[Reoperations of the thyroid gland]. / Reinterventii în chirurgia tiroidei.

Reoperative thyroid surgery may be necessary in recurrent simple goiters, thyrotoxicosis and especially cancers of the thyroid gland. The present series reviewed 33 cases representing 7.3 % from our experience consisting of 440 thyroid operations. Five patients had undergone two prior operation. Details of original procedures were available only for 26 patients, the first operations being carried "extra muros" in 20 cases. There were 25 women and 8 men with mean patient age 44.5 (range 22-75) years, which had undergone one prior operations. The interval between the primary operation and the second one varies between 5 days and 44 years. Eleven cases had benign lesions: eight with uni or bilateral nodular goiters and three thyrotoxicosis (two with Basedow-Graves'disease and one with toxic adenoma) for which nodulectomy, subtotal lobectomies or thyroidectomies were performed. In twenty one cases the surgical indication was done for persistent or recurrent thyroid carcinomas (16 papillary, two follicular and one case each of medullary, anaplastic and malignant lymphoma). Among these 6 patients underwent completion total thyroidectomies associated in 9 another patients with radical or modified neck dissection and in the 6 remaining cases conservative procedures (lobectomies, tumoral excision) of the gland or nodes were done. Complications, includes two recurrent laryngeal nerve palsy, two spontaneously healed esophageal fistulas and one case each of permanent hypothyroidism and hypoparathyroidism. Reoperative thyroid surgery constitute a valuable surgical procedure for persistence or recurrence of benign and especially malignant thyroid lesions but is associated with significant increased risk of functional and anatomic complications rate than those of the initial surgery.

Subcutaneous Granuloma Annulare.

Dear Editor, Subcutaneous granuloma annulare (SGA) is considered a rare clinical variant of granuloma annulare, a common self-healing chronic inflammatory disorder that may appear in childhood as well as in adult age (1-3). A 29-year-old female patient reported the onset of several small subcutaneous nodules on the dorsal aspect of the second interphalangeal joint of the left medius finger and the left elbow, accompanied by vague joint pain, had occurred 13 years ago. Specific markers for rheumatoid arthritis were negative, leading to a diagnosis of sero-negative rheumatoid arthritis, for which treatment with methotrexate was initiated. No clinical benefit was obtained and the treatment was abandoned. New nodules continued to appear on several distal joints of the fingers of both hands and, in the last 6 months, on the second right toe. The course of the disease included spontaneous remission of some of the nodules. Personal medical history was significant for a thyroid nodule, surgically removed at the age of 22. A general physical exam did not reveal pathological changes. A clinical dermatological exam at the time of presentation revealed several round to oval, deep subcutaneous, indurated, asymptomatic, discreetly pigmented lesions with a diameter of 4-6 mm, located on the dorsal aspect of the interphalangeal joints of the fingers of both hands (Figure 1) and the second right toe. Hematologic and biochemical tests were within normal limits, as well as the serological tests for rheumatoid factor, ANCA, ANA, and anti-CCP antibody. Hand radiographs did not show geodes, marginal erosions, or narrow joint spaces. A pathological exam of a subcutaneous nodule showed focally altered collagen surrounded by fibroblasts, phagocytes, rare lymphocytes, and neutrophils, as well as small capillaries (Figures 2-5), compatible with the diagnosis of a pseudorheumatoid nodule or benign rheumatoid nodule in the clinical and paraclinical context. SGA is considered a rare clinical and histological variant of granuloma annulare that predominantly affects children and occasionally young adults (1-6). In 1941, Ziegler first described a case of subcutaneous nodules that appeared concomitantly with classical cutaneous lesions of granuloma annulare, as well as the histological aspect of these nodules similar to that of rheumatoid nodules (RN) (7). Since then, several case reports in the literature refer to the subcutaneous lesions of GA as "pseudorheumatoid nodules", "deep granuloma annulare" or "palisading granuloma" (3,4,8). Most reported cases of SGA occur in the first three decades of life: 98% according to Muhlemann, 79% according to Andersen and Verdich, 62% according to Studer; most cases occur in children between 2 and 6 years of age (9). Lesions often regress spontaneously, but recurrences are common in 19%-75% of the patients, often on the same anatomical areas (9,10). Reported SGA cases in adult patients predominantly affected women, and typically involved multiple lesions located on the hands, feet, ankles, and inferior pretibial area (4-6). The etiology and pathogenesis of SGA are not completely understood. Precipitating factors such as insect bites, infections with Borellia spp., herpetic virus, EBV, Streptococcus spp., PUVA-therapy, several drugs, physical trauma, acute phlebitis, and post-surgery sepsis have been considered (8). There is evidence for the pathogenic involvement of an immunological mechanism, possibly a delayed type hypersensitivity reaction mediated by T-cells that triggers a panniculitis-type inflammatory response (8,10). Correlations between SGA and systemic diseases such as diabetes mellitus, sarcoidosis, HIV infection, or autoimmune diseases have not been found (8). A positive diagnosis of pseudorheumatoid nodules relies on clinical and anamnestic data. Differential diagnosis includes rheumatoid nodules, benign rheumatoid nodules, foreign body reactions, hematomas, abscesses, and infectious granulomas (3,5). Pseudorheumatoid nodules and SGA have a low risk of progression to a systemic connective tissue disorder. In the presence of subcutaneous nodular lesions with an uncertain clinical diagnosis, cutaneous biopsy, hematological and immunological tests, and imaging may be performed to establish a positive diagnosis. Skin biopsy is the most useful test for the diagnostic approach because, even though it is sometimes difficult to interpret, a pathological exam may offer important data to distinguish between rheumatoid and pseudorheumatoid nodules. Necrobiosis may be identified in the deep dermis and subcutaneous tissue, and rarely in the deep soft tissues. Necrobiosis is less important and less deep than in rheumatoid nodules, as well as less extensive and less diffuse than in lipoidic necrobiosis (6). Anomalies in the morphology of the deep cutaneous structures may coexist with typical changes in classical granuloma annulare. Immunohistochemical studies using specific histiocyte markers such as CD68/PGM1 proved to be occasionally useful in differentiating SGA from other granulomatous conditions (11). Several tests are necessary to exclude an association with a systemic disease: hemoleucogram (absence of leucocytosis), ESR (normal values), acute phase reactants (negative fibrinogen, RCP), autoantibodies (negative ANA), and rheumatoid factor (negative). SGA is a benign disorder with esthetic implications and sometimes functional impairment. Surgical excision is only required for juxta-articular nodules causing functional impairment. Partial therapeutic benefit was reported after the administration of dapsone, clorambucil, isotretinoin, potassium iodide, or intralesional/topical steroids. Even though the risk of systemic involvement is low, periodical follow-up of these patients is required given the reported cases of associated systemic connective tissue disorders (8,12).

Human papillomavirus 52 positive squamous cell carcinoma of the conjunctiva.

Human papillomavirus (HPV) infection is strongly associated with several human cancers; the most known genotypes involved being HPV 16 and HPV 18. We report the detection of HPV 52 in a sample taken from a 47-year-old patient with squamous cell carcinoma of the conjunctiva of the left eye. The method used for the detection of HPV was real time polymerase chain reaction. The evolution was favorable after surgical removal of the tumor and the patient was explained that long-term follow-up is essential to avoid recurrence.

[Total parathyroidectomy with forearm graft in tertiary hyperparathyroidism]. / Paratiroidectomia totala cu autogrefon glandular la antebrat în hiperparatiroidismul tertiar.

Autonomic and persistent hypersecretion of PTH is a frequent and tormenting complication of the patients with chronic renal dialysis for end stage renal disease (ESRD). In these cases, surgery remains a therapy option with real effects on clinical status of patients, especially in perspective of a renal transplant. The authors present the case of a patient with tertiary hyperparathyroidism for which a total parathyroidectomy followed by autotransplantation of small glandular fragments in forearm muscles was performed. The postoperative clinical and immunological statuses were favorable with the disappearance of pruritus and osteoartralgia with improvement of psychic behavior and normalization of calcium blood level. Considering the parathyroidectomy as a palliative stage in the treatment of ESRD, the authors discussed a hierarchy system of both indications and surgical alternatives to be considered in this condition. In well selected cases this surgical method represents an attractive and easy possibility to control and later adjustment of the hyperfunction of remained parathyroid tissue, avoiding in this way a very risky intervention.

[Minimally invasive approach of the cervical endocrine glands]. / Abordul minim-invaziv al glandelor endocrine cervicale.

Improved preoperative functional and topographic diagnostic techniques and availability of intra-operative hormone monitoring, stimulated the introduction of video-assisted minimally invasive operations in parathyroid and thyroid surgical pathology. The first cases of such pathology operated on in our clinic are presented. The first one is a 62 year old man with renal hyperparathyroidism consecutive to a chronic renal insufficiency and hemodialysis from five and three years respectively. The technique of a minimally invasive gapless resection of all four "adenomised" parathyroid glands using laparoscopic and classic instruments is described. Fragments of one gland are implanted in the left forearm musculature. The second case was a 48 year old woman with a three cm diameter right toxic adenoma. With a lateral 15 mm incision, dissociation of the musculature and adequate moving of the retractors the excision of the thyroid nodule was done in 25'. The video-assisted minimally invasive approach allows magnification and adequate identification and removal of endocrine secreting tissues in thyroid and parathyroid pathology. The authors believe that these techniques represent a feasible and attractive alternative to conventional surgery.

Sneddon syndrome: rare disease or under diagnosed clinical entity? Review of the literature related to a clinical case.

Sneddon syndrome is defined by the association of livedo racemosa and recurrent cerebrovascular ischemic lesions. The annual incidence is 4/1,000,000. This syndrome particularly affects young women, some reports suggesting a family predisposition. It is a chronic, progressive, arterio-occlusive disease of unknown etiology that involves small and medium-sized arteries. It is usually associated with antiphospholipid antibodies. We report the case of a female patient with Sneddon syndrome with significant family history, personal history of stroke, epilepsy, migraine, cardiovascular involvement, three miscarriages, cognitive decline, noncompliant to therapy, in the absence of antiphospholipid antibodies. This paper aims to analyze the main characteristic features and management of Sneddon syndrome by conducting a literature review related to a clinical case.

[Total parathyroidectomy without autotransplantation in the management of "refractory" renal hyperparathyroidism]. / Paratiroidectomia totala fara autotransplant glandular in tratamentul hiperparatiroidismului renal "refractar".

UNLABELLED: The optimal surgical treatment in patients with refractory renal hyperparathyroidism (RHP) on hemodialysis for end stage renal disease is still a point of controversy. The high percentage of recurrences after standard surgical procedures i.e. subtotal parathyroidectomy (SPTx) and total parathyroidectomy with autotransplantation (TPTx + At) reactualised the practice of total parathyroidectomy (TPTx). MATERIAL AND METHOD: Fortythree patients with RHP underwent surgery between 1994-2009. There were 24 SPTx and 6 TPTx + At, both procedures determining 20.7% (6 cases) recurrences so in the last five years TPTx was performed in a series of 13 cases (7 men and 6 women, with median age 43, 6 years; range 22 - 65 years and median dialysis time before PTx 8,2 years; range 3 -12 years. Parameters studies included demographics, preoperative and follow-up laboratory tests, surgical techniques, pathology results and postoperative immediate and medium term results. RESULTS: Main indications for PTx were severe bone disease, soft tissue calciphycations, neuro muscular phenomena, grossly elevated iPTH and sometimes hypercalcemia. TPTx was done in 12 patients, the 13th one suffering a completion PTx one year after outward exeresis of only two glands. Postoperatively the majority of symptoms markedly improved and the values of calcaemia, phosphatemia and alkaline phosphatasis normalised together with low or no measurable level of iPTH. One patient required a re-exploration for a cervical hematoma but no one presented permanent hypocalcemia or recurrent hyperparathyroidism. Pathology revealed nodular hyperplasia in all the cases, a parathyroid carcinoma but also an incidental thyroid papillary microcarcinoma in a complementary thyroidectomy. CONCLUSIONS: TPTx alone proves to be an equally safe and successful as another techniques currently used in management of RHP eliminating the hyperparathyroid status but being superior with regard to aparition of recurrences. The procedure is indicated especially in cases with aggressive, refractory forms of RHP without the prospect of renal transplantation.

[Experimental study regarding the ureteral cicatrization pattern in rabbit]. / Studiu experimental asupra pattern-ului de cicatrizare ureterala la iepure.

UNLABELLED: This study aimed to elaborate an experimental model for ureteral cicatrization following surgical lesion, with direct involvement in urological therapy. MATERIAL AND METHODS: The study was realized on a group of 9 female rabbits on which we have performed ureteral surgery. First surgical event consisted in partial cut of the left ureter following transperitoneal approach, ureteral stent insertion and the suture of the ureteral wound. The second surgical event has accomplished the harvesting of the ureteral fragment during cicatrisation process and was performed at various times from the first surgical event, accordingly at 1, 2, 3...6 days--on different rabbits. 3 rabbits composed the witness group. Fragments were fixed in formol 4%, and histologically stained with hematoxilin-eosin and van Gieson. RESULTS: In the first two days we have observed an obvious inflammatory process on the postoperative ureteral scar. In days 3 and 4, the limited fibrosis appeared in the 2nd day engaged a peak in the 4th day when appeared a sketch of ureteral lumen constriction. In the 5th and 6th day the fibrosis process underwent a moderate resolution, simultaneously with a local diffuse congestion, marker for the remodeling processes of the connective matrix. CONCLUSION: Animal cicatrisation model follows the same pattern as in human but at different timing so as extrapolation requires considering these facts.

[Cystic mucinous tumors of the pancreas]. / Tumorile chistice mucinoase ale pancreasului.

Mucinous cystic tumors (MCTP) are uncommon borderline lesions of the pancreas that may often be misdiagnosed as pseudocysts and have unknown propensity to malignity. During the last two decades in our clinic of 38 patients with cystic lesions of the pancreas two presented MCTP: a 48-year-old woman with a cyst located in the body and tail of the pancreas and a 59-year-old man with a tumor situated in the head of the gland producing an obstructive jaundice. Ultrasonography and computer tomography confirmed the presence of the cystic mass in both patients but the precise diagnosis was made only after the histologic examination of the removed lesions. With an attempted curative resection: distal pancreatectomy with preservation of the spleen in the first case and a Whipple procedure in the second one, both cases were cured. Pathology do not reveal malignant transformations. Both patients were alive, had no complaints or recurrences at 12 and 24 month after surgery. The treatment of choice in such cystic tumors is surgical removal as untreated these lesions may progress to neoplastic degeneration.

[Parathyroid carcinoma in a patient on hemodialysis for renal failure]. / Cancer paratiroidian la un bolnav cu insuficienta renala cronica în regim de hemodializa.

Parathyroid carcinoma is a rare endocrine neoplasm with difficult histological diagnostic and unpredictable evolution. More unusual are the cases appearing in the course of end-stage renal disease on maintenance dialysis (22 observations in medical literature). A 46-year-old man suffering of chronic glomerulonephritis and renal failure for 13 years, having been on hemodialysis for three years, complains of asthenia, adynamia, muscle weakness, progressive osteoarticular pains, itching. The preoperative iPTH was 71/ng/ml, seric Ca2+/1.23 mmol/l, seric Ca/2.6/mmoli/l, seric P/2.02 mmol/l. Clinical and ultrasonographical examinations revealed a left "thyroid nodule" of 44 x 37 mm but no images of the parathyroid. Upon surgery, three parathyroid glands (two from the right side and the superior left one) were identified and excised after the frozen section. The fourth gland was not found but the resected "nodule" together with the adjacent thyroid lobe proved a parathyroid carcinoma upon paraffin examination. The clinical course after operation was uneventful. The authors underlined the criteria and difficulties in the pathologic diagnosis of parathyroid carcinoma and also the principles of surgical treatment based on their experience of three cases.

[Melanotic neurofibroma, clinical and histopathologic diagnosis. Case report]. / Neurofibromul melanocitar, diagnostic clinic si histopatologic. Caz clinic.

Melanotic neurofibroma is a rare benign tumor, derived from peripheral nerve sheath, whose originality consists in the presence of melanic pigment. The clinical diagnosis is difficult to establish, requiring the histopathological exam to make the difference between melanotic neurofibroma and the other pigmented tumors. Although, sometimes neither the anatomopathological exam can establish the final diagnosis, requiring supplementary studies. Melanotic neurofibroma has a good prognosis and the malignization is rare. The elective treatment is surgical, represented by the complete excision of the tumor.

[Bulbantrectomy with truncal vagotomy in the surgical treatment of duodenal ulcer]. / Bulbantrectomia asociata vagotomiei tronculare in tratamentul chirurgical al ulcerului duodenal.

Duodenal ulcer benefits of very efficient medical treatment. In currently medical practice exist many cases with complicated duodenal ulcer (by stenosis or penetration in neighbor organs like pancreas or biliary tract or painful forms etc.) to which surgical treatment is necessary. Based on the retrospective study of 116 patients operated between 1991-2002 years for gastric or duodenal ulcer, this paper demonstrates that bulbantrectomy associated with bilateral truncal vagotomy (63.7% of cases) is the best surgery in the treatment of duodenal complicated ulcer or resistant to the medical procedures. Provided by correct indication, the intervention is the most pathogenic, offering the best immediate and long term postoperative results. If the bulbantrectomy is contraindicated (critical general status, etc.), the alternative is a bilateral truncal vagotomy associated with a drainage procedure: pyloroplasty (6.9% of cases) or gastroenterostomy. When the vagotomy are contraindicated or cannot be correctly performed, a large gastrectomy (29.3% of cases) followed by gastroduodenal (preferable) or gastrojejunal anastomosis are practiced.