Simultaneous Approach of Colo-Rectal and Hepatic Lesions in Colo-Rectal Cancers with Liver Metastasis - A Single Oncological Center Overview.

Introduction: Management of synchronous colorectal cancer with liver metastases (SCLM) is still on debate, regarding timing, indications and complications of the 3 strategies: classic approach (first tumor resection), simultaneous resection and reverse approach (liver first). A retrospective single-centre evaluation of synchronous approach was accomplished, focusing on surgical technique, indications and complications. Material and Methods: Between 2017 and 2020, 31 SCLM patients benefited from synchronously colorectal and hepatic approach: segmental colectomies/rectal resections, simultaneously with liver metastasectomies (associated with radiofrequency ablation). Post-therapeutic imaging monitoring was performed from every 3 - 6 months. There were no perioperative complications related to the combination of the procedures, low morbidity and zero postoperative mortality. Results: The follow-up period was 10 - 40 months: 13 patients had no evidence of recurrence, 10 had hepatic metastases in regression, 4 patients had signs of peritoneal carcinomatosis and 4 showed progression of liver disease; all patients were on chemotherapy. During follow-up 4 patients died. Conclusions: Experience shows that the simultaneous approach of recto-colic and hepatic resections in colo-rectal cancers is a safe procedure, with low morbidity, the limits being dictated by the size of the liver metastases. The results at long-distance must be drawn by further consistent trials.

Challenges in the Surgical Management of Patients with Diabetic Neuropathy.

Background: Diabetes Mellitus represents a major socio-economic issue both by influencing the patient's quality of life and also considering the impact on the healthcare system. Diabetic neuropathy is one of the main complications associated, in most cases being present from the moment of diagnosis. Considering the high incidence of diabetes among patients with biliodigestive surgical conditions, a thorough analysis of the evolution and management of these patients is necessary. Materials and Methods: The association between the evolution of diabetic patients with biliodigestive conditions and diabetic neuropathy as well as risk criteria and associated complications were analyzed in a descriptive, correlational study (314 patients) conducted in the Dr. I. Cantacuzino Clinical Hospital during 2020-2022. In the study, the patients were distributed into two groups, one consisting in patients without diabetes mellitus (control group) and the second further subdivided into two groups of study, first (2a) containing patients with type II with diabetic neuropathy and high and medium risk rate, and a second one (2b) including patients with diabetes mellitus type II with confirmed neuropathy and low risk rate. Clinical and laboratory evaluations were performed and management protocols applied. Results: Statistically significant correlations were highlighted between diabetic neuropathy and the variables tested which were subsequently combined to achieve a risk score and a management protocol. Conclusions: Diabetes mellitus associated with diabetic neuropathy represents a negative prognostic factor for the postoperative outcome being associated with high risk of morbidity and mortality. The risk score and the management protocol described as results of this study represent feasible solutions and a subservient instrument in preventing the occurrence of complications in patients with bilio-digestive surgical pathologies in order to improve the prognosis and survival of the patients.

Assessment of the Risk of Colorectal Cancer in Patients with Diabetes Mellitus.

Background: The increased incidence of both colorectal cancer and diabetes mellitus, as well as the fact that they are important causes of high morbidity and especially mortality, place the two pathologies on the list of priorities of the health system. There are studies which have observed that diabetes mellitus is directly involved in carcinogenesis and is an independent risk factor for colorectal cancer. The diabetic patient requires a complex medical-surgical approach, so setting the risk criteria for them can be the starting point for improving the survival rate. Materials and methods: The association between colorectal cancer and diabetes mellitus as well as screening criteria were analyzed in a descriptive prospective study (442 patients) conducted in the Dr. I. Cantacuzino Clinical Hospital during 2017-2018. In the study, patients were distributed in two clusters, one with diabetes mellitus (N = 194) and one without diabetes mellitus (N = 248) in which basic clinical and laboratory evaluations were performed followed by screening colonoscopies. Results: Statistically significant (p 0.005) correlations were highlighted between 7 of the variables tested and the positive results on colonoscopy, which were subsequently combined to achieve a risk score. Conclusions: Diabetes mellitus is an independent risk factor and a negative prognostic factor for colorectal cancer. The risk score described as a result of this study is a feasible, simple solution for early detection of precursor lesions or neoplasms with the ultimate goal of improving the prognosis and survival of these patient.

Early Complications after Gastrectomies for Locally Advanced Gastric Cancer.

Background: The post-operative results as well as the short and middle-term outcome of surgical procedures for gastric cancer depend on several general and local conditions, mainly on the stage of neoplasia. Delayed diagnosis and intervention are correlated with a high rate of postoperative morbidity and mortality. Methods: 76 consecutive patients underwent surgical treatment for gastric cancer over a time span of 5 years (2015-2019), in the 1st Surgical Department of "Dr.I.Cantacuzino" Clinical Hospital. There have been 46 distal gastrectomies, 12 DI total gastrectomies and 18 DII total gastrectomies, 8 of them with multi-organ resection. Results: Among them, 50 patients had a favorable evolution, 7 developed complications which were manageable through a conservative approach, while 19 needed one or more reinterventions. We encountered 10 cases of severe sepsis and MSOF, followed by exitus. Conclusions: The surgical treatment of locally advanced gastric cancer poses many challenges both in terms of postoperative evolution and oncologic prognosis.

Pancreatic Neuroendocrine Tumors - Case Series and Literature Review.

Background: Neuroendocrine tumors (NETs) are a heterogeneous group of tumors with various clinical manifestations and biological behavior. Among the most common neuroendocrine tumors (NETs) are pancreatic neuroendocrine tumors (PNETs). They are considered to be relatively rare tumors; however, more recent studies on NET epidemiology have demonstrated an increasing incidence and prevalence over the past 30 years. Aims: We intend to compare the strategy used in a real life clinical environment in the case of pancreatic neuroendocrine tumors, as opposed to an ideal model, as presented in literature. Materials and methods: Our case series consist in 18 patients with neuroendocrine pancreatic tumors diagnosed and treated in the Surgery I department of Clinical Hospital Dr. I. Cantacuzino over a 10-year period (2009-2018). We made a retrospective analysis of these patients, of their diagnosis particularities and choice of treatment and a review of the literature. Results: Out of these 18 cases, 13 had functioning tumors (11 insulinomas and 2 gastrinomas) and 5 non-functioning tumors. Most of the tumors were located in the tail of the pancreas (12 cases) the others were located in the body (1 cases) and the head of the pancreas (5. cases). Surgical treatment consisted in 10 enucleations (3 of them laparoscopic) and 8 pancreatic resections, 2 of them associated with splenectomy and in one case a liver metastasectomy was also performed. The mean follow-up was 12 months. No local or distant recurrences were found with one exception, one female which presented after one year with a cephalic pancreatic tumor that proved to be an adenocarcinoma. Conclusions: Diagnosis of PNETs may be difficult even in the presence of a hormonal hypersecretion syndrome. Nuclear imaging with octreotide is useful for locating the tumor and also for the detectionof any possible occult tumors which cannot be identified through the use of conventional imaging. All PNETs should be considered as potentially malignant, and the use of the term benign should be particularly avoided, which is why tumor grading based on the mitotic count and Ki-67 index must be established for every case. Surgical treatment remains the only with curative potential.

Diabetes Mellitus as a Risk-factor for Colorectal Cancer Literature Review - Current Situation and Future Perspectives.

Colorectal cancer and Diabetes Mellitus represent a major public health issue, first, by the number of new cases which are at an alarming rate. Secondly, by the negative effect over the quality of life, socio-economic status and lifespan, representing high morbidity and mortality causes. Diabetes Mellitus is the disease of the century with a global prevalence (standardised-age) which doubled since 1980, rising from 4,7% to 8,5% in adult population. In 2012, the estimated number of fatalities caused by Diabetes Mellitus and other related complications was at 3,7 million, out of which 43% were patients under the age of 70. Neoplasia represents the second cause of death, after cardiovascular disease. The occurrence of Colorectal cancer (CRCA) is rated for men and women at 3rd and 2nd place. However, the rate of mortality from CRCA is in the 4th place, representing 8,5% out of the total cancer related deaths. 52% of these cases are recorded in underdeveloped countries, considering their level, this reflects a very low survival rate. Moreover, every year, approximately 1.4 million cases are being diagnosed out of which 55% appear in overdeveloped countries. Screening for colorectal cancer refers to the periodical evaluation of the asymptomatic patients who are at a risk of developing this type of neoplasia. The colorectal cancer contains a series of particularities which makes it ideal for screening. Since the end of the 19th century there has been a high suspicion that type II diabetes, through direct etiological mechanisms, may play a part in carcinogenesis (breast, endometrium, colorectal, pancreas, liver, non-Hodgkin's lymphoma). At the moment, the relevant published literature presents type II diabetes as an independent risk factor for colorectal cancer. Although, despite experimental proof, many epidemiological studies, case-controlled studies and meta-analysis, there still is the necessity for prospective studies which can intensify the existing results and can allow the colorectal cancer screening to adapt to these patients.

Surgical Complications of Peritoneal Dialysis.

Peritoneal dialysis (PD) is a method of renal function replacement which has a series of advantages like greater autonomy of the patient with fewer hospital visits and better preservation of residual renal function, but it has also disadvantages. The main disadvantages are a limited life-time due to peritoneal membrane failure and the risk of infections. The main complication of PD remains peritonitis, which is responsible for the most cases of method failure. There are also other complications which incorrect treated may lead to failure of the method: mechanical complications, abdominal wall defects, exit site and tunnel infections. Encapsulating peritoneal sclerosis is a rare entity found in PD patients but with high morbidity and mortality. We have retrospectively analyzed the patients with end stage renal disease under peritoneal dialysis which were admitted to Surgical Clinic "I. Juvara" of the Clinical Hospital "Dr. I. Cantacuzino" between 2007 and 2017 for surgical complications related to PD. The patients were assigned in two groups: with non-infectious and infectious complications. We have found 109 patients which have had 126 surgical interventions related to peritoneal dialysis. Out of these, 30 interventions consisted in catheter removal for loss of ultrafiltration capacity, so these were excluded from analysis. The lot resulted consisted in 80 patients with 91 complications: 42 non-infectious and 49 infectious. Mean age was 60.5 (+-12.3) years. Sex distribution was 2.75/1 male/female. Diabetes mellitus was present at 45 (56,25 %) patients. Comparing the patients with non-infectious with those with infectious complications we found significant association between type of complications and the length of PD in the sense that infectious complications tend to appear later than the non-infectious. Also, the loss of peritoneal dialysis is strongly associated with infectious complications. Looking inside groups we found that abdominal wall defects are associated with the history of previous abdominal surgery (p 0,001). Regarding the morbidity and mortality only infectious complications had associated mortality in our study, there were no significant differences in morbidity rate between groups. Between all these patients we have also identified 16 with encapsultating peritoneal sclerosis. In most cases the diagnosis was established during the intervention for another complication. We have registered a 20% morality rate at these patients. Conclusions: Noninfectious surgical complications are not raising problems for diagnosis or surgical treatment, but an incorrect treatment may lead to failure of the PD. Infectious complications and especially peritonitis remains the main cause of method failure. These are generating the highest rates of morbidity and mortality from peritoneal dialysis complications. Even if the immediate surgical intervention for peritonitis related to peritoneal dialysis is usually unnecessary, surgical observation is absolutely mandatory in every case. The absence of a response to the proper medical treatment is an indication for peritoneal cavity exploration inclusive by laparoscopy/laparotomy. Any delay in diagnosis and definitive treatment can lead to loss of peritoneal membrane function and even death of the patient. Encapsulated peritoneal sclerosis is a rare but serious complication of PD. The risk for developing EPS increases with the duration of PD treatment. No predictive and reliable screening tests especially in the early stages of EPS were found. So, it is important not to underestimate the clinical symptoms, diagnosis being based on a high index of suspicion. The only established basic treatment of EPS is enterolysis of peritoneal adhesions, and time should not be unnecessarily wasted on conservative treatment.

Soft Tissue Infections in Diabetic Patients.

Background: the patient with diabetes has an increased susceptibility to infections, with negative evolutionary potential leading to increased morbidity and mortality compared to the general population. The cause is the alteration of immune defense mechanisms, the hyperglycemic environment leading to alteration of neutrophil function, suppression of the antioxidant system and humoral activity, systemic micro and macroangiopathy, neuropathy, depression of antibacterial activity of the genitourinary and digestive tract. Infections localized at the soft tissue (skin, fascia and aponeurosis, subcutaneous tissue, muscles) in the diabetic patient require a complex medico-surgical approach in which aggressive surgical treatment should be complemented by metabolic balancing and sustained antibiotic therapy. Materials and methods: these peculiarities will be exposed and analyzed in a retrospective descriptive study performed at the General Surgery Clinic. Juvara of the clinical hospital Dr. I. Cantacuzino, during the period of Jan. 2013- Dec.2017, which followed the type of lesions, their localization, the germs involved, the comorbidities, the biologic parameters, the antibiotic and surgical treatment as well as the postoperative evolution. The study does not include patients with localized infections in the diabetic foot, a particular pathological entity that will be analyzed separately in a separate study. Results: 150 diabetic patients with soft tissue infections localized in the upper limb, calf, thigh, perineum, abdominal and thoracic wall were identified. The most frequent localization was found in the lower limb (54%). The incidence of these infections was higher in males (55%), and the most affected age group was 60-69 years (38%). Most patients had type II diabetes (93%). Among the associated comorbidities, cardiovascular diseases and obesity are the most common, explaining to a large extent the complicated evolution, potentially lethal of this pathology. From the bacteriological perspective, a plurimicrobian flora is identified, staphylococcus aureus being most frequently encountered. The antibiotic treatment was initiated immediately empirically, subsequently according to the antibiogram; the most commonly used antibiotic classes being cephalosporins and carbapenems. Surgical interventions were in their majority of debridement and necrectomy, but in a few cases limb amputation was necessary. In particular, the number of surgical interventions performed in the same patient and in the same hospital stay was between 1 and 7 interventions. Conclusions: Soft tissue infections in the diabetic patient have a heterogeneous aspect with specific particularities requiring careful clinical examination, multidisciplinary treatment including rapid, serial surgical interventions to control the growing aggression of the germs involved. Fast and caseadapted therapeutic decisions, careful observation of the patient's general condition and of the wound several times a day are essential to achieving favorable postoperative outcomes.