Does the Overall Survival of the Resectable Periampullary Carcinomas Correlate with High Expression of p53 and ki67?

Introduction: Periampullary carcinomas represent a group of tumors that develop in a complex area, implying different anatomical structures. The most common histological type of periampullary carcinomas is the adenocarcinoma. The pancreatic type of periampullary adenocarcinomas has the worst prognosis. Immunohistochemical markers, such as ki-67 and p53, can be used in predicting survival. Material and method: we selected the patients with periampullary adenocarcinomas, intestinal or biliopancreatic type, with resectable tumors, and we performed immunohistochemical stains for ki-67 and p53 markers. The overall survival was analyzed according to the expression of immunohistochemical markers, TNM staging, tumor grade and perineural invasion. Results: Sixty-seven patients were included in the study. The median overall survival for the whole cohort was 12 months, with a 2-year survival rate of 25%. High rate of tumor proliferation (ki67 more than 80%) was significantly associated with shorter overall survival (median survival 3 months compared with 17 months for the group with ki67 index less than 80%). A high expression of p53 protein has been associated with low overall survival. The low survival was associated with poorly differentiated tumor grade and lymph node status. Conclusion: Both immunohistochemical expression of ki67 and p53 can be used as prognostic and predictive factors for overall survival of patients with resectable periampullary adenocarcinomas.

Spontaneous Biliary-Enteric Fistulas and Associated Complications: An Overview.

Spontaneous biliary-enteric fistula (SBEF) is an abnormal communication between the biliary tree and the gastrointestinal tract which develops as a result of biliary or gastrointestinal disease. Iatrogenic fistulas, due to surgery or instrumental exploration, are not included in this definition. R. Colombo, in 1559, was the first to describe SBEF as an occasional finding during an autopsy. In almost 90% of cases the cause of SBEF is chronic recurrent cholelithiasis. Less common causes are penetrating peptic ulcers and neoplastic infiltration from the biliary or gastrointestinal tract. The most common type of SBEF is cholecystoduodenal fistula and the least common is choledochoduodenal fistula. There are various complications associated with SBEF but often these are not promptly recognized by patients or physicians and diagnosis and treatment may be delayed for years. The most important complication, which can be considered pathognomonic for SBEF, is gallstone ileus which manifests clinically as acute or chronic mechanical intestinal obstruction. Gallstone ileus, a rather rare complication of a rather common pathology, biliary lithiasis, is found in 0.000015% of hospitalized patients but in 0.0003% of surgical patients. It is mainly found in women over the age of 65, with a male to-female ratio of 1:5. There are various forms of occlusion, related to the sites of gallstone impaction, with various clinical characteristics and degrees of severity. These include Bouveret syndrome ( 10% of cases) with impaction in duodenum or pylorus, and the more common Barnard's syndrome (5-75% of cases) in which the site of impaction is in the terminal ileum right before Bauhin's valve. For diagnosis, the radiological signs which make up Riglerâ??s triad or tetrad, are essential, and are best visible on magnetic resonance. The the gold standard is contrast-enhanced computed tomography scan. Regarding the surgical management, one-stage simple enterolithotomy is reserved for the oldest patients and the most severe cases. Nowadays, is performed more and more frequently by laparoscopy. In more favorable cases radical treatment of the occlusion, the biliary lithiasis and the SBEF is recommended, either as a one-stage procedure or in two stages with the second procedure performed after few weeks.

Laparoscopic Approach of Primary Hydatid Cyst of the Pancreas - Case Report and Literature Review.

The pancreatic localization of the hydatid cyst is exceptional, even in countries where hydatid disease is considered endemic. We describe a female patient, 63 years old, with hydatid cyst of the pancreas. The diagnosis was difficult because the presentation was that of an epigastric cyst of unknown origin, with no suggestive radiological and ultrasonography features. We performed a laparoscopic exploration of abdominal cavity which revealed a retrogastric cystic mass developed from the pancreatic body. The surgical treatment consisted in puncture, evacuation of proligera, lavage with hypertonic serum, partial excision of the pericyst and drainage of the cavity. The postoperative course was uneventfull and the patient was released after 5 days. The follow-up at 6, 12 and 24 month did not show relapse. Through this observation and a review of the literature, we discuss the diagnostic and therapeutic difficulties of this rare localization of the hydatid cyst. Hydatid cyst is a rare cause of a cystic lesion of the pancreas, especially in endemic areas. Surgery still remains the most effective treatment option. Laparoscopic approach is feasible and secure but requires a trained team with experience in minimally invasive surgery.

Laparoscopic Cholecystectomy in Cirrhotic Patients.

Laparoscopic cholecystectomy is the gold standard procedure in patients with cirrhosis and symptomatic gallbladder disease or acute cholecystitis. In this retrospective study we evaluated laparoscopic cholecystectomy in patients with cirrhosis based on Child-Pugh score as a predictor of morbidity. In the First Surgical Clinic of Iasi, from 01 jan 2010 to 31 jan 2020, we performed 111 laparoscopic cholecystectomies in Child-Pugh A, B, and C cirrhotic patients. Intraoperative difficulty (grade 3 Cuschieri) was experienced in 32 patients (28.8%). Highly vascular sub hepatic adherences have been reported in a quarter of all patients. Intraoperative incidents were more frequent 27 (24.3%) compared to laparoscopic cholecystectomy performed in other patient groups. The conversion rate to open cholecystectomy was 6.3% (7 cases). Mean operative time was 84 min. Mean duration of hospitalization stay was 4.7 days. The morbidity rate was 16.2% of patients and included bleeding, intraabdominal fluid collections and wound complications more common in patients with Child-Pugh Cirrhosis B and C. The results are dependent of the perioperative management of the liver function.

The Pancreatic Endocrine Tumors - Experience of First Surgical Clinic Iasi.

Pancreatic neuroendocrine tumors (PNETs) are rare and characterized by widely variable clinical presentation and often challenging surgical management. Methods: Retrospective study conducted during the last 15 years at the First Surgical Clinic of the Iasi St Spiridon University Hospital, and which included all the patients diagnosed with pancreatic endocrine tumors by immunohistochemistry. Results: There were 26 cases diagnosed with PNET. The male/female ratios was 7/19 and mean age 41.93 +- 2.48 years (range 20-79 years). Of the PNET cases 13 were insulinomas, 5 gastrinomas, 2 gastrinomas associated with other endocrine neoplasms (Wermer syndrome), 5 non-functional endocrine pancreatic tumors and 1 ACTHoma. Clinical manifestations depended on tumor type: hypoglycemia and Whipple triad for insulinoma, Zollinger Ellison syndrome and complicated peptic ulcer (hemorrhage, perforation) for gastrinoma, Cushing syndrome for ACTHoma. Biological diagnosis included biological markers (e.g. insulin, gastrin and cortisol). Tumor site and size at diagnosis were determined by ultrasound, CT-scan, angiography, PETscan, octreoscan and intraoperative ultrasound. Surgical procedures for PNET insulinomas were: tumor resection - 6 cases; left splenopancreatectomy - 3 cases; left spleen-preserving pancreatectomy - 2 cases; pancreaticoduodenectomy - 2 cases. We also present 4 cases of gastrinoma with multiple ulcers and multiple surgical interventions for hemorrhage and perforation with peritonitis. The two patients with Wermer syndrome also had ulcers complicated with hemorrhage and peritonitis and parathyroid adenoma. Nonfunctional pancreatic endocrine tumors were diagnosed in 5 women of which in 3 the tumors were located in the pancreatic tail (in which splenopancreatectomy and left pancreatectomy with spleen preservation were performed) and in 2 in the pancreatic head (in which pancreaticoduodenectomy and Beger type operation were performed). Conclusions: Knowledge of clinical signs of secreting tumors and exploring the patients are of crucial importance for management of PNETs. Immunohistochemistry is mandatory for confirming the diagnosis and assessing the proliferation and biological behavior of the tumor, thus facilitating the administration of specific therapy. Aggressive surgical treatment is indicated, even in advanced stages.

Abdominal Actinomycosis Mimicking Colon Cancer.

Introduction: Abdominal actinomycosis is a rare granulomatous inflammatory disease caused by a Gram-positive anaerobic bacterium Actinomyces israelii, manifesting as inflammatory mass, or abscess formation. Evolution is slow and steady in inflammatory contiguous extension without limit organ that lends itself to confusion with abdominal malignancies. Methods: We performed a retrospective study on the patients with abdominal actinomycosis operated in the First Surgical Clinic, "St. Spiridon" University Hospital Iasi; between 1980 - 2018 there have been 13 cases (4 men and 9 women) with a mean age 44.07 years admitted for abdominal tumors (7 cases) or pelvic inflammatory disease (6 cases). Results: We identified as predisposing factors: IUD maintained over 10 years (6 cases), foreign bodies 2 cases (a toothpick probably perforated colon, gallstones lost in peritoneum), diabetes (3 cases), immunodepression. All cases were operated by laparotomy (9 cases) or laparoscopic approach (4 cases). We describe five of these cases of actinomycosis that had been mimicking a colon cancer: ileo - cecal - 3 cases, transverse colon - one case and on the greater omentum - one case, followed by specific treatment with penicillin, with good evolution. Conclusions: Abdominal actinomycosis should always be included in the differential diagnosis of abdominal tumors. Preoperative diagnosis, difficult but possible, can avoid surgery. Treatment with antibiotics is necessary for the healing of the disease. Postoperative control is mandatory, with relapses possible.

Laparoscopic Management in Morgagni Hernia - Short Series and Review of Literature.

Morgagni hernia occurs after a congenital retrosternal diaphragmatic defect; it is a rare form of diaphragmatic hernia (1-3% of cases). In general, this pathology is diagnosed in children; in adults it is frequently discovered in emergency or incidentally. Methods: We prospectively evaluated a series of 8 patients admitted to First Surgical Clinic, St. Spiridon Hospital, Iasi during the period 2011-2017. Results: Out of 8 patients, 6 were operated on, one patient refusing surgery (followed periodically); the patient who was 91 years old had serious associated diseases that made surgery contraindicated. Symptomatology was nonspecific: in 5 cases Morgagni hernia was discovered during the exploration of an associated pathology, either with cardiopulmonary symptoms of dyspnea or palpitations. In 2 cases, the clinical aspect suggested an occlusive syndrome (the herniated organ is usually the transverse colon). The laparoscopic approach was used in all cases: two conversions were recorded due to the tight adherences of the herniated viscera (gastric, colon, epiplon). In 4 cases, the surgical cure of hernia was performed by suture and in 2 cases with prosthesis: dual mesh in one case and polypropylene mesh in another case. We did not register morbidity and the mean postoperative stay was 4 days (range 2-6 days). Conclusions: Hernia Morgagni betrays a rare pathology. The most common is asymptomatic but in complicated cases it is a cause of acute surgical abdomen. Surgical treatment is indicated even for asymptomatic cases due to serious complications Morgagni hernia may develop. The laparoscopic approach is ideal, as reduction of viscera in the abdomen is easy and the defect will be repaired by suturing or using a prosthesis, depending on its size.

Laparoscopic Treatment of Intraabdominal Cystic Lymphangioma.

UNLABELLED: The abdominal cystic lymphangioma (CL) in adults is a rare benign tumor of the lymphatic system. METHODS: We report a retrospective study from January 2002 to Decemberr 2014 concerning 18 patients who underwent surgical removal of a CL, 9 patients with laparoscopic approach included. The localization, size, and number, diagnostic, treatment and results have been reported for patients approached laparoscopically. RESULTS: There were 8 women and 1 man with median age at diagnosis was 35,6 years (range 20-51 years). Clinically, the main symptom was an abdominal pain found in 8 patients (88.8%). Physical examination revealed an abdominal mass in 5 patients (55.5%). The CL was asymptomatic in four patients; the discovery of CL was performed preoperatively during an ultrasound for another pathology (n=3) or intraoperatively (n=1). US exam CT scan usually allow the preoperative diagnosis. The most common site was shared equally between the mesentery (n = 3; 33%) and left retroperitoneum (n = 3;33%), followed by the right retroperitoneum and the posterior cavity of the lesser omentum and great omentum, each one case. The most common procedures performed were: laparoscopic total cystectomy of a closed cyst in two patients and evacuation of larger cysts followed by total cystectomy in seven patients. No conversion, no mortalities and no morbidity was noted. Mean hospital stay was 3.4 days. No recidive after 28 months in the average after treatment. CONCLUSIONS: The laparoscopic approach is the gold standard in the treatment of intraabdominal CL.We recommend complete surgical excision to avoid recurrence.

Laparoscopic Approach to Primary Splenic Cyst: Case Report and Review of the Literature.

Splenic cysts are rare benign lesions of the spleen, often asymptomatic and incidentally discovered during imaging studies. While many splenic cysts remain asymptomatic and do not require intervention, surgical management becomes essential in cases of symptomatic cysts, large cysts, or when malignancy cannot be ruled out. Laparoscopic surgery has emerged as a minimally invasive and effective approach for treating splenic cysts, offering advantages such as shorter hospital stays, reduced postoperative pain, and faster recovery. In this case report, we describe our experience with laparoscopic surgery for a symptomatic splenic cyst in a young patient.

Laparoscopic Hartmann Procedure-A Surgery That Still Saves Lives.

BACKGROUND: A Hartmann operation, which is the intervention by which the lower part of the sigmoid and the upper part of the rectum are resected with the closing of the rectal stump and end colostomy, has as its indications: advanced or complicated rectosigmoid neoplasm, moderate biological condition of the patient, peritoneal sepsis, intestinal occlusion and fragile colonic wall, especially in the context of inflammatory changes. The Hartmann procedure can save lives even at the cost of a stoma reversal failure. METHODS: The cases operated with the Hartmann procedure by an open approach or laparoscopic approach in our clinic, between 1 January 2016 and 31 December 2020, were admitted in this study and their medical records were reviewed, also making a comparison between the two types of approach. Univariate statistical comparisons but also a multivariate analysis was performed. RESULTS: We performed 985 operations for intestinal and colonic occlusion (7.15% of the total operations in the clinic), 531 (54%) were non-tumor occlusions and 454 (46%) were occlusive tumors (88 Hartmann operations). Of these, 7.3% were laparoscopically performed (7 laparoscopic Hartmann operations and 23 diagnostic laparoscopies). A total of 11 cases (18%) also had colonic perforation. We compared laparoscopic Hartmann with open Hartmann and observed the benefits of laparoscopy for postoperative morbidity and mortality. The presence of pulmonary and cardiac morbidities is associated with the occurrence of general postoperative morbidities, while peritonitis is statistically significantly associated with the occurrence of local complications that are absent after the laparoscopic approach. CONCLUSIONS: The Hartmann procedure is still nowadays an operation widely used in emergency situations. Laparoscopy may become standard for the Hartmann procedure and reversal of the Hartmann procedure, but the percentage of laparoscopy remains low due to advanced or complicated colorectal cancer, poor general condition both at the first and second intervention, and the difficulties of reversal of the Hartmann procedure.

Gallstone Ileus. What therapeutic options are there?

Gallstone ileus is a rare disorder in emergency surgical practice with diagnosis usually difficult and only achieved at surgery. The current approaches are: enterolithotomy, cholecystectomy and fistula repair (one-stage surgery), enterolithotomy with cholecystectomy performed later (two-stage surgery) and only enterolithotomy (most reported surgical procedure). METHODS: The clinical, operative and follow-up data on 14 consecutive patients treated in our clinic for gallstone ileus was retrospectively reviewed. RESULTS: Gallstone ileus was recorded in 0.06% of all operations for biliary lithiasis and 1% of all enteric occlusions. There were 11 women and one men, with a mean age of 77.3 (range 67-100) years. There was a mean delay of 3.16 days for onset of symptoms to admission. Urgent laparotomy confirmed gallstone obstruction and a cholecysto-duodenal fistula (13 cases) or cholecysto-colonic fistula (1 case). We performed one stage surgery in 4 cases, enterolithotomy alone in 8 cases (one case operated initially in another surgical service), Hartman procedure, cholecystectomy and fistula repair in one case and a spontaneous evacuation of the gallstone with cholecystectomy and fistula repair later in another case. We recorded 2 deaths in patients with multiple comorbidities in which only enterolithotomy was performed and with 1 and 2 reinterventions, respectively. Postoperative stay was 9.4 days for cases with simple enterolithotomy and 18.6 days for cases with radical treatment. We did not record any recurrence. CONCLUSIONS: Although rarely encountered in surgical practice, gallstones ileus should be noted in the differential diagnosis of intestinal obstruction in patients with a past history of biliary disease, occlusive syndrome, pneumobilia and possibly ectopic gallstone. The one-stage procedure should be the offered to stabilized patients, but in cases with associated comorbidities, only enterolithotomy represent a best option. KEY WORDS: Gallstone ileus, Cholecystoduodenal fistula, Intestinal Obstruction.

Abdominopelvic Actinomycosis-The Diagnostic and Therapeutic Challenge of the Most Misdiagnosed Disease.

Abdominopelvic actinomycosis is a rare chronic or subacute bacterial infection caused by Actinomyces israelii, a Gram-positive anaerobic bacterium that normally colonizes the digestive and genital tracts, clinically presented as an inflammatory mass or abscess formation. METHODS: We reviewed the medical records of the patients from our clinic with abdominopelvic actinomycosis who underwent surgery between 2002 and 2022. In this period, 28 cases (9 men and 19 women) were treated. The mean age was 43.36 years and they were hospitalized for abdominopelvic tumors or inflammatory tumors in 15 cases and inflammatory disease in 13 cases. RESULTS: Causes of actinomycosis in the studied group were an intra-uterine contraceptive device in 17 cases, foreign bodies in 2 cases, diabetes in 4 cases, stenting of the bile duct in 1 case, and immunodepression. For 6 patients, we performed surgery by open approach and for 21 patients by a laparoscopic approach. For nine patients, abdominopelvic actinomycosis had been mimicking a colon malignancy (cecum and ascending colon, four cases; transverse colon, two cases; and on the greater omentum, three cases) and for six patients, a pelvic tumor (advanced ovarian cancer). After surgery the patients underwent specific treatment with antibiotics, with good results. In two cases we discovered and treated hepatic actinomycosis, one case by a laparoscopic approach and one case by a percutaneous approach. In our lot we noticed three recurrences that required reintervention in patients who had had short-term antibiotics due to non-compliance with treatment out of four such cases. CONCLUSIONS: For abdominopelvic malignancies, actinomycosis should be included in the differential diagnosis, as well as for inflammatory bowel diseases and bowel obstructions. We have a wide range of patients considering the rarity of this condition. Long-term antibiotics are necessary to prevent recurrence.

Laparoscopic approach for nonparasitic splenic cysts and splenic abcesses.

Splenic cysts are classified as primary (parasitic and nonparasitic) or secondary cysts. The aim of this study was to evaluate the efficacy of laparoscopic approach in surgical treatment of splenic cysts and abscesses. METHODS: Between 2002 and 2017, 17 patients underwent laparoscopic approach for splenic cysts and abscesses: 9 laparoscopic splenectomies (4 hydatid cysts, 3 primitive nonparasitic cysts, one posttraumatic cysts and one abscess) and conservative laparoscopic treatment 8 patients (2 hydatid cysts, 2 primitive nonparasitic cysts, 2 secondary cysts and 2 abscesses). The lateral approach with a four-trocar technique was used. Patient demographics, diagnosis, and outcomes were reviewed. RESULTS: In laparoscopic splenectomy, spleen volume was 300 ml and blood loss 30 - 65 ml. There are 3 conversions and 2 postoperative complications (Clavien II). No late complications were observed during the follow-up. CONCLUSIONS: The laparoscopic approach to splenic cysts offers many advantages and may be the treatment of choice for this pathology. Spleen-preserving techniques should be attempted in every case of splenic cyst types 1,2,3, especially non-parasitic cysts, in young patients. KEY WORDS: Abcesses, Splenic cysts, Laparoscopic approach, Laparoscopic splenectomy, Laparoscopic cyst excision.

Posterior approach pancreaticoduodenectomy: best option for hepatic artery anatomical variants.

Pancreaticoduodenectomy is the best treatment for the patients with malignant tumors of the pancreatic head. However, the procedure is also recommended in some benign pancreatic tumors. The posterior approach allows early dissection of the superior mesenteric artery, portal vein and retroportal pancreatic lamina, before any pancreatic or digestive transection. We present a 42 year old woman diagnosed with a pancreatic tumor. The clinical and biological data suggested the diagnosis of insulinoma. The computed tomography showed a nodule located in the pancreatic head with a typical vascular pattern for endocrine tumor. The exam also revealed a rare vascular variant, a common hepatic artery which arises from the superior mesenteric artery. A pancreaticoduodenectomy has been performed. We used the posterior approach which allowed the correct dissection and exposure of the abnormal common hepatic artery. The postoperative course was uneventful. Posterior approach during the pancreaticoduodenectomies avoids arterial injuries that might compromise the liver arterial supply. It is especially indicated when preoperative imaging studies diagnose anatomic variants of the hepatic arteries.

Preoperative warm-up using a virtual reality simulator.

BACKGROUND AND OBJECTIVES: All modern surgical procedures require a high level of cognitive and psychomotor skills achieved using different training methods, but could be influenced by fatigue and other psychological factors. We evaluated the effect of warm-up exercises on operative laparoscopic performances. METHODS: The surgical team operated on a consecutive series of 20 patients with gallstones. Patients were randomly allocated in 2 groups: group A to be operated on without warm-up exercises and group B to be operated on after a short-term warm-up. All the patients were operated on by the same surgical team. The full-time records of the operation were analyzed by 2 independent reviewers. A modified simplified Global Rating Score (GRS) was used to assess the surgical procedures. A training module using the Lap Mentor simulator was designed for the warm-up. RESULTS: Better performances were noted by both observers in group B only regarding "Respect for tissue" scores (3.75 0.16 vs 4.43 0.20, P=.021 and 3.87 0.22 vs 4.57 0.20, P=.041) achieving significant or marginally significant differences for all categories; GRS scores for "time and motion" and "overall impression" tend to be better after warm-up, but differences failed to reach statistical significance in our series. CONCLUSION: Surgeons, even the most experienced in laparoscopic surgery, can increase specific psychomotor skills associated with a laparoscopic environment by doing simple exercises on a virtual reality simulator, just before an operation. These improvements are reflected in more accurate handling of tissue during laparoscopic cholecystectomy.

Protective or Risk Factors for Postoperative Pancreatic Fistulas in Malignant Pathology.

INTRODUCTION: Malignant tumors are associated with a low incidence of postoperative pancreatic fistulas. The presence of peritumoral fibrosis is considered the protective factor for the development of postoperative pancreatic fistulas after pancreatic resections for pancreatic ductal adenocarcinomas. METHODS: We analyzed a series of 109 consecutive patients with pancreatic resections for malignant pathology: pancreatic ductal adenocarcinomas and periampullary adenocarcinomas. The incidence of postoperative pancreatic fistulas has been reported in tumor histological type, in the presence of peritumoral fibrosis, and in the association between adenocarcinomas and areas of acute pancreatitis. The data obtained were processed with the statistical analysis program SPSS, and statistically significant p were considered at a value <0.05. RESULTS: For the entire study group, the incidence of postoperative pancreatic fistulas was 11.01%. The lowest incidence was observed in the group of patients with pancreatic ductal adenocarcinomas (4.06% vs. 25.72% in the group with periampullary adenocarcinoma), with a p = 0.002. The presence of peritumoral fibrous tissue was observed in 49.31% of cases without pancreatic fistulas, and in 54.54% of cases that developed this postoperative complication (p = 0.5). Also, the peritumoral fibrous tissue had a uniform distribution depending on the main diagnosis (56.14% in pancreatic ductal adenocarcinoma group vs. 37.04% in periampullary adenocarcinoma group, with a p = 0.08). In the group of patients who associated areas of acute pancreatitis on the resections, the incidence of postoperative pancreatic fistulas was 7.8 times higher (30% vs. 3.8%, p = 0.026). CONCLUSIONS: Peritumoral fibrous tissue was not a factor involved in the developing of postoperative pancreatic fistulas. The association of adenocarciomas with areas of acute pancreatitis has led to a significant increase in postoperative pancreatic fistulas, which is a significant and independent risk factor.

Adrenal schwannoma.

BACKGROUND: Adrenal schwannomas are very rare tumors that are difficult to diagnose preoperatively. We report the case of a left adrenal schwannoma incidentally discovered in a 55-year-old man during a postoperative checkup for a cutaneous malignant melanoma. METHODS: The biological evaluation was unremarkable, and the radiological examination revealed the adrenal mass that was first considered a metastatic lesion. Adrenalectomy was performed by the laparoscopic approach. RESULTS: The postoperative course was uneventful. Histological examination established the correct diagnosis of schwannoma, which was also confirmed by immunohistochemical staining. CONCLUSIONS: A nonsecreting adrenal mass can be easily misjudged, especially in the context of a recently operated on malignancy. Unilateral adrenal metastasis needs pathological confirmation, as it can dramatically affect prognosis. Unusual tumors of the adrenal gland may be found incidentally, and a malignant context will generate difficulties in establishing the right management. Complete laparoscopic excision is the treatment of choice whenever feasible and will also clarify pathology.

A European surgeon: Thoma Ionescu (Thomas Jonnesco)--founder of the Romanian school of surgery (1860-1926).

Thoma Ionescu, the distinguished surgeon and anatomist, is rightly considered the founder of the Romanian school of surgery and topographic anatomy whose achievements became well-known in Europe and North America. He introduced several new surgical techniques, as wall as rachianaesthesia, and identified and formulated the main principles of rectal and uterine oncologic surgery. Moreover, he was the first to describe the paraduodenal fossae and the internal retroperitoneal hernias. His other contributions consisted of studies on the effects of cervical sympathectomy and, obviously, the development of experimental surgery.