Intermesenteric appendicular abscess, a diagnostic challenge; case report and review.

The appendicular origin of an intermesenteric abscess is rarely suspected prior to surgery, due to atypical clinical presentation and poor sensitivity of exploratory methods. A 43-year-old male was admitted for recent pain and mild tenderness in the epigastrium, slight emesis, leucocytosis (C-reactive protein was not determined), with no pathological findings on simple abdominal radiological examination (Rx). Abdominal ultrasound(US) and endoscopy were irrelevant. The abdomen became moderately tender, distended; diffuse enteric gas,slightly impaired bowel movement could be demonstrated by anew Rx. CT (oral contrast) was performed in the 3rd day:edematous infiltration of the mesentery and of a left-flank digestive loop (jejunal, sigmoidian?), small-size fluid collection(with extraluminal air-level) and paretic loops in the proximity, but normal wall-appearance of the caecum and its surrounding fat; the CT result was inconclusive (perforated diverticulosis or malignancy?). Barium enema: normal,including the caecum. Installation of vesperal fever, progressive mid-abdominal pain, tenderness and formation of a mass were the rationale for open mid-line laparotomy, discovering a large intermesenteric abscess, secondary to perforated gangrenous intermesenteric appendicitis. Surgical outcome of appendectomy was normal. A high index of suspicion may be suggested by: atypical clinical presentation (fever; ileus;presence or formation of a tender, periumbilical, mass) and CT findings (abscess; extraluminal air; ileus).

Principles of surgical treatment of Zenker diverticulum.

BACKGROUND: Pharyngo-esophageal diverticula are most frequently described in elderly patients, having symptoms such as dysphagia, regurgitation, chronic cough, aspiration and weight loss. The etiology remains controversial, although most of the theories are linked to structural or functional abnormalities of the crico-pharyngeal muscle. With the therapeutic attitude varying from conservative to surgical (with associated morbidity and mortality), the importance of knowing the etiopathology and clinical implications of the disease for establishing the management of the case is mandatory. The aim of the study is the reevaluation of the methods and therapeutic principles in pharyngo-esophageal diverticular disease, starting from the etio pathogeny. MATERIALS AND METHODS: Our study group is made up of 11 patients with surgical indication for Zenker diverticulum, operated between 2001 and 2011. RESULTS: During that period, more patients were diagnosed with this pathology, but the surgical indication was carefully established, in conformity with the actual practice guides, which involve the evaluation of the clinical manifestations determined by the diverticulum, as well as the identification and interception of the pathological mechanisms by the therapeutic gesture. CONCLUSION: Although it has a "benign" pathology, the esophageal diverticulum requires complex surgical procedure that implies significant morbidity.

[Surgical treatment of esophageal diverticula]. / Tratamentul chirurgical al diverticulilor esofagieni.

The aim of this paper is to evaluate the methods and therapeutic principles of esophageal diverticula pathology. We analyze the main pathological mechanisms which establish the therapeutic attitude linked with a complex pretherapeutic evaluation. In our study we enrolled 12 patients operated between 2001-2009 for esophageal diverticula with different topography. In this period of time there were much more patients diagnosed with this pathology, but the need for surgery was establish very tight regarding the actual practical guide which impose the identification and interception of physiological mechanisms by the surgical procedure. We highlight the particular technical details, as well as the important differences of postoperatory complications according to the topography of the diverticula pouch.

Association of common genetic variants with colorectal cancer risk in a Romanian sample.

Recently, several genome-wide association studies identified and validated loci at which common genetic variants influence the risk of colorectal cancer. We aimed to test the association between eight SNPs and colorectal cancer in a Romanian case-control sample. We genotyped rs10795668, rs16892766, rs3802842, rs4444235, rs4779584, rs4939827, rs6983267, and rs9929218 and we statistically tested the association with the disease. Five SNPs (rs6983267, rs4939827, rs3802842, rs4444235, rs10795668) showed an association with colon and rectal cancer. Three of them proved to be statistically significant: rs6983267 and rs4939827 risk alleles were significantly associated with rectal cancers (p = 0.031 and p = 0.004 for homozygous, p = 0.002 and p = 0.005 for heterozygous). For rs3802842 we found a greater risk for colon than rectal cancer with an OR of 2.26 (CI = 1.04-5.88, p = 0.040) for the dominant model. The rs4444235 confirmed the risk for both homozygous and heterozygous carriers, with the greatest ORs of 1.49 (CI = 0.61-3.61) for heterozygote. For rs10795668 we found an increased risk for rectum cancer vs. controls with an OR of 1.46 (CI = 0.66-3.21), and for rectum cancer vs. colon cancer (OR = 2.19; CI = 0.87-5.55). This is the first Romanian study that confirms previously-identified associations with colorectal cancer risk for five out of eight SNPs investigated and underlines the necessity of extensive replication using larger samples.

[Features of Krukenberg-type tumors--clinical study and review]. / Particularitati ale tumorilor de tip Krukenberg--studiu clinic si review.

Krukenberg-type tumors (KT) are rare among ovarian metastases, but responsible for the most frequent diagnostic confusions with ovarian cancer. They are peculiar: uncertain pathogenesis, challenging etiological diagnosis, poorer prognosis for the primary. We studied 9 cases, with a mean age of 52 years, operated since 2001; no case was discovered as a result of prophylactic oophorectomy. Timing of TK diagnosis: 3--metachronous, 4--synchronous, as incidental discovery and 2--retrospective pathological diagnosis. Site of primary: 3--gastric, 5--colonic or appendiceal, 1--breast. Imaging appearance was useful only if interpreted in clinical conditions. Morphology: 7/9 bilateral, solid or mixed gross appearance, oval, mean diameters 9.4/7.8 cm. Microscopy: in 8 KT of digestive origin, 3--signet-ring cell carcinoma, 3--mucinous adenocarcinoma, 2--mixed pattern; 1 KT or breast origin was diagnosed by immunohistochemistry; 6/9 presented microscopic peritoneal despite a lack of strong correlation with the appearance of carcinomatosis or cytology of ascites. Survival: 3--no evidence, 5--disease-free after 4-13 months, 1--survived 2 years after debulking (4 years after colectomy). Clinical, evolutive and prognostic features of KT are determined by the biologically behavior of the primary (rapid lymphatic and hematogenous spread to the ovary), so the benefit of surgery is limited. Bilateral ovarian tumors, particularly in premenopausal women, must raise a high index of suspicion for KT, before or during surgery; diagnosis is a team challenge.

Pseudo-achalasic behaviour of a middle thoracic esophageal squamous cell carcinoma.

Pseudo-achalasia is a rare pathologic entity that mimics idiopathic achalasia, usually secondary to malignant infiltration of the cardia. Its significance is related to the fact that it may be difficult to distinguish from primary achalasia; the outcome and therapeutic course are different. In fact, a large variety of processes may be responsible for the development of a secondary achalasia syndrome; we present a case with pseudo-achalasia due to a middle thoracic esophageal squamous cell carcinoma.

[Full-thickness replacement using intraperitoneal mesh in large incisional hernia]. / Substitutia cu mesa intraperitoneala in defectele eventrale voluminoase.

Parieto-suture (simple closure or Judd-Mayo technique) is appropriate for most incisional hernias, but not in case of large or complex parietal defect. In these peculiar cases, prosthesis mesh is recommended, biased by two factors: biodisponibility of the material related to the choice of parietal insertion. In practice, fascial onlay is abandoned in favour of extra/retro-muscular onlay, which offers a better vascular support for mesh implantation and is ideal if anatomic closure is feasible. Occasionally, full-thickness replacement is a must in large incisional hernia, in order to restore parietal competence. Technically, substitution is easy to perform, followed by a low rate of in-hospital complications; the same is true if recurrence occurs. In exchange, the hazard of enterocutaneous fistula requires appropriate measures for visceral protection. Our commentary regarding the advantages and disadvantages of intraperitoneal (pro-epiploic) mesh placement, as well as technical details, are based on 10 years of surgical practice.

[Simultaneous bilateral breast carcinoma--case study and review of primitive bilateral breast cancer]. / Carcinom mamar bilateral, simultan. Studiu de caz si review asupra cancerului mamar bilateral primitiv.

Bilateral breast cancer is uncommon and difficult to define because it may manifest as simultaneous, synchronous or metachronous tumours. The true clonal origin and biologic behaviour are still controversial. Following a right breast contusion, bilateral breast tumours were diagnosed in a 74 old female patient; the left one, neglected for 3 years, typically scirrous; the right one with cystic, pseudo-inflammatory appearance. Sonography and fine-needle cytology concluded: left, carcinoma (T3bN1Mx); right, benign nodule with traumatic hematoma. Three sessions of chemotherapy were followed by simultaneous left Madden mastectomy and right simple mastectomy (frozen sections negative for malignancy). Histopathology: left, invasive lobular carcinoma (ypT4N0Mx); right, micropapillary invasive carcinoma mixed with adenoid cystic carcinoma. After another 3 chemotherapeutic sessions, right axillary lymphadenectomy was performed. Both lesions were evaluated by immunohistochemistry and the TNM pathological classification was reconsidered; left, ypT4N1Mx; right, ypT3N0Mx. Considering the natural history, histopathological and immunohistochemical patterns of the two tumours, these seem to be distinct but shearing a common favourable biologic behaviour. No genetic studies were performed in the absence of specific risk factors. Based on clinical, epidemiologic, morphologic and genetic evidence, bilateral breast cancers (synchronous or metachronous) are considered to be a special evolutive entity of breast cancer. Our case suggests that, in the absence of risk factors for bilaterality of breast carcinoma: description of bilateral breast cancers based on diagnostic chronology of the two tumours is arbitrary; they may occur sporadically and have independent evolution; their biology rather resembles a multiple primitive malignancy than a true bilateral breast cancer.

[Small intestinal hemorrhage due to rare etiology. Diagnostic difficulties and therapeutic approaches]. / Hemoragia digestiva de cauza enterala atipica. Dificultati diagnostice si terapeutice.

Understanding of the pathogenesis, diagnosis, and treatment of lower GI bleeding has drastically changed during the last 50 years, but it continues to be a frequent cause of hospital admission and also a factor in hospital morbidity and mortality. Acute lower gastrointestinal hemorrhage (ALGIH) represents only 20% of the GI bleeding and the small intestine is the site of hemorrhage in about 1% of cases. Although in the last four decades, diagnostic methods for locating the precise bleeding point improved greatly, still the adequate localization of the lesion is very difficult to achieve through algorithmic approaches. We performed a clinical study and we retrospectively analyzed 5 patients (mean age = 59,8 years, 1 female) who had a surgical intervention for acute lower GI hemorrhage in the last decade, in order to emphasize diagnosis difficulties when the bleeding arises from small lesions in the small bowel that is not easily accessible for direct visualisation. Surgery was the treatment of choice in every case consisting in segmental resections of the involved small bowel, along with viscerolysis and exploratory gastro-jejunostoma. The mortality rate was 20% (1 postoperative death of cardiac etiology). There have been no specific postoperative complications in the other four patients and a good outcome was reported. The diagnosis is particularly difficult and when colonic and upper gastrointestinal evaluations fail to identify a source of bleeding, a small intestinal source should be considered. We can conclude that the most important factor in the management of ALGIH is determination of specific localization of the lesion.

[Ectopic intestinal varices in cirrhotic patients; an infrequent cause of severe intestinal bleeding]. / Varice ectopic intestinal la bolnavul cirotic; cauza rara de hemoragie digestiva inferioara acuta.

We report on a cirrhotic patient, with history of colecistectomy, admitted for acute digestive bleeding. Esogastric causes were excluded by endoscopy; due to continuous hemorrhage, the patient was operated in the next 20 hours. The cause was established during the operation; solitary omfalo-enteric varices, with active vascular fistula. Preoperative etiology of acute intestinal bleeding may be difficult to establish, sometimes even during the surgical intervention. We comment upon rare causes of acute intestinal bleeding, mainly ectopic varices determined by portal hypertension.

[Osteo-articular manifestations after suppurative pancreatitis]. / Manifestari osteo-articulare consecutive supuratiei pancreatice acute prelungite.

Osseous and joint manifestations (decalcification, osteolysis, osteonecrosis; poliarthrytis; periarticular fat necrosis) are sometimes encountered in chronic pancreatitis or carcinoma, but exceptional after severe acute pancreatitis, especially infected pancreatic necrosis. Pathogenesis of calcium deficiency in acute pancreatitis is multifactorial, including extensive lipolysis and metabolic disturbances. We report on a healthy, young male, that developed decalcification and polyarthritis consecutive to a long-outcome, severe acute pancreatitis. We comment upon hypocalcemia, as a rare complication of acute pancreatitis.

[Infiltrating mucinous carcinoma developed on chronic anal fistula; diagnostic and surgical difficulties]. / Carcinom coloid infiltrativ grefat pe supuratie cronica ano-rectala; dificultati de diagnostic si tratament chirurgical.

Anal carcinoma is rare; fistula-in-ano is sometimes mentioned among other premalignant conditions. Chronic anal fistula is associated with malignant transformation to mucinous adenocarcinoma, difficult to diagnose in the anal region and associated to a poor prognosis. Malignant transformation to infiltrating colloid carcinoma was surprised during a one year period, in a patient with long-standing perianal fistula (24 years). Inflammatory changes of the perineal region and other peculiar characteristics (such as neoplastic spread following supurative pathways) were responsible for diagnostic and surgical difficulties.

[Incisional hernia repair using full-thickness intraperitoneal mesh]. / Substitutia alloplastica intraperitoneala pentru defecte parieto-abdominale eventrale.

Prosthetic materials proved to be a real success for incisional hernia repair, still there is a strong debate regarding the best mesh and procedure to be used. Most surgeons avoid full-thickness replacement with intraperitoneal mesh because, occasionally, an intense inflammatory response may lead to severe adhesions or enterocutaneous fistula. Still, interposition of the omentum between the abdominal contents and the mesh is a safe and natural method of visceral protection. Since July 1998, we used this technique in 33 cases treated for antero-lateral abdominal defects, operations that were followed by only 15% early and 3% late complications. Monofilament polypropylene meshes (Bard, Davol Inc.) were used in most cases. Although our results need further evaluation, may be considered favourable on short and medium term comparing to Romanian experience, which is based mainly on extraperitoneal placement of the mesh. The study is a good opportunity to review the literature regarding this issue.

[Medio-thoracic esophageal stenosis, produced by pseudotumoral ulcer]. / Ulcer esofagian solitar, cu stenoza mediotoracica pseudoneoplazica.

A non-specific esophagitis developed in a young male, apparently determined by heavy abuse of alcohol. Shortly after, a stenotic pseudo-tumoral mediothoracic esophageal lesion was diagnosed. Although there was a high index of suspicion regarding the caustic origin of the lesion, cancer could not be excluded using current diagnostic methods. Temporary feeding jejunostomy was followed by uneventful total esophagectomy and gastric pull-up. Pathologic examination of the resected specimen was a surprise, revealing an esophageal ulcer based on massive severe non-specific esophagitis. Retrospectively, the ulcer was judged as primitive or idiopathic. We discuss some etiopathogenic aspects of common secondary esophageal ulcers (related or not to reflux disease), in contrast with idiopathic esophageal ulcers.

[Intestinal obstruction by biliary ileus; clinical experience and literature review]. / Ocluzia intestinului mezenterial prin calcul biliar (ileus biliar); experinta clinica si revizuirea literaturii.

BACKGROUND: Gallstone ileus is an unusual and peculiar complication of biliary lithiasis. Less than 1% of gallstones migrate into the gut, causing 25% of non-strangulated small bowell obstructions in elderly population. Diagnosis is difficult, leading to late operation. Considering the median age of the patients and the fact that in most cases surgery is delayed, there is a lot of dispute regarding the best approach. Recent technical facilities in diagnostic and surgical practice seem to be irrelevant for the general outcome. MATERIAL AND METHOD: All 6 patients operated since 1981 (median age 67 years, 5 female) were retrospectively analyzed, to determine the most valid option. Biliary ileus was recorded in 0.16% of all operations for billiard lithiasis and 1.52% of all enteric occlusions. There was a mean delay of 4.2 days for onset of symptoms to admission and further 5 days to surgery. Particular elements suggesting the ethiology were absent in most cases. In all cases the gallstone migrated in the duodenum. The obstruction was jejunal (3 patients), proximal ileal (2 patients) and distal ileal (1 patient). Enterolithotomy was practiced in 3 cases, with subsequent cholecystectomy and fistula closure in 1 case; one-stage repair in 2 cases and enterolithotomy with temporary external drainage of the fistula (cholecystostomy) in 1 patient. RESULTS AND CONCLUSIONS: There were no specific (fistular) complications; 1 aged patient with distal occlusion died because of severe metabolic disorders. The most "favourable" cases were those with very large gallstones occluding the jejunum. Smaller stones were less symptomatic, resulting in delayed diagnosis and surgery; the more aboral the occlusion, more indication for abstention regarding primary repair of the fistula.

[Roux-en-Y gastrojejunostomy: indications, technique, results]. / Rezectia gastrica cu gastrojejunostomie à la Roux-indicatii, tehnica, rezultate.

61 gastrojejunostomies were constructed between 1981-1999 in 58 cases (43 cases were operated between 1991-1999). 30 cases have previously suffered various gastric operations; in 28 cases the Roux-en-Y was the first gastric operation (27 operated on between 1991-1999). Radiologic and endobioptic studies were routine for diagnostic and follow-up evaluation, but various scintigraphic studies were performed in selected cases. The surgical technique was tailored for each case, according to the preoperative strategy. The indications for surgery were the following: 19-reflux disease; 14-severe peptic disease (9-reccurence, 3-postbulbar lesion, 2-juxtacardial ulcer); 8-peptic disease associated to reflux disease; 8-gastric cancer; 8-various early or late complications after gastrectomy; 1-lymphocytic gastritis. There were 4 early reoperations and 3 deceased. In 3 cases late reintervention was mandatory (for Zollinger-Ellison syndrome, peptic ulcer secondary to gastrectomy for cancer, Roux-stasis syndrome) and the Roux pattern was preserved; in 2 cases the antireflux effect of the operation was lost after the reoperation.

[Long-term evolution of a T-tube in the common bile duct]. / Evolutia pe termen lung a tubului Kehr în calea biliara principala.

We present the case of an elderly and frail woman, admitted for obstructive jaundice 9 years after cholecystectomy, lithotomy and T-tube drainage. The presence of a T-tube remnant in the common bile duct was suggested by imaging techniques, along with a megacholedocus. Because of the risks associated with advanced biliary cirrhosis, the endoscopic retrieval and lithotripsy was the first therapeutical attempt but failed. Lithotomy and cholangio-jejunostomy by open surgery were followed by a surprising favourable course.

[Total duodenal diversion in hiatal hernia with pathological duodenoesophageal reflux (preliminary results)]. / Diversie duodenala totala în hernia hiatala cu reflux duodenoesofagian patologic (rezultate preliminare).

For some patients, reflux disease means also duodenogastric, as well as gastroesophageal reflux; they may suffer because of duodenoesophageal reflux. For these patients, a simple surgical restoration of the cardial competence may prove to be insufficient; on the contrary, an indirect approach, using vagotomy and duodenal diversion may be a good therapeutical option in selected cases. In our hands, total duodenal diversion has already proven to be a good technical solution for the surgical treatment of the postoperative reflux disease, so we decided to expand its first choice indications to hiatal hernia cases, in the presence of duodenoesophageal reflux. Therefore, our study presents the results of the first 7 cases, operated on since 1995. No case had been gastric operated before, but 4/7 had already suffered a cholecystectomy. Duodenoesophageal reflux is discussed: etiopathogenesis related to surgical approach, using standard antireflux surgery (failures of the hiatal techniques and their causes) or total duodenal diversion (technical aspects, antireflux efficiency, secondary functional effects, pros and cons, therapeutical indications).

[Clinical and therapeutic considerations in pseudomyxoma peritonei]. / Consideratii clinice si terapeutice despre pseudomixomul peritoneal.

Pseudomyxoma peritonei (PMP) is an uncommon clinical entity, lacking a precisely defined etiopathogenesis. Its clinical features are not specific and diagnosis is difficult. We analysed 10 patients, all of them women, whom we had treated surgically in combination with intraperitoneal chemotherapy. Postoperative complications had been minimal and no death had occurred. 5 patients were followed up in time, 4 of them presenting a favourable evolution (2 required reintervention), and 1 patient decreased. We analysed up-to-date therapeutic approaches and the benefit of their combinations in order to identify the optimal therapeutic strategy. We consider that the combinations surgery + intraperitoneal chemotherapy or surgery + intracavitary radiotherapy are the most effective up to date.