomosis (38 patients) as the most important moment in this development, as the manual performance anastomosis is considered difficult due to the problems imposed by suturing in a deep space. Postoperative course of patients who benefited from stapled anastomosis was simple although many patients had a poor biological status. We encountered only one small fistula, which was dealt with conservative. Patients in this group had immediate postoperative results significantly better than the comparative group with manually performed anastomosis. Introduction of stapler techniques increased the proportions of patients who benefited from palative total gastrectomies for advanced gastric cancer. We consider that a method to solve the frequent complications, insured an increased intraoperative comfort, reduced the number of postoperative complications, increased survival and improved patients quality of life.

[Rare location of a hydatid cyst- in the upper mediastinum migrating into the spinal channel]. / Chist hidatic cu localizare rara: intrarahidiana si cervico-mediastinala.

The authors report a rare and difficult case of hydatic cyst. The case was rare due to the location of the hydatic disease in the upper mediastinum and because of the onset of the disease with a complication: a spinal cord compression syndrome produced by the migration of the hydatic cyst into the spinal channel. The case was difficult because of the diagnostic problems--especially to establish the topography of the lesion and surgical management.

[The treatment of rectal cancer--the optimizing possibilities]. / Tratamentul cancerului rectal--posibilitati de optimizare.

The authors studies 280 rectal cancers treated in the first surgical clinic of Iasi in the period 1981-1994. Although surgery is the main treatment of these tumors, it cannot be and it must be not used alone. Surgery must be associated with radio- and chemotherapy, because is the only way possible to increase the number of resections for rectal tumors and the survival rate. For the 263 tumors operated the resectability was 73, 5%: Milles's operation 101 (36, 7%), Dixon's operation 81 (30, 79%), other operation 91 (33, 11%). We consider that Dixon's operation is the best choice for the tumors in the stages A and B of Dukes classifications. Preoperative radiotherapy can influence the tumor volume (downstaging) and decrease local recurrences to about 10-15%. Surgery alone must be practiced only in emergencies. Postoperative chemotherapy is mandatory and it reduces local recurrences and delays metastasis evolution.

[The Shouldice procedure in the surgical treatment of inguinal hernias]. / Procedeul Shouldice în tratamentul chirurgical al herniilor inghinale.

The Shouldice repair gained a major importance in the treatment of inghinal hernias provided by the excellent results that had been obtained in the Shouldice Hospital on more than 200,000 cases. This study analyze prospectively 101 cases of inguinal hernias that had been treated using the Shouldice procedure with in a 3 year period, comparative with a control cohort of 102 cases of inguinal hernias treated using classic procedures (Bassini, Kimbarowski). The data analyze was performed using Kruskal-Wallis H test and t Student test. The immediately postoperative results have been favorable in 95% cases and the long term postoperative results have been very good in 99% cases (a unique recurrence in a multiple recidivated patient). The result of this study proves that Shouldice repair has advantages comparative with classic treatment: short postoperative hospitalization, low incidence of complication and recurrence.