Long-term outcome of an unusual haemophilic pseudotumour.

Haemophilia, a lifelong congenital bleeding disease, is a highly demanding disorder, due to the costs of its replacement therapy. In the absence of this pivotal treatment, life expectancy and quality of life are deleteriously affected. As illustration, we present a 14 years long follow-up of a patient with severe haemophilia A, treated sporadically with fresh plasma, cryoprecipitate and factor concentrates, who developed a giant iliopsoas pseudotumor. Since he was an infant, under on demand therapy with fresh frozen plasma, cryoprecipitate and low doses of factor concentrates he presented many spontaneous bleedings, developing multiple disabling arthropathies. At the age of 14 years, an iliopsoas hematoma occurred, which relapsed several times, developing an iliopsoas pseudotumour. After 5 years, sepsis with Klebsiella was diagnosed. A CT scan revealed fistula between the pseudotumor and the gut. Under antibiotics, the evolution of sepsis improved, but over a period of 10 months 5 episodes of haematemesis and melena, followed by one episode of macroscopic haematuria occurred; two months later he developed an inguino-crural mass, which fistulized through the abdominal wall. A mixt german-romanian team solved the clinical concern. After 108 hospitalization days and consumption of 104840 IU factor VIII he left the clinic in good condition. One year later, the temporary colostomy with anus praeter was closed. The follow-up reveals now, after almost 10 years with favourable outcome, that the patient is well, active within his family and profession.

[Laparoscopy-assisted total vaginal hysterectomy with transperitoneal lymphadenectomy for early cervical cancer--surgical technique]. / Histerectomia totala vaginala asistata laparoscopic cu evidare ganglionara pentru cancer de col incipient--tehnica operatorie.

UNLABELLED: Cervical carcinoma remains an important health problem. The classical surgical approach for cervical cancer is radical hysterectomy (Wertheim's operation). Our paper presents the technique of laparoscopic assisted radical vaginal hysterectomy with transperitoneal lymphadenectomy, as well as the details for the dissection of obturator, paravesical, pararectal fossae, and parametrectomy. The major advantage of this techique is that the entire abdominal part of the procedure is performed under direct observation, therefore minimizing the visceral or vascular injury. CONCLUSION: Our experiences suggest that this type of approach is feasible and offers the possibility to remove a greather number of lymph-node as compared to the classical approach. An increased experince will prove helpful in performing the entire procedure laparoscopically.

[Gastric necrosis, rare complication after laparoscopic gastric banding--case report]. / Necroza gastrica, complicatie rara dupa gastric banding--prezentare de caz.

In the last years, laparoscopic gastric banding has become a popular surgical option for morbidly obese patients, because of the minimally invasive and easy surgical technique, its reversibility, and the possibility to calibrate the stoma. Gastric necrosis, as a complication of laparoscopic gastric banding, has been rarely reported. We present the case of a 34 -year-old pregnant patient (18 week pregnancy) with 5 days history of abdominal pain. She had undergone laparoscopic adjustable gastric banding 24 months earlier with a body mass index (BMI) of 43 kg/m2. Diagnostic workup was very difficult because the patient was pregnant and we can use only ultrasonography and clinically signs. After initial conservative management, the patient underwent urgent surgery and we found an anterior gastric prolapse through the band with necrosis of the herniated stomach. A longitudinal (sleeve) gastrectomy was performed. The postoperative evolution was god and the patient left our clinic after 9 day. Emergency sleeve gastrectomy could represent a good option to treat, in a safe way.

[Thyroid cancer--the malignant lesions in the contralateral lobe]. / Cancerul tiroidian--leziunile maligne din lobul contralateral.

AIM: This study analysed the frequency of the malignant lesions in contralateral thyroidian lobe after completion thyroidectomy for malignant lesions in the ipsilateral lobe, in order to establish which patients have indication of total thyroidectomy. MATERIAL AND METHOD: There were studied retrospectively 228 patients which had completion thyroidectomy after histological confirmation of the thyroid cancer in the ipsilateral lobe. RESULTS: Thyroid cancer in contralateral lobe was found in 94(41.2%) patients. One (4.7%) of patients with cancer < 1 cm in ipsilateral lob had malignant lesions in the contralateral lobe. In patients with ipsilateral lobe cancer > 1 cm, the frequency of malignant lesions was between 42.8% and 47.6%. CONCLUSION: The very high frequency of malignant lesions in the patients with ipsilateral thyroid cancer > 1 cm impose total thyroidectomy in these cases.

[The placement of Tenckhoff peritoneal dialysis catheter by laparoscopic approach--our experience]. / Plasarea cateterului Tenckhoff pentru dializa peritoneala prin abord laparoscopic--experienta noastra.

UNLABELLED: Ambulatory peritoneal dialysis is an alternative to haemo dialysis for patients with End Stage Renal Disease (ESRD). This study evaluates our experience in laparoscopic placement of Tenckhoff Catheter (TC) for peritoneal dialysis. METHODS: Between december 2000 and december 2007 in the II Surgical Clinic of Timisoara the laparoscopic implantation of the Tenckhoff catheter was performed in a lot of 56 patients with ESRD with mean age 53.04 years (limit between 17-80 years). In this lot of patients 66 laparoscopic procedures were performed--58 catheter implantation, 2 catheter changing, 2 repositioning, 2 adhesiolysis and 2 withdrawn. Mean operative time was 47.3 min. (limits 35-90 min.). RESULTS: Immediate functionality ratio (< 30 days) was 98.11% of cases. The immediate post-operative complications were: leakage of dialysis solution in three patients (5.35% of cases), bleeding from the incision in three patients (5.35% of cases) and one patient (1.78% of cases) with a migration of the TC, case who required replacement of the catheter performed also by laparoscopy. The late post-operative complications were: obstruction with omentum of the catheter in two patients (3.57% of cases), massive leakage in one patient (1.78% of cases), migration of the TC in one patient (1.78% of cases), tunnel infection in one patient (1.78% of cases) and peritonitis in two patients (3.57% of cases). In all these patients laparoscopy replacement of the catheter was required. The minor complications were: exit site infection in 3 patients (5.35% of cases), tunnel infection in 7 patients (12.5 % of cases), incisional hernia in one patient and pleural effusion in one patients (1.78% of cases). CONCLUSIONS: Laparoscopic placement of TC is a successful method compared to other procedures. The great advantage is the direct visualization and fixation of the TC in the pelvis.

[Reparation of the parcel defect of duodenum with pediculated jejunal patch by laparoscopy. Experimental study]. / Repararea leziunii parcelare duodenale cu patch jejunal pediculat pe cale laparoscopica. Studiu experimental.

The objectives were to evaluate the intraoperative aspects of the repairing by laparoscopy of a parcel duodenal defect, using a pediculated jejunal patch and to emphasize the intraoperative complications. The research has been made on 6 pigs. The pediculated jejunal patch was been achieved by excluding from the intestinal tract of a 2-4 cm segment with nutritional pedicle and the cut of intestinal tube on the anti-mesenteric border. The suture of the duodenal defect has been accomplished in one layer manner. The animals were followed 2 hours, under anesthesia. There was not intraoperative mortality, wether conversion to laparotomy. There was been a good cover of the defect, without any leakage. We did not notice intraperitoneal blood or bile. The duodenoplasty with pediculated jejunal patch is effective. The laparoscopic accomplishing of this procedure has no complications and it can be applied in clinical activity for selected cases.

[Reconstruction of cervical esophagus by using laparoscopically assisted jejunal loop harvesting and microsurgical transfer]. / Reconstructia esofagului cervical utilizând prelevarea asistata laparoscopic de ansa jejunala si transferul microchirurgical.

For segmental cervical esophageal reconstruction, the free transfer of jejunal flap tends to become a standard procedure. Graft harvesting by laparotomy presumes increased morbidity at donor area level. There was described by now in the literature laparoscopic techniques for harvesting of jejunal graft, which have reduced the complications following laparotomy. We wish to present here an experimental model of laparoscopically assisted harvesting of jejunal flap used for reconstruction of cervical esophagus by free transfer. The harvesting of jejunal segment was achieved in 12 dogs; 4 cases subsequently underwent microsurgical free transfer. There are presented original contributions of authors. The harvesting average time was 115 minutes; the meantime graft ischaemia was 48 minutes in 4 cases with microsurgical transfer. Postoperative survival was 100%. Graft viability was achieved in 75% at 12 hours and 50% at 24 hours. No major operative accidents were recorded. We present a standardized experimental model, which could be an usefull guide in human therapeutics.

[Benign esophageal strictures--outcomes of coloesophagoplasty in Surgical Clinic II Timisoara]. / Stenozele benigne ale esofagului --rezultate ale reconstructiei esofagiene cu colon în Clinica a II-a Chirurgie din Timisoara.

Esophagoplasty is obviously a proper choice of treatment; postoperative outcomes should be very good because of benign type of lesions, but morbidity-mortality are high due to the complexity of the intervention. Our purpose is to emphasize the utility of coloesophagoplasty like a very feasible surgical option, based to our short and long term outcomes. This paper relies on the retrospective analysis of all cases admitted to II-nd Surgical Clinic Timisoara in a 20 years period (1983-2002), having coloesophagoplasty for benign esophageal stenosis. There were performed 45 such interventions (16 men, 29 women); the mean age was 35.7 years (15-68 years). The pathology included postcaustic lesions (42 cases), peptic lesions (2 cases) and esophageal leiomyoma (1 case). Postoperative morbidity occurred in 22.6% of patients. The graft functionality was good and very good in 86.6% of patients at discharge. Postoperative mortality was 6.6%.

[When to prescribe scintigraphy in the exploration of thyroid nodules?]. / Cand prescriem scintigrama tiroidiana în explorarea nodulilor tiroidieni?

Scintigraphy is employed almost systematically in current medical practice for initial thyroid nodules investigation. More and more authors observed that scintigraphy has lost importance confronted with others modern exam, but there are no statistical essay to demonstrate this fact. The aim of our work was to study, on 369 patients, the real contribution of scintigraphy to establish diagnosis and therapeutical strategy. Scintigraphy was truly useful only in 47 (12.7%) patients. We may conclude that thyroid scintigraphy ought to be indicated only in low TSH thyroid nodules, ectopic goiter and, eventually, in metastasis uptake radioactive iodine.

[Experimental model of orthotopic uterus transplantation in the laboratory rat]. / Model experimental de transplant uterin ortotopic la sobolanul de laborator.

This study develops and standardizes an experimental model of uterus transplantation in the laboratory rat. Twelve orthotropic uterus transplantation were done. Animals were randomized in three groups. Postoperative survival was 100% and 75% at 72 hours. Recipients were euthanased at 24 hours, 48 hours and 72 hours and the grafts were harvested. Patency of the microsurgical anastomoses was 100% at 24 hours, 63% at 48 hours and 0% at 72 hours. The explanted uterine grafts were fixed in formalize and analyzed under light microscopy. The acute allograft rejection starts during the second day after transplantation. In additional dissection, anatomy of the pelvic region with regard to the topography of the uterus, tube and ovarian vessels was studied. This model of uterus transplantation in rats proposes a standardized tool for further research regarding cellular mechanisms of the acute allograft rejection and, for future, pregnancy of the transplanted uterus.

[Percutaneous treatment of the liver hydatid cysts under sonographic guidance]. / Punctia transcutanata ghidata ecografic în tratamentul chistului hidatic hepatic.

This paper is a retrospective study of the first 51 cases of liver hydatid cysts, which underwent a conservative treatment between April 1996-December 2000. There were 28 females and 23 males with a mean age of 40.1 years (7-65), which had 63 liver hydatid cysts. In the right liver lobe were located 46 cysts, in the left liver lobe were located 7 cysts and in 10 cases cysts were located in both liver lobes. In 4 cases a pulmonary hydatidosis was associated. Abdominal ultrasound and CT scan were routinely performed and the cysts were classified in type I and II after Gharbi's classification. All of these 63 cysts were treated by ultrasound guided fine-needle percutaneous puncture with aspiration and instillation of sterile alcohol 95 degrees. Pre and postoperative the patients were treated with mebendazol or albendazol. They were followed-up by ultrasound and CT scan examination in the second day postoperative and monthly. No new cysts were noted during an average follow-up of 14.7 months and maximal cyst diameter decreased with minimum 72%. Two episodes of reversible anaphylaxis were encountered. The mean hospital stay was 3.3 days. In this paper the indications for conservative treatment and preliminary results of this method are discussed.

[Surgical treatment of thyroid nodules. The immediate results after different thyroidectomy methods]. / Tratamentul chirurgical al nodulilor tiroidieni. Rezultate imediate dupa diferite tipuri de tiroidectomie.

The extension of the resection for thyroid nodules depends both on nodules' nature and immediate or late postoperative complications risks. This clinical study analyzed the immediate complications appeared after partial thyroidectomy comparatively with those developed after total thyroidectomy. We studied 1411 patients operated in two clinics (from Romania and from France) which have two different attitudes concerning the width of the resection. Paralysis of recurrent laryngeal nerve occurred in 1.0% of patients with partial thyroidectomy and 3.0% of patients with total thyroidectomy, while only one patient (0.6%) developed permanent hypoparathyroidism after total thyroidectomy. In conclusion, total thyroidectomy can be performed by experimented surgeons with a recurrent or parathyroid injury risk similar to partial thyroidectomy. However, the surgeon should take into account the patient survey capacity and the discomfort produced by life substitutive treatment.

[Thyroid scintigraphy: its place in preoperative diagnosis of thyroid nodules?]. / La scintigraphie thyroïdienne: quelle place dans le bilan préopératoire des nodules thyroïdiens?

AIM OF THE STUDY: To evaluate the real contribution of the thyroid radionuclid scanning in the preoperative evaluation of the thyroid nodules. MATERIAL AND METHOD: The authors prospectively studied 369 patients who underwent surgical intervention: 160 (43.4%) for isolated nodules and 209 (56.6%) for multinodular goiters. RESULTS: The scintigraphy of the thyroid was performed in 281 (76.2%) patients: 39 (13.8%) patients with nodules less than 1.5 cm in diameter and 242 (86.2%) patients with nodules more than 1.5 cm in diameter. In 234 patients (83.3%) the scintigraphic evaluation did not bring any utile information for the therapeutic decision. The scintigraphy proved its utility only in 47 patients, which represents 16.7% from the scintigraphic exams performed, or 12.7% from the patients that underwent a surgical procedure. CONCLUSIONS: In the presence of thyroid nodule or multinodular goiter, the scintigraphy is indicated only in decreased TSH level, suspicion of ectopic thyroid or retrosternal goiter.

[Experimental model of heterotopic renal transplantation in rat]. / Model experimental de transplant renal heterotopic la sobolan.

This study describes the experience with a new technique for heterotopic kidney transplantation in the laboratory rat. This technique combines already known aspects in renal experimental transplantation, with technical improvements added to each surgical step. Ten heterotopic kidney transplantation were performed. Immediate postoperative survival was 100% and at 48 hours was 90%. The patency of the vascular anastomosis checked at 72 hours in survivors was 100%. As a preliminary study, 20 renal hilum dissections were done, noting the topographical aspects of the renal vessels. Representing a standardized and easy to use model, this solid organ transplantation technique is a valuable tool for studying the immunological and physiopathological aspects of transplantation and for refining the microsurgical skills.

[Difficult laparoscopic cholecystectomy]. / Colecistectomia laparoscopica dificila.

From 2505 cases operated between 1994-2000, the authors selected a lot of 889 cases of difficult cholecystectomy, which after classical criteria would have been classified as contraindications of laparoscopic procedure. This study analyzed of intraoperative incidents, the conversion rate and particularities of operative tactics and techniques. The lot of patients includes 889 cases of difficult laparoscopic cholecystectomy. The patients were selected according to classical contraindications of laparoscopic cholecystectomy: obesity, liver cirrhosis, previous operated abdomen, severe cardio-pulmonary diseases, ages over 70 years, acute cholecistitis. The rate of intraoperative incidents and accidents was 19.9% (177 cases), in comparison to intraoperative incidents and accidents rate in "easy" laparoscopic chole-cystectomy which was 15.5% (251 cases from 1616 patients). The conversion rate in case of difficult laparoscopic cholecystectomy was 6.1% (55 patients) and 3.2% in the lot of "easy" cholecystectomy. The postoperative morbidity was 6.4% (57 patients) and 5.5% (147 patients) in the lot of "easy cholecystectomy. The postoperative mortality was 0.6% (6 deaths) and 0.3% (5 deaths) in the lot of "easy" cholecystectomy. In this paper are discussed the modalities and the technical particularities of a difficult laparoscopic cholecystectomy, able to lowering the risk of operative incidents and postoperative complications. In conclusion, laparoscopic cholecystectomy can be safely performed to the majority of patients with lithiasic cholecistitis, by an experienced surgical team.

Lymph distribution of different non-steroidal anti-inflammatory drugs assessed by microsurgical cannulation of the thoracic duct in rat.

The motility of lymphatic vessels is regulated by arachidonate metabolites and, therefore, can be altered by cyclo-oxygenase blockers such as non-steroidal anti-inflammatory drugs (NSAIDs). In order to investigate the lymphotropic properties of different NSAIDs, pharmacokinetics in plasma and lymph following intragastric administration of three model compounds, namely racemic ibuprofen, tenoxicam and nabumetone, were investigated in rats. Microsurgical cannulation of the thoracic duct allowed cumulative sampling of lymph fluid up to 48 hrs (n = 16). Pharmacokinetic parameters in plasma were determined in a control group (n = 12). Concentrations of R-, S-ibuprofen, tenoxicam, nabumetone and the metabolites OH-ibuprofen, COOH-ibuprofen and 6-methoxy-2-naphthyl-acetic acid (6MNA, metabolite of nabumetone) were monitored in lymph and plasma by HPLC. To quantify the lymphotropic properties of the investigated compounds, a "lymphatic clearance" was defined by dividing the amount recovered in lymph fluid by the corresponding area under the plasma concentration-time curve (AUCP). The "lymphatic clearance" substantially differed between the investigated compounds (mean +/- SD: R-ibuprofen 6.71 +/- 3.15 microliters/min, S-ibuprofen 3.24 +/- 1.20 microliters/min, tenoxicam 8.74 +/- 8.11 microliters/min, nabumetone 46.05 +/- 26.08 microliters/min and 6MNA 6.32 +/- 2.96 microliters/min). The overall recovery of the investigated compounds in lymph did not exceed 5% of the doses given. The known fact that lymphatic drainage is regulated by arachidonate metabolites might suggest that NSAIDs differing in their lymphotropic properties could result in different responses of lymphatic vessels to an inflammatory fluid load.

[A microsurgical approach to drainage of the thoracic duct in the rat]. / Abordul microchirurgical al drenajului ductului toracic la sobolan.

Study of thoracic lymph flow is still of interest in gastrointestinal absorption and lymph distribution of different drugs or in immunological studies. A microsurgical experimental model for cannulation of the thoracic duct in rats is described. The principle of the method is the end fistula described by Bollman, allowing the sampling of the total thoracic duct lymph output. A simple method of collecting lymph under free moving conditions was used. The lymph cannulations were one with 0.9 mm outer diameter silicone tubing in 24 Sprague-Dawley rats with an average preoperative weight of 300 +/- 30 g. The daily lymph output measured for up to 10 days in the awake and unrestrained rats varied between 24.4 ml and 97.7 ml/day (average 45.6 ml/ day). The hourly lymph output varied between 0.55 ml and 5.8 ml (average 1.9 ml/h). Patency of the lymph fistulas was 87.5% at five days and 64.3% at the end of the experiment. The rats with failed fistulas presented various degrees of thickening of the lymphatic vessel wall. The average weight loss at the time of euthanasia was 72 g (24%). An accurate technique under the operation microscope and the use of silicone tubing may offer a reliable method in experiments requiring the sampling of the whole thoracic duct lymph output for limited periods of time.

Intraperitonealisation of pancreas and multiple coeliostomy--a possible approach to reduce mortality of acute necrotizing pancreatitis.

The authors report their experience with surgical treatment of acute necrotizing pancreatitis. 207 of 411 patients with acute pancreatitis were operated upon. Acute necrotizing pancreatitis was found in 126 individuals. The following surgical procedures were used: subtotal spleno-pancreatectomy in 26 cases (20.6 per cent), necrectomy or sequestrectomy in 25 cases (19.7 per cent), and conservative procedures, including drainage or incision of the pancreatic capsule, in 76 cases (70.6 per cent). Most of the operations were delayed emergency interventions. The authors found adequate exposure of the pancreas as well as on proper drainage of the lesser sac and retroperitoneal areas essential. This can be accomplished by means of the authors' procedure called "intraperitonealisation" of the pancreas and by multiple coeliostomy.