[Abdominal tuberculosis--a surgical reality]. / Tuberculoza abdominala--o realitate chirurgicala.

Abdominal tuberculosis is a rare disease, with non-specific findings. Peritoneal tuberculosis is a frequent cause of low gradient ascites. The records of 22 patients (Il males, 11 females, mean age 41,17 years, and range 17-74 years) diagnosed with abdominal tuberculosis (TBC) in First Surgical Clinic, "St. Spiridon" University Hospital Iasi between 1995 and 2006 were analyzed retrospectively and the literature was reviewed. From these 22 patients diagnosed with abdominal tuberculosis, there were: peritoneal TBC in 16 cases, intestinal TBC in 5 cases, mesenteric lymph nodes TBC in 1 case. The patients with intestinal TBC, were presented with complications, 2 perforations with peritonitis, 1 intestinal obstruction, and 2 as ileo-cecal "tumors" solved by right colectomy, 4 enterectomy (3 entero-enterostomies and 1 ileo-colic anastomosis). The patients with peritoneal TBC were diagnosed by laparoscopy and peritoneal biopsy in 13 cases, and by laparotomy in 3 cases. In peritoneal tuberculosis ascites was present in 15 cases. Other common findings were weight loss (12 cases), weakness (5 cases), abdominal pain (15 cases), anorexia (5 cases) and night sweat (2 cases). Only two patients had chest radiography suggestive of a new TBC lesion. In those patients with peritoneal tuberculosis, subjected to operation, the findings were multiple diffuse involvements of the visceral and parietal peritoneum, white "miliary nodules" or plaques, enlarged lymph nodes, ascites, "violin string" fibrinous strands, and omental thickening. Biopsy specimens showed granulomas, while ascitic fluid showed numerous lymphocytes. Post operatory evolution and management were applied by the TBC Medical System and the patients were treated 6 months by tuberculostatics, with favorable evolution. Abdominal tuberculosis should be considered for diagnosis, in patients with non-specific symptoms of abdominal pain, fever, loss of appetite, abdominal distension and even symptoms of acute abdomen. Laparoscopy is the best approach for peritoneal tuberculosis, and emergency surgery is necessary for acute complication like obstruction and peritonitis. Specific antituberculosis drugs are indicated in postoperative period.

[Thermo-necrosis in nonresectable colorectal hepatic malignant tumors. Preliminary results]. / Termonecroza metastazelor hepatice nerezecabile de origine colorectala cu vapori de apa sub presiune. Rezultate preliminare.

MATERIAL AND METHOD: We report the 19 months followup results after thermo-necrosis with steam water of non-resectable colorectal liver metastases. The studied group included 24 (18 men + 6 women) cases, aged 39-85 (mean age = 61), that were subjected to thermo-necrosis procedure between 2004-2006. Thermo-necrosis was performed per primam (1 case with non-resectable primary tumor), or either synchronous (8 cases) or at up to 53 months (15 cases) after primary tumor resection, and implied delivering of 6.7 - 87 kiloJoules to targeted lesions (for a median of 5 targets per patient liver). Concomitant with thermo-necrosis, in 8 cases some metastatic lesions were also resected (for tumor mass reduction). Followup consisted in echographic, CT, clinical and laboratory evaluation each 1-2 month. RESULTS: The thermo-necrosis procedure was completed within 3 to 20 (median = 10) minutes, and no peri-operatory deaths or complication were recorded. After procedure, the treated lesions either shrunken or were stationary under imaging explorations; increasing images marked the time to tumor progression. Tumor progression was recorded in 12 cases, time to tumor progression ranging from 1 to 14 (median = 5) months; the follow up time for the remaining 12 cases ranging 3 - 18 (median = 8) months. Nine cases died at 6-15 (median = 9) months after thermo-necrosis; for the remaining 15 cases the followup time ranged 4-19 (median= 10) months. One year survival was 61%; median survival (50%) time was 9 months. CONCLUSIONS: Thermo-necrosis with steam water of non-resectable colorectal liver metastases associate low invasiveness, good compliance, and time interval for tumor progression and survival comparable or better than other thermo-necrosis techniques, representing a promising palliative therapy in secondary liver cancer.

[Conversion in laparoscopic cholecystectomy]. / Conversia in colecistectomia laparoscopica.

Laparoscopic cholecystectomy (LC) has become the gold standard in the treatment of symptomatic cholelithiasis. Some patients require conversion to open surgery and several preoperative variables have been identified as risk factors that are helpful in predicting the probability of conversion. The aim of this study was to analyze the factors that make LC difficult and determine conversion to open approach: Our study includes: 6985 cases which underwent LC and 1430 cases with open cholecystectomy, between March 1993 and April 2005 in our clinic of general surgery. The overall conversion rate was 5.1% (deliberate conversion--299 cases, conversion of necessity--62 cases). The conversion rate has decreased from 17.5% in 1993 to 3.2% in recent years. The most conversion happen after a simple inspection or a minimal dissection caused by the existence of perforation (105 cases), the discovery of a difficult anatomic situation (63 cases) or of another pathology (14 cases); more rarely, the conversion was necessary in the principal time, doing to hemorrhage (26 cases), impossible dissection (41 cases), visceral injury (1 case) or even at the end of the operation, doing to hemorrhage, loss piece or stone (10 cases), and other situations (101 cases). Significant predictors of conversion were acute cholecystitis , choledocholithiasis, past history of acute cholecystitis, male gender, gall bladder wall thickness exceeding 6 mm. In conclusion, based on our experience, we suggest limiting OC to patients with proven contraindications to LC (i.e., Mirizzi syndrome or systemic illness incompatible with general anesthesia or pneumoperitoneum), attempting LC in all other cases. Decision to convert to open approach is a proven of surgical maturity. Conversion must be decided from the beginning, in the moment of the recognition of a difficult situation and not after the occurrence of a complication.

[Liver resection for hepatocellular carcinoma in cirrhotic patients]. / Rezectia hepatica in carcinomul hepatocelular dezvoltat pe ciroza.

The incidence of hepatocellular carcinoma (HCC) in cirrhotic patients is increasing. Despite advances in imaging and laboratory screening which allow earlier diagnosis, the surgeon is all too often confronted with an HCC of advanced stage or arising in the setting of severe cirrhosis. Hepatic resection is still considered the treatment of choice for hepatocellular carcinoma in patients with liver cirrhosis. From 1998 to 2005, 6 patients (5 males, 1 female, age 52-70 years, mean age 64.1 years) with HCC associated severe, but well compensated liver cirrhosis (Child A-- 4 patients, Child B--2 patients) underwent 9 hepatic resection in our department. Mean tumor size was 56 mm (range 23-86 mm). Two of these lesions were in the left liver and four in the right lobe. Doppler ultrasonography was performed in all cases and CT in 3 cases to confirm the extension of the lesions. Laparoscopy was performed in 3 patients under CO2 pneumoperitoneum. The Pringle maneuver was not used. The transection of the liver parenchyma was obtained by the use of Ligasure and harmonic scalpel. Nine hepatic resections were performed: 7 segmentectomy and 2 non-anatomical resections. The resection margin was 1 cm. The mean operative time was 90 minutes (range 60-120). Mean blood loss was 250 ml and 2 patients required blood transfusion. One patient died on the tenth postoperative day from a severe respiratory distress syndrome and hepatic failure. Major morbidities occurred in three patients who developed moderate postoperative ascites, which resolved successfully with conservative treatment in two patients. Limited liver resection in cirrhotic patients with HCC is feasible with a low complication rate when careful selection criteria are followed (tumor size smaller than 8 cm, Child-Pugh A class and the good general conditions of the patients). Other medical and interventional treatments (chemoembolization, chemotherapy) can only slow the progress of HCC.

[Palliative therapy for malignant hepatic tumors with hyperthermia]. / Metode paleative de tratament al tumorilor hepatice maligne prin hipertermie.

Hepatocellular carcinoma (HCC) is one of the most common malignancies worldwide with an annual occurrence of one million new cases. The incidence of liver metastasis is much higher than the incidence of HCC. Overall nearly 50% of the patients with colorectal adenocarcinoma will develop liver metastasis. Surgical resection remains the "gold standard" for resectable hepatic neoplasms, but only a minority of patients present with lesions which are potentially curable. In these nonresectable hepatic tumors palliative treatment using focal necrosis by hyperthermia (radiofrequency, microwave coagulation therapy, interstitial laser photocoagulation, thermo-ablation with hot water steam) appear as a valuable alternative. Best results are reported in the case of associations of thermo-necrosis with general or intraarterial chemotherapy. These methods of treatment can be performed by percutaneous, laparoscopic or open approach. Precise guidance of the focal necrosis can be realized using CT scan, IRM and intraoperative ultrasound exam and the results are evaluated by the same techniques. The key element in the management of the malignant tumors of the liver is the cooperation between surgeon, intensive care physician, oncologist and specialist in interventional radiology, to appreciate the indication of therapy. Further controlled trials are required to define the precise indications and long term results of these methods of treatment.

[Meckel's diverticulum in laparoscopic era]. / Diverticulul Meckel în era chirurgiei laparoscopice.

A recent case of a Meckel's diverticulum diagnosed and successfully laparoscopically treated, triggered off a retrospective study on a series of 34 cases with Meckel's diverticulum admitted to the First Surgical Clinic between 1990-2003. We encountered 12 uncomplicated cases and 22 cases with a large panel of complications: 11 intestinal obstructions (volvulus 9, intussusceptions on a tumor-2), 9 cases with diverticulitis, 1 gastrointestinal bleeding and 1 case with Littre's inguinal hernia. Positive diagnosis was established intraoperatively and the surgical treatment was adapted according to the local situation (excision of the diverticulum or enterectomy). Out of 12 patients with uncomplicated Meckel's diverticulum 8 were subjected to prophylactic excision of the diverticulum. In 6 of these microscopic examinations were inclusions of gastric mucosa. Laparoscopy is safe, relatively inexpensive and efficient in the diagnosis and treatment of Meckel's diverticulum.

[Cholelithiasis after gastric surgery--possibilities and limits of laparoscopic approach]. / Litiaza veziculara dupa chirurgia gastrica. Posibilitatile si limitele laparoscopiei.

An increased incidence of cholelithiasis has been widely reported after gastric surgery. In the early phase of patient selection, previous gastric surgery has been considered a relative contraindication to laparoscopic cholecystectomy. Between 1999-2003, in our clinic, laparoscopic cholecystectomy was attempted on 3145 patients. Of these patients, 37 patients had gallstone, which occurred several years (mean 17.9 years) after gastric surgery for peptic ulcer (34 cases), gastric cancer (1 case) and hiatal hernia (2 cases). Surgical procedures that had been performed included Billroth I gastrectomy (14 cases), Billroth II gastrectomy (15 cases), truncal vagotomy and piloroplasty (6 cases), and Nissen (2 cases). On this group there were 19 chronic cholecystites, 17 acute cholecystites and one cholesterolosis with gallbladder polyps. One patient was diagnosed with gallstone in common bile duct, successfully removed preoperatively after endoscopic sphincterotomy. The laparoscopic approach was possible in 26 cases. The technical difficulty after Cuschieri was level III--26 patients and level IV--11 patients (reconversion). The mean operative time was 75 minutes. The postoperative evolution of the patients was good in 36 cases. One case had a biliary fistula. The mean postoperative hospital stay was 3.6 days for laparoscopic cholecystectomy and 9 days after conversion. The postoperative adhesions determine the main technical difficulty, but it proved to be a relative contraindication for laparoscopic cholecystectomy for gallstones after gastric surgery. Clear visualization of anatomic structures and landmarks, and scrupulous hemostasis are needed to perform a safe laparoscopic cholecystectomy in these patients.

[Male gender-- difficulty factor in cholecystectomies for cholelithiasis]. / Sexul masculin--factor de dificultate în colecistectomiile pentru colelitiaza.

Male gender has been recognized as a risk factor for an increased conversion rate of laparoscopic cholecystectomy and more severe disease in those with symptomatic cholelithiasis. The aim of this study was to determine the effect of male gender on the clinical presentation of symptomatic cholelithiasis, relation between male gender and acute cholecystectes, the operating time, the frequency of conversion and postoperative morbidity. The medical records of all patients with symptomatic cholelithiasis from 31 mars 1993 to 31 mars 2001 (4145 patients) were evaluated. These cases were divided into four groups: A--elective laparoscopic cholecystectomy group--patients with cholecystectes with elective laparoscopic cholecystectomy (3995 cases); B--patients with acute cholecystectes whose laparoscopic cholecystectomy was performed successfully (660 cases); C--acute conversion group converted to open surgery (240 cases); D--acute open group with elective open cholecystectomy. The study reveals that males suffer from a severe form of cholecystectes that raise difficulties when laparoscopic cholecystectomy is performed.