Seven years of Non-invasive Follicular Thyroid Neoplasm with Papillary-like Nuclear Features (NIFTP): Rate of Acceptance and Variation of Diagnostic Approaches Across Different Continents.

CONTEXT: Noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) was introduced as a new entity replacing the diagnosis of noninvasive encapsulated follicular variant of papillary thyroid carcinoma (PTC). Significant variability in the incidence of NIFTP diagnosed in different world regions has been reported. OBJECTIVE: To investigate the rate of adoption of NIFTP, change in practice patterns, and uniformity in applying diagnostic criteria among pathologists practicing in different regions. METHODS: Two surveys distributed to pathologists of the International Endocrine Pathology Discussion Group with multiple-choice questions on NIFTP adoption into pathology practice and whole slide images of 5 tumors to collect information on nuclear score and diagnosis. Forty-eight endocrine pathologists, including 24 from North America, 8 from Europe, and 16 from Asia/Oceania completed the first survey and 38 the second survey. RESULTS: A 94% adoption rate of NIFTP by the pathologists was found. Yet, the frequency of rendering NIFTP diagnosis was significantly higher in North America than in other regions (P = .009). While the highest concordance was found in diagnosing lesions with mildly or well-developed PTC-like nuclei, there was significant variability in nuclear scoring and diagnosing NIFTP for tumors with moderate nuclear changes (nuclear score 2) (case 2, P < .05). Pathologists practicing in North America and Europe showed a tendency for lower thresholds for PTC-like nuclei and NIFTP than those practicing in Asia/Oceania. CONCLUSION: Despite a high adoption rate of NIFTP across geographic regions, NIFTP is diagnosed more often by pathologists in North America. Significant differences remain in diagnosing intermediate PTC-like nuclei and respectively NIFTP, with more conservative nuclear scoring in Asia/Oceania, which may explain the geographic differences in NIFTP incidence.

Pancreaticojejunostomy - Risk Anastomosis after Cephalic Pancreaticoduodenectomy.

INTRODUCTION: The authors bring to attention pancreaticojejunalanastomosis (PJA) performed after cephalic pancreaticoduodenectomy(CPD). This type of anastomosis is renowned forits high risk of complications. Among these complications, pancreatic fistula (PF) is distinguishable due to a significant frequency, averaging 10%. It is perhaps the most unsafe type of anastomosis in digestive surgery, due to its pancreatic partnership. Performing a sealed APJ can be considered a great achievement: a digestive lumen is set in contact with a brittleparenchymal structure, centred by a delicate excretory channel, difficult to anastomose in itself. MATERIAL AND METHODS: We studied two distinct groups of patients undergoing CPD. A first group - 58 cases operated on between 1967 and 1983, and the second one - 70 cases operated on between 1984 - 2013. In all cases we performed PJA; by in-continuity loop technique in the first group, and with separate loop in the second group. In the second group we used a variant own technique that does not allow anastomotic loss of pancreatic fluid. Thus, a decline in the incidence of PF from 20% to 8% was obtained, the final percentage corresponding to group two. Of the 8% of patients with PF losses were recorded strictly at pancreatic level, with no bile or food contamination. Stenting was recorded for biliary- and pancreaticojejunal anastomoses in group two. DISCUSSIONS: The percentage of PF after CPD did not show anynotable revival when comparing the 1980s period to the present. Also, mortality due to FP is approaching 40%, adaunting figure. The multitude of technical options for restoring bowel movement after CPD, over 80 procedures, further confirms the lack of safety and trust in relation to PJA.The authors bring forward several surgical gestures addressing PJA, gestures capable of providing an 8% frequency of PF,percentage which we consider to be reasonable. CONCLUSIONS: The authors consider PJA stenting mandatory.Placing an isolated PJA on the short branch of the "Y", separate from the biliary and food flow, prevents the formation of a complex fistula. The proposed technique does not require a"duct - to - mucosa" type or "telescoping" type pancreaticojejunalanastomosis.

Morbidity after Ultra Low Anterior Resection of the Rectum.

Anterior resections of the rectum, used as an alternative to amputation of the rectum, are performed more and more frequently, being presently indicated for neoplasms located ata distance of 7 to 4 cm from the anus. Complications of low and ultra low anterior resections are not at all negligible, and local neoplastic recurrence rate is significantly higher than after amputation of the rectum. However, literature data recommends low and ultra low anterior rectal resections, even if sometimes the method indications are pushed to the limit or the interventions are performed at the patient's request, in order to avoid permanent colostomy. The authors of this article aim to outline a true picture of the changes caused by anterior resections of the rectum, low and ultra low, so that, without denying the merits of these resections, the entire postoperative pathology that occurs in these patients is depicted and understood. Ultra low rectal resections, up to 3-4 cm from the anus, bring important morphological and functional changes to the act of defecation and to anal continence. These changes in colo-anal bowel movement have a much higher incidence than postoperative genitourinary disorders. Another important aspect emerging from the present study is related to the increased incidence of anastomotic disunity, stenosis and various degrees of incontinence, complications that often can only be solved by completion of rectum amputation and permanent colostomy. In addition, the functional outcomes of these ultra low resections are not always at the level expected by the patient. Also, in terms of surgical performance, the higher share of specific complications of the procedure raises questions with regard to the technique. For all these reasons the authors consider it necessary to review the lower limit to which an anterior rectal resection can descend.

"Difficult" Colorectal Polyps - Therapeutic Approach.

INTRODUCTION: Endoscopic polypectomy is the gold standard in the treatment of colorectal polyps. The importance of polypectomy rests primarily on the fact that polyp-type lesions present a high risk of malignant degeneration, colorectal polyps being able, if left unattended therapeutically, to generate a colorectal cancer (CRC) - a lesion with a far more negative prognosis. Although preferable, endoscopic polypectomy of colorectal polyps is not always possible, multiple factors generating difficulties in performing this therapeutic measure. MATERIAL AND METHOD: We performed a retrospective study in the First Surgical Clinic of the "Prof. Dr. Alexandu Trestioreanu" Bucharest Oncology Institute, spanning a period of 3 years (2008-2011), in which time 224 patients were diagnosed by colonoscopy with colorectal polyps, of whom 222 patients benefited from endoscopic polypectomy. The aim of the study was to identify "difficult" polyps and to identify the criteria for endoscopic surgery versus classic surgery as a therapeutic indication. RESULTS: Presence of "difficult" polyps was observed in 37.56% of the patients diagnosed with colorectal polyps. In over 88% of cases endoscopic polypectomy was possible, and for the remaining patients classic surgery was the therapeutic solution opted for. CONCLUSIONS: Presence of "difficult" polyps generates inconveniences in performing endoscopic polypectomy, increasing the risk of postoperative complication occurrence, as well as the duration of the operation. If the criteria for characterizing polyps as "difficult" are relatively well-established, the choice between endoscopic and classic surgery as a therapeutic measure is left at the free will of the operating surgeon, with the exception of situations in which classic surgery is resorted to for oncological reasons.

Intestinal obstruction management in patients with advanced abdominal neoplasia.

BACKGROUND: The present study describes the difficulties encountered in the diagnostic process and treatment of intestinal obstruction developed by patients with advanced abdominal neoplasia. METHODS: This unicentric and retrospective study evaluates patients suffering from intestinal occlusion operated on at the First Surgical Clinic of the Oncology Institute in Bucharest, over a period of 4 years (2010 - 2013). Of these, 61 cases in which the occlusion occurred on the background of an advanced abdominal neoplasia were selected. We considered as advanced those cases of abdominal cancer where curative oncologic treatment is no longer possible due to the evolution stage. RESULTS: The random selection of the study period, the introduction of all the patients identified with this type of pathology, as well as the concentration of advanced abdominal neoplasia at the Oncology Institute in Bucharest are the elements that allow us to state that the results of this study are representative. Particularities related to the clinical aspects of the intestinal occlusion in these patients, as well as difficulties in establishing the correct diagnosis were encountered.Surgical cure of the occlusion, with palliative aim of course,was possible in only 47 cases (representing 77.05%). CONCLUSIONS: A standard treatment course cannot be devised for this type of patients. Palliative care, indispensable in cases of advanced neoplastic disease, remains the sole therapeutic method available for patients with no surgical cure for the obstruction. The main objective, for the entire study lot, was to ensure an as high as possible quality of life,a factor we must bear in mind as often as possible when choosing a surgical solution. Of course, when surgical treatment can be applied, overcoming the occlusive episode prolongs these patients' life and can even allow for other courses of complementary treatment to be undertaken.

Choleperitoneum due to intrahepatic bile duct rupture - case report.

Non-traumatic perforations of the bile ducts are unfrequently encountered entities, all the more when they affect the intrahepatic bile ducts, exteriorizing their biliary content in the great peritoneal cavity. Reporting such a case has determined the authors to perform a careful overview of the cases present in the literature. An observation that can be made based on these is that the obstruction of the main bile duct due to lithiasis determines, by pressure increase, the dilation of the bile system branches, all on the background of an unknown malformation of the intrahepatic bile ducts.

Multiple polyps and colorectal cancer.

INTRODUCTION: Malignant degeneration as a possible course of evolution of colorectal polyps renders their diagnosis and therapeutic management a prophylactic act in the prevention of colorectal cancer (CRC). MATERIAL AND METHOD: The study was conducted over a period of 3 years (2008-2011), during which 1,368 colonoscopies were performed in our service. The aim of the study was to identify patients presenting multiple colorectal polyps and to determine their risk factors for developing CRC, as well as to establish the appropriate therapeutic conduct. RESULTS: Presence of multiple polyps was recorded in over 40% of the patients identified with colorectal polyps of any kind. Dysplastic modifications observed during the histopathology exam presented a high incidence in the case of patients with multiple polyps, ranging from low-grade dysplasia to incipient CRC. CONCLUSIONS: Dysplastic modifications and carcinomatous foci were identified mostly among patients with multiple polyps.Only benign lesions or in situ carcinomas benefited from endoscopic treatment, poorly differentiated carcinomas or those invading the submucosa being treated by conventional surgery. Patients diagnosed with colorectal polyps require a rigorous post-therapy follow-up protocol, able to identify any eventual polyposis recurrence.

Surgical treatment in stenosing rectal cancer.

INTRODUCTION: Rectal cancer represents an important health issue, which involves multidisciplinary treatment, posing a major surgical challenge, both in terms of diagnosis and treatment. MATERIAL AND METHOD: Between 2009-2013, we analysed 83 patients with stenosing rectal cancer operated on at the Clinic of General Surgery II of Colentina Clinical Hospital and at the Clinic of General Surgery I of "Prof. Dr. Al. Trestioreanu"€ Oncology Institute, in Bucharest. Gender distribution was: 51 males and 32 females. Average age was 65 years old. The most frequently encountered symptoms were colicky abdominal pain and rectorrhagia. 25 patients presented intestinal occlusion phenomena at admission, the other 58 cases being in subocclusive stage. RESULTS: In occlusive stages: 17 patients presented with resectable tumour, while 8 patients had locally advanced neoplastic forms (€œfrozen pelvis€), left iliac colostomy with tumour biopsy being the chosen approach. In subocclusive stages: 5 cases had unresectable tumours for which left iliac anus with tumour biopsy was performed; 53 cases presented with resectable tumour, for which the Hartmann procedure (12 patients) and left iliac colostomy with tumour biopsy (41 patients) were performed. Depending on the histopathological result, patients were submitted to radio- and chemotherapy.Tumour resection was possible in 70 cases (84.33%), only 34 of these (40.96%) being with radical intent. CONCLUSIONS: Treatment for stenosing rectal cancer is multimodal,represented by surgical approach, radio- and chemotherapy. The rationality behind surgery as a first therapeutic gesture in the given study group was represented by the need to treat occlusive type complications, patients benefitting subsequently from radio- and chemotherapy. The opportunity of a second surgical intervention, with the objective to remove the tumour, was established based on the therapeutic response to radio- and chemotherapy.

Retropancreatic approach in the treatment of pancreatic suppurations.

The authors present an additional retropancreatic access path used in the treatment of suppurations that are subsequent to severe acute pancreatitis. The approach utilized by them, namely the submesocolic one, involves the performance of the decollement and reclining to the right of Treitz's angle, thus granting full access to the pancreatic compartment situated to the left of the superior mesenteric vascular pedicle. The indication for the use of this retropancreatic approach is determined on CT scan criteria, after receiving the data offered by the oral and intravenous contrast media. The ratio between the collections and Treitz's angle can be evaluated accurately. The usage of this access path is not isolated, classical approaches being concomitanlty used as a rule through the omental bursa and the retroduodenopancreatic approach. The method presented is meant to complete the range of already accepted approaches and offer some guarantee with regard to the decrease of retropancreatic suppurative processes, with the purpose of reducing either planned or selective reinterventions. The experience of the authors is still limited (12 cases), and their presentation must be appreciated as a preliminary note which impels to reflection upon a complete debridement of suppurated necroses. It offers a short and direct path to the retropancreatic space, which is often impossible to reach through the wide access path of the omental bursa.

Juxtapapillary duodenal diverticula early and late clinical and therapeutical implications.

The aim of this paper is to identify the early and late implications of JPDD for biliary pathology, as well as for endoscopic therapy and classical surgery dealing mainly with lithiasis. This paper is based on a retrospective study comprising a number of 675 ERCP performed on 601 patients between 1997-2007, out of which 399 cases were followed by therapeutic measures. A total of 79 procedures were performed on 65 cases with JPDD. The main criteria were: gender, age, indications regarding the performance of ERCP+/-ES, complications that occurred while carrying out these procedures. In all the cases examined (601) the percentage of JPDD reported was of 10.81%. The rate of complications in the sphincterotomized patients without JPDD was 5.75% and the rate in the sphincterotomized patients with JPDD was 14.89%. In conclusion, the paper discusses the clinical and therapeutic implications of JPDD in biliary pathology. It has been found that JPDD is an important etiological cause for the late diseases occurring after cholelithiasis surgery. JPDD also leads to immediate therapeutic implications such as: difficult cannulation and high incidence of ERCP+/-ES complications.

[Experimental model of pancreas transplantation with portal or systemic drainage in laboratory rats]. / Model experimental de transplant pancreatic cu drenaj portal sau sistemic la sobolanul de laborator.

The aim of this study was to develop an experimental model of pancreas transplantation in rats as a standardized tool for research in transplant immunobiology. Brown Norway (donors) and Lewis (receptors) rats, males, with an average weight of 220 grams, were used. The diabetes was induced in recipients using streptozocin. The pancreas was harvested with a duodenal stump, a segment of aorta containing the celiac and superior mesenteric artery and the portal vein and transplanted as follows: Group A (n=8) - systemic venous drainage; Group B (n=8) - portal venous drainage. The exocrine drainage of the pancreatic graft was established by para-topic reintegration of the graft duodenal stump in the recipient. Postoperative follow-up consisted of daily measurement of glycemia and macroscopic evaluation of the proximal duodenal stump mounted as a cutaneous stoma. Overall postoperative survival at 8 days was 87,5% for Group A and 75% for Group B. Glycemia levels started to regain normal values in both groups, at 2 days postoperatively. Rejection started at 9 and 10 days postoperatively for Group A and B respectively, being expressed by the gradual re-appraisal of hyperglycemia that followed necrosis of the proximal duodenal stump. The experimental model described is functional and has the advantage of being used either with portal or systemic drainage of the pancreatic graft. The results obtained show no significant difference between the time-points of normal postoperative glycemia when either systemic or portal venous drainage were used.

[Cefepime (Maxipime) treatment efficacy in surgical patients ]. / Eficienta tratamentului cu Cefepime (Maxipime) la bolnavii chirurgicali.

Between September and December 2001 in the "Caritas" Surgical Clinic of Bucharest has been conducted a clinical study for the efficiency of Cefepime (Maxipime) treatment in surgical patients. Introduced in therapy in the last decade of the XXth Century, Cefepime (Maxipime) is the most active 4th generation cephalosporin, due to its extended spectrum of activity and its high resistance against beta-lactamases. Cefepime (Maxipime) has a very large spectrum, including the majority of the microorganisms implicated in surgical infections: Enterobacter, Klebsiella pneumoniae/speciae, Proteus mirabilis, Bacillus fragillis, Pseudomonas aeruginosa, Serratia, Citrobacter and other Gram-negative bacilii, Gram-positive cocci (Staphylococcus aureus, Streptococcus pneumoniae, Streptococcus pyogenes). The clinical study included 30 surgical patients, the selection criteria being the severity of the present infection or the potential risk after major (abdominal) surgery. We introduced Cefepime (Maxipime) as first choice of monotheraphy, except: severe, life threatening nosocomial infections, when we associated Cefepime (Maxipime) with aminoglycosides; failure of another antibiotheraphy schema, when we associated Cefepime (Maxipime) with aminoglycosides; suspicion of anaerobe contamination, when we associated Cefepime (Maxipime) with metronidazole. The results of our study support the utilization of Cefepime (Maxipime) as the best choice antibiotic in severe surgical infections, especially in the intensive care and surgical units. Cefepime (Maxipime) can be synergically associated with aminoglycosides and imidazoles (metronidazole).

[Mini-invasive treatment, through endoscopic papillo-sphincterectomy, of post-surgery biliary fistulae]. / Tratamentul miniinvaziv, prin papilosfincterotomie endoscopica, al fistulelor biliare postoperatorii.

External biliary fistulas associated both with open and laparoscopic biliary surgery, need a quick solution to prevent local and general complications. Open surgical treatment was the only solution until the minimally invasive techniques, such as endoscopy, were developed. The authors present 10 cases of postoperative external biliary fistulas, successfully treated by endoscopic papillosphincterotomy alone, technique which is compatible with other endoscopic procedures of treatment, performed in association with endoscopic papillosphincterotomy or not.

[Endoscopic sphincterotomy in the treatment of common bile duct benign lesions (experience with 100 cases)]. / Papilosfincterotomia endoscopica în tratamentul afectiunilor benigne ale caii biliare principale (experienta a 100 de cazuri).

The authors present the experience of the first 100 endoscopic sphincterotomy performed in Caritas Hospital, Surgery Department between 1997 and 2000 for CBD benign lesions treatment. The patients to whom we performed this procedure had a biliary syndrome associated mostly to obstructive jaundice of unknown etiology previously diagnosed echographically or by ERCP. The etiology was in 72% of the cases represented by migrated, residual or primary common bile duct stones. The aim of the procedure was the removal of the stones. We performed endoscopic sphincterotomy either before or after laparoscopic or open surgery. The morbidity was 8% and the related mortality was 0%. Endoscopic sphincterotomy is an efficient procedure for the treatment of the benign obstruction of the common bile duct and not only. Our results were similar to those published by other authors.