Localisation and preservation of the autonomic nerves in rectal cancer surgery - technical details.

Iatrogenic surgical injury to pelvic autonomic nerves followed by genitourinary dysfunctions are well known problems after total partial mesorectal excision for rectal cancer. The purpose of our paper is to present the useful anatomical landmarks for a safe nerve-sparing surgery in rectal oncology. Over the course of a total mesorectal excision we describe and illustrate the key risk zones of autonomic nerve injury based on our experience in rectal surgery and on the revised literature.

Temporary protective loop ileostomy in open low rectal resection -- an alternative technique.

The paper presents a simplified method for performing a temporary protective loop ileostomy as a result of our experience in 33 cases of low rectal resections for cancer.The particularities of this technique are: the skin incision is smaller than the muscle one, the seromuscular layer of the loop is fixed at the skin level only by marking a small portion of the antimesenteric wall, with no mucosal eversion. No supporting rod is used. The reversal requires resection of the thickened freemargins and enterorrhaphy. It involves a direct approach and avoids median laparotomy and segmental bowel resection.There was no case of peristomal abscess, bleeding, prolapse,retraction of the loop after the stoma was formed. Four patients(12.12%) had peristomal dermatitis. Five patients (15.62%) had high output fluid losses with electrolyte disorders, one of them(3.12%) with acute renal failure. Closure was performed after 6 weeks on average for the colorectal anastomoses and 10 weeks for the coloanal ones. We recorded a case (3.12%) of enterocutaneous fistula that was managed conservatively and 4 cases(12.12%) of incisional hernia, all of them surgically treated. No mortality was attributed to either creation or closure of the temporary loop ileostomy. It is a simple and fast technique in accordance with the temporary character of its indication.

[Adenoid cystic carcinoma of the breast--two case reports]. / Carcinom adenoid chistic mamar--prezentare a doua cazuri.

Adenoid cystic carcinoma is a rare type of breast carcinoma with a good prognosis. It represents less than 0,1% of breast carcinomas. We present two cases of adenoid cystic carcinoma diagnosed in the Surgical Department of Coltea Hospital in the last 3 years. The first case is a 66 years old patient with a breast tumor that has clinical and imagistic features compatible with a benign diagnosis. The frozen sections established the diagnosis of adenoid cystic carcinoma, confirmed by histopathologic examination of paraffin embedded tissue and immunohistochemistry. The second case is a 68 years old patient with a breast tumor located in the central quadrant of the left breast, with skin infiltration. Preoperatory fine needle aspiration is sugestive of a papillary tumor, so the cytologic exam cannot establish malignancy. The frozen sections established the diagnosis of ductal invasive carcinoma and histopathologic examination of paraffin embedded tissue and immunohistochemistry established the diagnosis of adenoid cystic carcinoma associated with ductal invasive carcinoma grade I and adenomyoepitelioma. The cytology had a false papillary aspect, in fact there was amorphous material contained in pseudoluminal spaces. In both cases the treatment was surgical resection with tumor excision and free resection margins. In the second case lymphadenectomy was also performed.

Management of recurrent inguinal hernias: a prospective study of 163 cases.

There remains debate as to how recurrent inguinal hernias should be managed. This study aimed to establish a management plan for recurrent hernias. From 1991-2000, 163 patients were operated on for recurrent inguinal hernias. The average interval from the initial surgery to recurrence was 46 months (range 10 days-13 years). The initial surgery prior to recurrence was Shouldice and other techniques without mesh in 142 cases, a Stoppa or a Lichtenstein procedure in ten and three cases, respectively, and laparoscopic repair in eight cases. The recurrent hernias were treated with a Shouldice repair in 52 cases (31.9%), the Lichtenstein technique in 48 cases (29.4%), a totally extraperitoneal laparoscopic repair in 40 cases (24.5%), and a Stoppa procedure in 23 (14.1%). The approaches to management evolved with time: the use of prostheses for recurrent hernia repair increased from 10% in 1991 (2/10) to 100% in 2000 (22/22). In contrast, the Shouldice repair decreased from 90% (18/20) in 1991 to 0% (0/22) in 2000. The Lichtenstein technique was first employed in 1993, in patients with a history of a conventional, laparoscopic, or Stoppa repair and has increased to represent 77% of cases (17/22) in 2000. The Stoppa technique has not been used since 1998. The use of a totally extraperitoneal laparoscopic approach went from 11% (2/18) in 1992 (introduction of the technique) to 23% (5/22) in 2000 and is reserved for recurrence after a Lichtenstein procedure or after conventional repair in working and/or physically active patients without any contraindications to general anesthesia. Prosthetic reinforcement has become the norm in the treatment of recurrent hernias. Given a previous conventional repair, the prosthesis can be placed by either an anterior or posterior approach. The approach is dependent on the level of activity and operability of the patient. If the recurrence follows a totally extraperitoneal or a Stoppa procedure, then the Lichtenstein intervention is recommended. A recurrence after a Lichtenstein procedure should be treated by a totally extraperitoneal approach.

[Is laparoscopic treatment of adhesions a valid approach for postoperative abdominal pain?]. / L'adhesiolyse laparoscopique est-elle licite dans les ventres opérés douloureux?

The role of post-operative adhesions in chronic abdominal pain remains controversial. The aim of this study was to assess the value of laparoscopic treatment of adhesions for chronic post-operative abdominal pain in 32 patients. Over a period of 8 years, 32 patients (25 women and 7 men) with a mean age of 41.5 years (18-69) were hospitalized for chronic abdominal pain of more than 6 months duration, without an obvious underlying neoplasm or psychiatric disorder. They had all undergone at least one previous abdominal operation (mean, 1.9; range, 1-5), with a mean follow-up of 28 months (6-82). The mean duration of the pain was 18 months (6-65) and in 24 of the 32 cases it was mainly hypogastric. Other than the presence of a scar, the clinical examination was completely normal. Prior to hospitalization, 163 different laboratory tests, 162 radiological investigations, including 13 CT scans and 3 MRIs, and 25 endoscopies had been performed. A pneumoperitoneum was made by "open laparoscopy" in 23 cases and with Verres needle in 9 cases. Eight patients (25%) did not have any adhesions, but 6 of them were found to have a gynecological problem (endometriosis). In this group, the laparoscopy lasted 34 minutes (15-45) and the mean hospital stay was 48 hours. In 24 cases, adhesions were found and selected. This was thought to be complete in 22 cases (91.6%). There was a strict correlation between the adhesions and the scar in 85% of cases. In 5 cases, the adhesions were associated with another intervention. There were no conversions. The mean duration of surgery and hospitalization was respectively 56 minutes (32-120) and 3.2 days. There was no mortality and the morbidity rate was 4.1% (1 monopolar injury). The average follow-up was 26.7 months: 22 of the 24 patients who had freeing of adhesions were evaluated after at least 6 months of follow-up. In 10 cases, the pain had completely resolved (45%), in 6 it had decreased (27%) and in 6 cases it was unchanged or had even worsened (1 case of endometriosis). Laparoscopic exploration for chronic post-operative abdominal pain, after an extensive work-up performed after a suitably long delay post-surgery, can be used to detect and treat adhesions in 3/4 cases. In the absence of another lesion, the pain is lessened in 72% cases. However, if there is another lesion, laparoscopic treatment of adhesions is less effective with respect to the pain, but it nevertheless can identify an.

[Hydatid cyst of the head of the pancreas--a clinical case]. / Chist hidatic de cap de pancreas--caz clinic.

Case report of a 41-year-old man, admitted because of intense sclero-tegumentar jaundice, epigastric pain and brings. The altered general state, because of obstructive jaundice (the total bilirubyne 9.6 mg%, with D 5.8 mg% and I 3.8 mg%, the alkaline phosphatase 650 u.i./l) determined the effectuation in emergency of an endoscopic retrograde cholangiopancreatography, which included also a minipapilosfincterothomy. On obtained the spectacular improvement of the jaundice (the total bilirubyne 1.3 mg%) which permitted the extension of the imagistics explorations, establishing the diagnostic of cystic tumour of the head of the pancreas, but on could't specify the etiology. On made the surgical approach, founding a hydatic cyst of the head of the pancreas; on practised the parasite inactivation, the cyst evacuation, pericysto-jejuno-anastomosis on a loop in Y "à la Roux" and cholecysto-gastro-anastomosis. The postoperative evolution was favourable.

[The place of conservative surgery in the complex oncologic treatment of breast cancer]. / Locul chirurgiei conservatoare în cadrul tratamentului oncologic complex al cancerului de sân.

For a long time, breast-conserving surgery has been a subject of great interest and debate. Many researchers have tried to find strict criteria in selecting the patients who can benefit from such a treatment but this remains a goal to achieve in the future. In our surgical department, from 1984 to 2000, 1152 patients were diagnosed with breast cancer. 741 patients (64.1%) had advanced breast cancer and 411 patients (35.6%) were diagnosed in I and II stages. From the patients with early breast cancer only 57 (14.1%) had benefited of conservative surgery combined with adjuvant radiotherapy and chemotherapy. All patients received hormonotherapy. The surgical treatment consisted in a broad sectorectomy and axillary lymphadenectomy in all cases. We present the criteria for selecting patients in our study. The patients were followed for 2-5 years, with a mean period of 48 months and there were no significant differences between the trial with mamectomy and that with conservative surgery. There is presented a brief review of the literature in this field. Our conclusion is that the conservative surgery for breast cancer is a good method, which can be applied for selected patients and with a good follow-up.

[Use of prosthesis in inguinal hernia repair]. / Place des prothèses dans les cures de hernies inguinales.

AIMS: To evaluate the use of mesh in the evolution of hernia repair technique during a period of twelve years. PATIENTS--METHODS: From january 1991, to december 2002, 1306 patients 1136 men, 190 women, with inguinal hernia, with a mean age of 47.4 years old (15-98) have had an elective surgical repair. 1097 (83.9 per cent) were unilateral. 209 (16.1 per cent) were recurrent hernia. Clinical data, operative technique have been prospectively evaluated: Four techniques were used: Shouldice procedure, Stoppa operation and laparoscopic repair (TEP) in 1992 and Lichtenstein technique since 1993. RESULTS: During the study, meshes were used in 65.7 per cent of the patients respectively 33.3 per cent for Lichtenstein, 26.9 per cent for laparoscopic repair and only 5.3 per cent for Stoppa open procedure. During the study, prosthesis rate increased from 9.1 to 85.4 per cent for primary hernia and from 10 to 100 per cent for recurrent hernias. To day, Stoppa procedure is not yet performed. Herniorraphies decrease from 91.9 to 14.6 per cent. CONCLUSIONS: "Tension free" techniques represent 85.4 per cent of all procedures at the end of the study, specially Lichtenstein operation (65 per cent) which seems to become the new "Gold Standart" in inguinal hernia repair.

[Therapeutic options in locally advanced breast cancers]. / Optiuni terapeutice în cancerele mamare avansate local.

The authors are showing their experience on 394 locally advanced breast cancer in the last 10 years. In this trial were included the tumours larger than 5 cm, multiple tumours, tumours invading the skin or the thoracic wall with invaded or fixed axillary or supraclavicular nodes and acute carcinomatous mastitis. The optional therapeutic schedule was modified upon the stage. It consisted in pre- or postoperative radiotherapy, polychemotherapy or polychemo- or radiotherapy alone, associated with nonspecific immunotherapy and hormonotherapy. In patients with complex treatment the survival rate was 45.4% at 5 years and 12.3% at 10 years. The authors highlight the importance of the surgical treatment which offer a big potential in the context of the complex treatment.

[The surgical possibilities in locally advanced gastric cancer (LAGC)]. / Posibilitati chirurgicale în cancerul gastric avansat local (C.G.A.L.).

Most frequently the diagnostic of gastric cancer is established in advanced stages. Practically, was noticed that local evolution advances the appearance of metastases. The authors are presenting 159 cases of locally advanced gastric cancer (LAGC) out of 211 gastric cancers submitted to surgery between 1984-1995. The surgical possibilities in such situation specifically adapted to each case, are discussed. The operation has an important role in appreciating local and regional extension, solving complications and even performing radical resections.

[Pseudomyxoma peritonei (gelatinous peritonitis )]. / Pseudomixomul peritoneal (peritonita gelatinoasa).

UNLABELLED: Pseudomyxoma peritonei (P.P.) is characterised by the presence in the peritoneal cavity of 3 elements--mucinous neoplasic cells, mucinous ascites and diffuses mucinous implants. We analysed the patients treated in our service and we made a literature review. The study is a retrospective analysis on the 1984-2000 period. 6 patients were diagnosed with P.P., 2 females and 4 men, with medial age 63 years (53-75). Clinical findings and biologic analysis were not specific and the imagistic explorers didn't permit the preoperative diagnosis. The patients were submitted to variate surgical procedures, based on the benign (4 cases) or malignant (2 cases) character of the disease and on the origin of the lesions: cystadenoma of the appendix with secondary tumours of the ovary (the 2 females) and, respectively, cystadenoma and cytsadenocarcinoma of the appendix, mucinous paraenteric cyst with pseudomyxoma retroperitonei, mucinous recto-sigmoidian neoplasm (the 4 men). We practiced intraperitoneal chemotherapy with Thio-Tepa in 5 cases (intraoperative in 4 cases) and systemic, with 5-FU and mytomicine, in one case. The operative morbidity and mortality were null. All the patients were follow-up (average 4.2 years). The global 5-year survival rate was 60% (100% in the benign disease and 0% in the malignant form). CONCLUSION: P.P. is a rare disease, still poorly understood. The origin of the disease is the appendix (70-80%) and less frequently the ovary. It was divided in two distinct forms: disseminated peritoneal adenomucinosis and peritoneal mucinous carcinomatosis. The treatment associates radical surgery and intraperitoneal chemohyperthermia, in specialised centres, but the prognosis still remains poor (50-70% 5-year global survival rate).

[High obstruction in strangulated diaphragmatic hernia]. / Ocluzie înalta prin hernie diafragmatica strangulata.

Case report of a 57-year-old man, admitted in emergency, because of high occlusion and severe dyspnea. The physical examination and the imagistics explorations established the diagnostic of strangulated left diaphragmatic hernia. After a short re-equilibration, the surgical approach was made by left thoracophrenolaparotomy and on realize the visceral reduction, the treatment of visceral injuries and the plasty of the pretty high diaphragmatic defect with a nylon mesh. The postoperative evolution was difficult, with hemorrhagic gastropathy, blocked evisceration, pneumonia and left pleural empyema. The control at 10 months show a patient appearing very well, with a voluminous eventration (who need surgical treatment) with normal image on the chest radiography, left hemidiaphragm in normal position and immobile, the gastrointestinal tract sitting intraabdominal, without parietal injuries.

[Conversion in laparoscopic surgery]. / Conversia în chirurgia laparoscopica.

AIM: The conversion causes evaluation in dynamics. METHODOLOGY: The study is a retrospective analysis of the conversion to open surgery in 1993-2001 period, indifferently of the moment and the determinant cause. The yearly dynamics of the conversions was divided by operation types and surgeons. There were also analysed the moment and the cause of the conversion. RESULTS: There were realised 3961 laparoscopic operations (by 7 experienced surgeons and a lot of young surgeons), with 244 conversions (6.2%), percentage variable depending of the operation (3.3% in hernioraphies, 5.3% in cholecystectomies, 8.2% in gynecologic procedures, 12.1% in appendectomies, 33% in abdominal esophagus procedures, 33% in splenectomies) and on surgeon (until 0% and 8%); the differences until the surgeons don't depend on their experience and for the same surgeon, the experience accumulation doesn't reduce the conversion rate. The most conversions happen after a simple inspection or a minimal dissection (73.1% in cholecystectomy) caused by the existence of plastron, the discovery of a difficult anatomic situation or of another pathology; more rarely, the conversion happens in the principal time (23.4% in cholecystectomy), doing to hemorrhage, impossible dissection, visceral injury or even at the end of the operation (3.5% in cholecystectomy), doing to hemorrhage, loss piece or calculs. CONCLUSIONS: The conversion rate depends especially on the correctness of the indication of laparoscopic approach and not on the surgeon experience, what proves that it is a moment of surgical maturity. Decide from the beginning, in the moment of the recognition of a difficult situation and not after the occurrence of a complication, modifies neither the morbidity, nor the much discussed hospital stay.

[The laparoscopic procedures on abdomen with adhesions]. / Interventii chirurgicale laparoscopice pe abdomen cicatricial.

The scar abdomen is more and more seldom a contraindication of the laparoscopic approach. According to Rohr it is classified in scar abdomen after Mac Burney, suprapubic or supraumbilical approach and of the polyoperated patients. Our trial consists in 452 patients with laparoscopic operations consecutive open abdominal surgery (out of the 3900 patients undergoing celioscopic procedures between 1995-2001). The laparoscopic procedure was performed distant to the previous operation in 95.1%, on a neighboring organ to that initially conventionally operated in 4.1% or on the same organ in 3 patients (0.8%). We lead no preoperative fatalities, but the conversational rate was 12% (54 patients), due to the high-risk dissection or to the unsolvable bleedings by laparoscopic means (2 cases). The operative accidents consisted in visceral injuries soloed by laparotomy. Postoperatively we registered 5 port site seronas, 1 deep vein thrombosis and 1 pneumonia. The evolution and the mean hospitalization was the same for the scar abdomen patients with the operative procedure accomplished laparoscopically as for non previously operated patients. The data support the feasibility of the laparoscopic procedures on scar abdomen, using the "open laparoscopy" with a reasonably increased conversational rate.

[The therapeutical strategy for locally advanced breast cancer]. / Strategia terapeutica în cancerul mamar local avansat (C.M.L.A.).

As for the other cancers, the strategy of therapy of breast cancers is going to a unitary standardization. In our department between 1984-1999 we are operated 1040 patients with breast cancers, which means 25.3% of all cancers treated. 688 (64.3%) were CMLA, 646 (96.7%) of them were in patients women and 22 (3.3%) men. The mean age was 52.4 years (3-84 years). All patients were divided into two trials and analyzed: retrospectively (A) 312 (46.7%) and prospectively (B) 356 (53.3%) patients, 51.2% of patients was in III and IV TNM stage. The patients from trial B were treated concerning with specific therapeutically protocol, adapted by age, anatomopathological form, volume of tumor, skin or thoracic wall invasion, inflammatory lesions, lymph node invasion and physiological period. The results were: the increase of number of radical surgical interventions, the decrease of the morbidity, the increase of survival and a better quality of life.

[Analysis of 3100 laparoscopic cholecystectomies]. / Analiza a 3100 colecistectomii laparoscopice.

AIM: To evaluate the results of laparoscopic cholecystectomy (LC) in the 8 years period. PATIENTS AND METHODS: First LC in Coltea Hospital was performed in September 1993 and introduced for treatment of patients with gallbladder disease. From September 1993 to February 2001 LC was performed in 3100 patients. Mean age 51.2 years (ranged from 8 to 87 years) among 2512 women and 588 men. 232 (7.48%) of the cases were patients with acute cholecystitis. Intraoperative cholangiography was performed in 112 cases (3.6%). RESULTS: Conversion to open cholecystectomy (OC) was necessary in 111 patients (3.58%). Operative complications occurred in 16 (0.5%) patients: CBD lesions in 4 (0.12%) patients, bleeding from cystic artery--12 (0.38%) patients. In one patient CBD injuries was recognized at the time of operation and after conversion to OC primary ductal repair was performed. Postoperative complications occurred in 44 (1.41%) patients: a) local infection--in 15 (0.48%) patients (subhepatic abcess-3, wound infection-9. b) bile leakage--in 21 (0.67%) patients. c) haemoperitoneum because of the bleeding: from the abdominal wall at the trocar insertion site--in 2 patients, from a. cystica-one patient. d) obstructive jaundice due to stone in CBD--in 5 patients (endoscopic papillosphincterotomy and stone extraction was performed). There 21 reoperations due to complications: 13 laparatomies and 8 relaparascopies. Two patients (52 and 64 years old) died after LC-mortality 0.06 per cent. Mean hospitalisation day was 3.8. CONCLUSIONS: To prevent iatrogenic CBD injuries correct preparation with a clear identification of the anatomic structures is essential. Relaparascopy and endoscopic retrograde cholangyopancreatography can be successfully used in the treatment of complications after LC.