[Choledochal cyst as a complex malformation of the intra and extrahepatic bile ducts]. / Chist coledocian congenital--anomalie complexa a cailor biliare intra si extrahepatice.

The authors present the case of a 64 years woman with a choledochal cyst along with a complex malformation of both intra and extrahepatic bile ducts. The patient was admitted with a diagnosis of acute and underestimated cholecystitis, which was in fact a real acute severe suppurated angiocolitis located at the cystic cavity level along with severe hepato-renal failure. As long as the choledochal cyst evolves as a stand-alone entity, it can frequently be associated with other malformations of the bile ducts--such as choledochal duct stenosis or abnormal connection of the common hepatic duct with pancreatic ducts. The main dilatation was engulfing the whole common bile duct with a fusiform aspect, and the cranial end is opening into a long hepatic duct from which were emerging several biliary segments branches, for both hepatic lobes. This aspect of a multistage convergence with four branches which is opening into a long hepatic bile duct and then in the choledochal cyst, represents an unusual malformation which does not respect the rules described by former published authors.

[Classical and laparoscopic therapeutic options in surgery for hepatic abscess]. / Optiuni terapeutice clasice si laparoscopice în chirurgia abceselor hepatice.

Although lots of modern surgical and imaging techniques have been developed and last generation antibiotics are in use, the difficulties in the diagnosis and treatment of hepatic abscesses are still a rather sombre reality. Our research concerning 14 patients submitted to surgery within the last ten years can be thought of as a record, considering the poor number of cases in the last decades. So, our study also includes the possible clinical or imaging errors, the technical details of the surgery, the attitude towards the abscess cavity and the still obscure etiology in most of the cases. The correlation between the surgical risk and the rest of the hepatic volume, evaluated by computed scanning technique, represents another objective of this paper. In the large or in the multiple disseminated abscesses, the small area of the remaining functional hepatic tissue, was correlated to the postoperative slow or even bad evolution in two cases. The radiological, ultrasound and scanner control showing the reducing or disappearing of the abscess cavity after drainage in all the cases, represent an argument of the correct therapeutic approach.

[Surgical strategy in laparoscopic repair of hiatal hernia and procedures for gastroesophageal reflux]. / Elemente de strategie operatorie în chirurgia laparoscopica a herniilor hiatale si a refluxului gastroesofagian.

The authors discuss about 68 celioscopy antireflux procedures, carried out for transhiatal hernia accompanied by gastroesophageal reflux, during a period of 8 years, between 1996 and 2003. The aim of this research is a clinical and technical comparative study, in fact between the posterior total or partial fundoplication and the anatomical procedures. In order to have a complete evaluation of the risks and results, the authors discuss the indications of each procedure, a series of specific intra and postoperative complications, including conversions and reinterventions, for each procedure. The authors also refer to the difficulty degree, the time required for each procedure, to find out the ways of improving these parameters. Although the number of patients is quite small, in this experience, posterior fundoplication seems easier and safer, whenever possible. The Nissen procedure, which technique is more laborious, seems to offer a better postoperative evolution and more long - lasting results in time.

[Unusual hemorrhagic complication after surgery for severe generalized appendicular peritonitis]. / Complicatii hemoragice neobisnuite dupa o peritonita apendiculara grava operata.

The 22 year old male patient, was admitted in hospital for severe generalized peritonitis subsequent to acute perforated appendicitis and toxico-septic shock. On examination and relying on the previous history of the patient onset of the perforation was start assessed to have occurred some days earlier. Severe generalized, putrid peritonitis was found on surgery of the peritoneal cavity. Appendectomy was successfully carried out with a simple ligature of the appendix stump, and the ligature of the mezooappendix was performed without identifying the appendicular artery. Early in the postoperative stage there occurred diffuse bleeding localized in the peritoneal cavity. The source of the bleeding could not by found at the first reoperation. Subsequently the septic syndrome evolved simultaneously with the bleeding in a milder form, however, leading to growth in size of retroperitoneal hematoma. On marking the diagnosis, relying on CT examination, a new, second surgery was performed which afforded evacuation and drainage of the retroperitoneal hematoma. The authors have remarked and have tried to clear up the circumstances which had been conductive to the occurrence of hemorrhage, a thing absolutely unusual in the evolution of diffuse peritonitis by perforated acute appendicitis.

[Controlled stomach fistula for acute operated ulcer. Case report]. / Fistula gastrica dirijata pentru ulcer acut postoperator perforat. Prezentare de caz.

The authors analyze the case of a 65 old woman which was hospitalized for sigmoidian stenosant and haemorrhagical neoplasm, confined to the colic wall, without peritoneal or hepatic metastases, and without peritoneal or parietal invasion. Surgical management included sigmoidectomy and termino-terminal anastomosis for reconstructing intestinal transit followed by peritoneal drainage. In early postoperative stage the aspect of generalized peritonitis occurs and there is suspicion of anastomotic fistulae. On surgery, acute and perforated gastric ulcer is found, located in close vicinity to the cardia, on the anterior side of the stomach. Suture of the perforation is undertaken with drainage of the peritoneal cavity, but successfully because fistulization of the sutured perforation followed. Under the given circumstances controlled drainage of the gastric fistulae was carried out, using a Folley probe extended through the fistulae orifice and through the anterior abdominal wall, lateral to the median incision. The blowing of the intragastric balloon and the setting into tension of the gastric wall to the front abdominal wall allowed the sealing of the fistulae route but it took about three months. This technical contrivance has afforded good postoperative evolution and recovery of the patient, who after five years from surgery is in a good condition and has no subjective complaints.

[Carcinoid tumors, leiomyosarcoma and invasive adenocarcinoma metastasis of the Treitz angle]. / Tumori carcinoide, leiomiosarcom si metastaza invaziva de adenocarcinom, ale unghiului duodeno-jejunal Treitz.

Our paper studies the quite rare occurrence of the digestive superior occlusive pathology, namely some causes which might induce partial or even total obstruction of the digestive tract, at the distal anatomical limits of the duodenum, also known as the Treitz angle. The first two described cases were carcinoid tumors, obstructive and ulcerated in the lumen of the same angle. The last two cases were an obstructive leiomyosarcoma and an invasive mesenteric metastasis from a right colon cancer, which cause a total external compression of the Treitz angle, clinically manifested as a complete food intolerance, as a first symptom. Concerning the clinical evolution, these are totally different lesions, malign, metastasis and neuroendocrine tumors, which occurred at the same level, had a totally different clinical evolution and surgical approach, only three of them developing at good postoperative course. The imaging, clinical and pathological diagnosis problems, the different specific surgical solutions, the postoperative care and finally the rarity of this level of obstruction of the small bowel, are the aim of this paper.

[The extraperitoneal transomphalic drainage of the postoperative hydatid cavity through the transposed round ligament detached from the liver]. / Drenajul transomfalic extraperitoneal în chistul hidatic al lobului stâng hepatic prin transpozitia ligamentului rotund detasat de ficat.

The transomphalic and then the transligamentary extraperitoneal drainage imagined by D. Burlui and its multiple use in the liver and the biliary tract surgery, is well known. Concerning the hepatic hydatid cysts, the drainage of the remaining cavity by the round ligament way is possible for most of the locations of the parasite, but it is less performed in the right liver lateral segments locations, too far situated, and also in the left liver locations. On the other hand, this specific method implies to place the drainage tube using the round ligament "in situ ", normally placed and inserted. We encountered an extremely large hydatid cyst of the left hepatic lobe, adherent to the anterior and posterior abdominal wall, spleen, stomach, pancreas and large bowel, which required to extend the incision to the left and make the necessary segmentation of the round ligament at its hepatic insertion. After pericystotomy and the evacuation of the cyst, the remaining cavity drainage was performed through the same round ligament whose free end was tightly fixed to the partial pericystotomy border. This transposition allowed the exteriorisation of the drainage tube in the same way as for the transligamentary and total extraperitoneal original method.

[Extraperitoneal transomphalic drainage of the posthydatid hepatic restant cavity by coelioscopic approach]. / Drenajul transomfalic extraperitoneal al cavitatii restante hepatice posthidatice pe cale laparoscopica.

Being often biliary contaminated and suppurative, the hydatid hepatic cyst is in fact a real parasitic abscess. So far its surgical approach represents the only credible possibility of treatment. Authors impart their experience regarding the external drainage of the restant posthydatid cavity, by using a completely extraperitoneal way of bringing out the drain, by means of the round ligament, an original method conceived and put into practice by Prof. D. Burlui in 1968. This technique is simple, without risks or complications, possible for most of the parasite hepatic locations, especially for the central segments, for which this method is superior to other surgical procedures. The greatest advantage of the extraperitoneal transomphalic route of the drain is the absence of the peritoneal losses and so the impossibility of biliary leakage occurrence. The radiological and the ultrasonic controls confirm the reduction and finally total fibrosis and disappearance of the remaining cavity, about two months after the surgery. In this moment the drainage may be suppressed. In December 2001, we added to this method an other original variant: the coelioscopic approach of the extraperitoneal transomphalic drainage of the restant posthydatid cavity, representing the aim of this paper.

Drainage of the common bile duct by the axial transomphalic extraperitoneal route.

AIM: A retrospective analysis was made of results obtained in 169 patients with axial transomphalic external biliary drainage, operated between 1984 and 1998. However, the authors' experience with this method covers a total of 773 cases in which this type of drainage was used between 1966 and 1998. METHOD: The technique is described in detail. The use of the omphalic ligament provides a completely extraperitoneal trajectory for biliary drainage tubing inserted between the two peritoneal layers of the ligament. RESULTS: Postoperative mortality and morbidity in the patients presented here were not related to the drainage procedure, but were related to the background illness, associated disturbances and the surgical procedures applied. Axial transomphalic biliary drainage has many indisputable advantages in comparison with other types of external biliary drainage. Indications and counterindications of the method are summarized. CONCLUSION: The technique is especially valuable because it protects biliary-digestive anastomoses and common biliary duct sutures, facilitating implantation of prostheses and reconstruction of the main biliary pathway, as well as benign and malignant stenoses.