Is Complete Excision Always Enough? A Quality of Sexual Life Assessment in Patients with Deep Endometriosis.

Background and Objectives: The aim of this study was to find the factors associated with the severe impairment of QoSL and the factors associated with a better score in QoSL, as well as the evaluation of pain symptoms and QoSL after the complete and incomplete excision of rectovaginal nodules. Materials and methods: The present prospective study was conducted in a single tertiary center for endometriosis where 116 patients underwent laparoscopic surgery for deep endometriosis during a 3-year period. The goal of the intervention was to excise all endometriotic implants while conserving the rectum. Intraoperative findings were recorded after the intervention, and the patients were classified according to the ENZIAN classification and rASRM scores. QoSL was assessed using the EHP-30 Module C (QoSL Score). Results: When comparing the mean scores before and 2 years after the surgery, a highly significant improvement was found for QoSL and dysmenorrhea (p < 0.0001). The complete excision of rectovaginal nodules led to a significantly better QoSL and lower dyspareunia (p < 0.0001) than incomplete resection (p < 0.02). Conclusions: This prospective study proves that the complete laparoscopic excision of all endometriotic implants improved the QoSL and decreased the pain score of dyspareunia. Incomplete rectovaginal nodule excision was correlated with a poorer QoSL and a lower improvement of dysmenorrhea, dyspareunia, and chronic pelvic pain scores than complete excision.

6 Years of Breast Reconstruction in One Center - An Objective Analysis.

Background: Breast cancer represents the most common type of neoplasm in women around the world. Breast reconstruction following mastectomy has become a demanding procedure in the treatment of patients suffering from breast cancer. Their major role is to improve the quality of life of women, leading to better aesthetic outcomes. Based on each type of reconstruction, the complications following surgery and the duration of hospital stay, the financial implications slightly vary. Methods: Our study included 168 female patients who underwent immediate or delayed breast reconstruction after mastectomy. We assessed the clinical management of each of these cases and we evaluated the average final cost of the treatment after the reconstruction, focusing on the reconstructive method used, the complications that occurred and the number of days of hospitalization. Results: The total cost of care in breast reconstruction surgery depends on the type of reconstructive procedure used, which consequently affects the duration of hospitalization of the patients. The expenses also depend on the materials that are used: the type of implant/expander or the use of ADM. Costs were higher in patients who underwent breast reconstruction using a latissimus dorsi flap associated with an implant, in comparison to reconstruction using a free flap. Conclusions: Breast reconstruction represents a crucial process in the management of women who underwent mastectomies following cancer and presumes variable financial resources, depending on the chosen reconstructive method.

Brachial Mycotic Pseudoaneurysms Due to Prosthetic Valve Infective Endocarditis: A Case Report and Review of the Literature.

Brachial mycotic pseudoaneurysms (BMPA) are a rare complication of infective endocarditis (IE), but potentially could be a limb-threatening condition. We present the case of a 38-year-old male referred to our department, complaining of the sudden onset of a painful pulsatile mass 5 x 10 cm in the right antecubital fossa that slowly progressed over time. Two years before this, he underwent aortic and mitral valve replacement with mechanical prosthetic valves and tricuspid annuloplasty for IE with methicillin-susceptible Staphylococcus aureus after a six-week course of intravenous antibiotherapy with oxacillin. Clinical examination of the right upper limb revealed a pulsatile and compressible mass with a normal temperature and without other clinical signs of inflammation. Pulse of the axillary artery, brachial and radial arteries were palpable. He was diagnosed by Doppler ultrasonography and digital subtraction angiography with BMPA. Furthermore, transesophageal echocardiography (TEE) revealed normal function of the aortic and mitral prosthetic valve with no signs of prosthetic valve endocarditis and no feature of congestive heart failure. Considering these clinical findings, surgical treatment was planned. He underwent re-section of the brachial pseudoaneurysm and arterial reconstruction. One year after the pseudoaneurysm resection, evolution was excellent. This manuscript presents this rare, uncommon complication after IE and also reviews the available surgical management strategies for this pathology.

Unusual Location of a Posterior Lipoma Originating From the Left Atrial Roof: Case Report and Review of the Literature.

Lipomas are the most common type of soft tissue tumors. They mainly are located in subcutaneous tissue in the body, including the heart. The cardiac location of lipomas is rare, mostly asymptomatic, and can cause life-threatening complications by rapid growth. The clinical symptoms, when present, occur in evolution with the growth in size, depending upon the location and degree of invasion in the endocardium. We present the case of a 63-year-old male patient with a large intrapericardial lipoma with an unusual location, originating from the left atrial roof. The initial symptoms of the patient were shortness of breath, dizziness, and mild dyspnea. Transthoracic echocardiography (TTE) was the first line diagnosis method, followed by computed tomography (CT); both showed a large posterior intrapericardial mass. Resection of a 12/8/5 cm lipomatous tumor mass was performed via median sternotomy, under cardiopulmonary bypass (CPB) on the beating heart. Histopathologic examination revealed the presence of diffuse proliferation of large- and medium-sized mature adipocytes consistent with the diagnosis of pericardial lipoma. The patient was discharged at home on the seventh postoperative day, with a marked improvement of his clinical state and effort tolerance. He did not present evidence of recurrence at his 1-year follow up.

Iatrogenic Iliac Arteriovenous Fistula Management after Lumbar Discectomy Surgeries: A Case Report and Review of the Literature.

Iatrogenic iliac arteriovenous fistula (IAVF) is an extremely rare complication after lumbar discectomy surgery (LDS), with potentially life-threatening consequences. An IAVF results from the close anatomic relation between the iliac vessels and the last lumbar vertebrae and the corresponding discs. We report the case of a 45-year-old woman who developed a large right IAVF 3 years after L4-L5-S1 laminectomy. The arteriovenous fistula (AVF) was successfully treated with an endovascular technique using a WALLSTENT self- expanding stent. The postoperative period was uneventful, and the patient was discharged from the hospital in good general condition on the third postoperative day.

Vaginal Reconstruction in Patients with Mayer-Rokitansky-Küster-Hauser Syndrome-One Centre Experience.

Background and Objectives: The Mayer-Rokitansky-Küster-Hauser syndrome is a congenital condition in which patients are born with vaginal and uterus agenesis, affecting the ability to have a normal sexual life and to bear children. Vaginal reconstruction is a challenging procedure for plastic surgeons. The aim of this study is to report our experience in the management of twelve patients with congenital absence of the vagina due to the MRKH syndrome. Materials and Methods: We performed a retrospective study on 12 patients admitted to the Plastic Surgery Department of the Clinical Emergency Hospital "Prof. Dr. Agrippa Ionescu", Bucharest, Romania, for vaginal reconstruction within a period of eleven years (January 2009-December 2019). All patients were diagnosed by the gynaecologists with vaginal agenesis, as part of the Mayer-Rokitansky-Küster-Hauser syndrome. The Abbe'-McIndoe technique with an autologous skin graft was performed in all cases. Results: The average age of our patients was 20.16 (16-28) years. All patients were 46 XX. The average surgical timing was 3.05 h (range 2.85-4h). Postoperative rectovaginal fistula was encountered in 1 patient. Postoperative average vaginal length was 10.4 cm (range 9.8-12.1 cm). Regular sexual life was achieved in 10 patients. Conclusion: Nowadays, there is no established standard method of vaginal reconstruction. In Romania, the McIndoe technique is the most applied. Unfortunately, even if the MRKH syndrome is not uncommon, less and less surgeons are willing to perform the procedure to create a neovagina.

TAAP vs. TEP in Inguinal Hernia Repair - What is the Evidence? A Single Center Experience.

GOALS: To evaluate the indications of TAAP vs TEP in the treatment of unilateral inguinal hernia and the limitations of each technique using the experience of our clinic. MATERIAL AND METHOD: The study is retrospective, extends over 4 years and includes patients with unilateral inguinal hernia operated using either TAAP or TEP technique. Results: We identified a number of 40 patients of which 25 were treated with the TAPP and 15 with the TEP technique. The mean age in the TAAP group was 42 years and 38 years in the TEP group. Mean surgery time for TAAP was 52 min; for TEP it was 62 min. Large inguinoscrotal hernias were operated with the TAAP technique. Conversion from TEP to TAAP was encountered in 2 cases, while conversion to open a hernia was encountered in 3 cases. No deaths were recorded in the follow-up time. Conclusions: Both TAAP and TEP are feasible surgical options to treat an inguinal hernia. The use of the TEP technique is limited by the size of the hernia defect while the TAAP technique has the advantage of larger intraoperative field, and an increased risk of injury to major abdominal organs.

When is Laparoscopy Avoided in the Treatment of Surgical Complications due to Crohn Disease.

Introduction: Crohn disease (CD) has seen a steady increase in incidence over the years in Romania. Laparoscopy had a slow evolution as a feasible therapeutic option for patients with CD. Material and Method: The study is retrospective. The period on which the data was gathered spread over 8 years (01.01.2011-01.01.2019). Data was retrieved from three Clinical Hospitals in Bucharest, Romania Results: the preoperative diagnosis of an intestinal fistula (p = 0,02), sepsis (p = 0.01 ) or increased age should be regarded as a limitation for a laparoscopic approach in CD complications. Also in emergency settings an open approach should be the mainstay treatment (approach p = 0.000001). Conclusion: Laparoscopy is a feasible surgical option in the treatment of surgical complication in CD. In order to increase the safety of the intervention, correct selection of patients is important.

Watch and Wait Strategy for Rectal Cancer: 15 Years After the First Published Study. Are We any Closer to the Non-operative Management of Rectal Cancer?

Introduction: Over time, the management of rectal cancer has undoubtedly evolved with the use of neoadjuvant radiochemotherapy. Material and method: The P.I.C.O.S guidelines were used to structure the questions and the research topic as to attain clinical validity. The results of the research were filtered in accordance with the PRISMA checklist. Results: We identified 42 papers. After screening 27 papers were used to complete the analysis. Discussion: There is an increased interest towards the non-operative management of rectal cancer, as up to 25% of patients with preoperative radiochemotherapy have demonstrated complete pathological response (absence of tumor cells on the operative specimens). This information leads to the tantalizing idea that in some cases, surgery can be avoided. Unfortunately, there is a lack of quality data to support this view. Due to increased interest in this subject, an international database in which patients with w w therapy can be enrolled and monitored. Up to now, the database contains over 900 patients. Also, quality prospective trials are emerging. Conclusion: Even with all these recent efforts, the wide-use of this therapy is precluded due to the absence of a standardized evaluation of these patients in the follow-up period.

Clinical Pattern of Surgical Crohn Disease Patients.

Backround/Objective: The aim of investigation was to evaluate if there is a pattern regarding the anatomical location of the disease and type of surgery performed/surgical indication. Also a analysis was performed regarding the complication rate in two subgroups deriving from urban and rural environments. Methods: Data was obtained from the medical records of patients with CD and centralized. Tests of statistical analysis included the CHY-SQUARE test and the results were presented as a retrospective, longitudinal study. Results: The group was formed of 60 patients. Patients with ileocolic disease were frequently diagnosed with obstruction and benefited from an enterectomy with anastomosis. Patients with colonic disease were frequently diagnosed with perforation and benefited from colectomy and stomy. Patients from rural areas had a milder evolution when compared with patients from urban enviroments. Conclusions: Although most patients with CD eventually require surgery, the indication could be anticipated by recognition of the concept of clinical patterns, and type of surgery required could be predicted if the clinical aspect of the patient/disease were identified.

Reintervention Rate Following Emergency Surgery for Crohn Disease.

Backround/Objective: To assess the impact of emergency surgery and postoperative recurrence in Crohn's disease (CD) and to evaluate the disease course while observing different factors that may influence it. Methods: Information on 37 consecutive patients which were diagnosed and operated in emergency for CD complications and the the relapse rate (regarded as a second surgery) were retrospectively evaluated. Results: The risk of relapse and second surgery was increased in males under 50 years and in those who benefited from an anastomosis during the first invervention while stomy seemed to reduce the rate of surgical relapse. The median duration until relapse was 2,3 years while a percentage of 33% required reintervention. Conclusions: The majority of patients with CD will undergo at least one surgical intervention during their lifetime and one third of them will relapse requiring a second intervention. Although medical treatment has seen great advancements, surgery requirements have remained unchanged as the mainstay treatment in emergent complications of CD. The age of the patients, smoking status and the postoperative medication influence the rate of postoperative recurrence.

Dissection of the Male Urethra Demonstrating Its Topographical Specificity.

The urethra is a long muscular tubular organ that changes its internal configuration as it traverses different regions. Therefore, the pathology of each region is distinctive, and regional characteristics may influence exploration and treatment. We set out to perform detailed dissections of the male urethra and illustrate the regional specificity for each urethral segment. Therefore, we dissected the vesical cervix, showing both the normal appearance and the appearance of prostatic middle lobe adenoma. We dissected the prostatic urethra, showing the seminal colliculus, ejaculatory ducts, and prostatic utricle. We revealed the membranous urethra surrounded by the striated sphincter. We have shown the appearance of the spongy urethral bulb with its cul-de-sac appearance, the aspect of the urethral lacunae, the navicular fossa, and the external urethral meatus. We performed cross-sections through the prostatic urethra as well as dissection of the bulbourethral glands at the level of the urogenital diaphragm. All the information obtained through dissection is illustrated in high-quality graphic form and correlated with clinical applications, making this work valuable teaching material.

Decoding Hepatic Portal Venous Gas: A Case Report.

Hepatic portal venous gas (HPVG) is an infrequent and life-threatening condition with high morbidity and mortality rates, which consists of the presence of gas in the portal vein and its branches. Improvements in imaging technologies have led to the diagnosis of HPVG in less severe circumstances, which, in turn, has only determined a small amelioration of the prognosis. We present a rare case of HPVG subsequent to paralytic ileus in a patient who attained long-term survival after the surgical treatment was performed. HPVG is considered to be associated with sepsis, parietal/mucosal damage, inflammation of the intraperitoneal organs, and meteorism, which may be found in a variety of pathologies. The severity of this pathology depends on the pre-existing conditions of the patients but also on how quickly a treatment plan is established and applied. As a correct and timely diagnosis is crucial for the increase of the survival rate in HPVG, greater attention shall be paid to the clinical manifestations and the differential diagnosis.

Options in Targeted Therapy for Advanced Cholangiocarcinoma: A 2024 Update.

Bile duct carcinomas have a different prognosis and genetic profile depending on their location; intrahepatic/extrahepatic or at the level of the gallbladder. Although in recent years there have been important advances in first-line therapy, second-line therapy in cholangiocarcinoma does not currently have a standard. Therefore at this level, there is an acute need for personalized treatment. The present article is a narrative review that aims to list the newest targeted therapeutic options for this type of cancer, based on identified genetic alterations. The literature selected for analysis includes phase 2 or 3 studies with targeted therapy in this disease and original articles no older than three years that describe the prevalence of the most common gene alterations in this type of cancer. PubMed/Medline, Scopus, and Clarivate-Web of Science databases were searched and keywords such as "cholangiocarcinoma," "biliary cancer," "targeted therapy," "gene amplifications," and "mutations" were used. This narrative review was designed taking into account the SANRA (Scale for the Assessment of Narrative Review Articles) criteria. The conclusions lead to the fact that next-generation sequencing testing is of particular usefulness in cholangiocarcinoma. Bile duct cancers are rich in targetable genetic alterations, and their treatment is in constant change, although much of the current data comes from phase II studies. There is a great need for the current options to be analyzed in phase III studies. Hence, the need of the oncological community to stay informed about targeted treatment options for cholangiocarcinoma is supported by the present article.

Cardiovascular Magnetic Resonance Imaging in Myocardial Disease.

Cardiovascular magnetic resonance (CMR) is the central non-invasive imaging investigation for the evaluation of myocardial disease. It is the well-established gold standard for measuring cardiac chamber volumes, systolic function, and left ventricular mass, and it brings unique information for therapeutic decisions. In addition, its tissue characterization capability, through T1, T2, and T2* mapping, as well as early and late gadolinium enhancement (LGE) sequences, allows to differentiate in many cases among ischemic, inflammatory, and infiltrative heart disease and permits the quantification of myocardial fibrosis, providing valuable diagnostic and prognostic information. This review aims to highlight the main CMR features of different cardiomyopathies.

Laparoscopic Intraperitoneal Onlay Mesh (IPOM) in the Treatment of Ventral Hernias: Technique Discussion Points.

Incisional ventral hernias (IVH) are a common occurrence worldwide. The resolve is fundamentally surgical. In this regard, laparoscopic treatment has become the standard. This paper aims to review intraperitoneal onlay mesh (IPOM) as a surgical solution for IVH and to explore the limitations and advantages in relation to the technique of mesh fixation, defect suture, seroma formation, and recurrence in accordance with the data published. The article is structured as a narrative review and relies on the Scale for the Assessment of Narrative Review Articles (SANRA) convention. In the analysis, we included articles published in the literature regarding the surgical treatment of ventral hernias (umbilical and incisional) through the IPOM technique. We explored data regarding the mesh fixation technique on the anterior abdominal wall (tacks or sutures), indications and limitations of defect closure, incidence of seroma formation, and recurrence rate. Laparoscopic IPOM is a better option for IVH up to 10 cm than the open technique with regard to aesthetics, length of hospital stay, and postoperative pain. There is no difference in recurrence rates. Suturing of the defect should be done to decrease seroma formation and maintain the functionality of the abdominal wall. Ideally, the suture should be done intraperitoneally or laparoscopically. Regarding pain in mesh fixation, there seems to be an increase in the short-term postoperative pain in the suture groups, but at six months, when compared to the tacks groups, there is no difference. New methods are being developed that include different types of glue but require large prospective, randomized trials if they are to be included in the guidelines.

A Review of Neoadjuvant Therapy and the Watch-and-Wait Protocol in Rectal Cancer: Current Evidence and Future Directions.

The treatment of rectal cancer underwent a significant change with the introduction of total mesorectal excision (TME), which substantially improved recurrence rates. However, TME is associated with complications such as fecal incontinence and poor bladder control, especially in tumors located near the anal verge. The watch-and-wait (WW) protocol has emerged as an alternative for patients achieving a clinical complete response (cCR) following neoadjuvant radiochemotherapy. This narrative review, developed according to the Scale for the Assessment of Narrative Review Articles guidelines, evaluates neoadjuvant treatments and the WW protocol for rectal cancer. Literature was sourced from the PubMed database using specific search terms related to neoadjuvant therapy and the WW protocol, resulting in 63 articles selected for discussion. Neoadjuvant treatment, including chemoradiation and short-course radiotherapy, is indicated for T3 and T4 rectal adenocarcinomas. Studies like the German Rectal Cancer Study Group and the PRODIGE 23 trial have shown the benefits of preoperative treatment, including improved disease-free survival and reduced local recurrence rates. However, challenges in adopting the WW protocol include the risk of local regrowth and distant metastasis. Immune checkpoint inhibitors have shown promise in mismatch repair-deficient patients, yet the data are insufficient to fully endorse WW for these cases. The WW protocol is viable for selected rectal cancer patients, with ongoing debates regarding criteria for inclusion. Key challenges include accurately identifying cCR and managing patients with near-complete responses. MRI and endoscopic evaluation are crucial for assessing treatment response, although achieving a pathological complete response remains uncertain. The WW strategy offers a potential organ-preserving approach in rectal cancer management but requires careful patient selection and comprehensive risk-benefit discussions. Further research is needed to refine criteria for inclusion and optimize treatment protocols, enhancing outcomes while minimizing invasive interventions.

Laparoscopic Management of Abdominal Echinococcosis: A Technical Report on Surgical Techniques and Outcomes.

This technical report explores the efficacy and methodology of laparoscopic surgery for treating abdominal echinococcosis, a parasitic infection caused by Echinococcus granulosus. We highlight the zoonotic nature of the disease, which predominantly affects the liver and occasionally other organs, noting the challenge of its asymptomatic progression that complicates timely diagnosis and intervention. We detail our surgical technique using a standard laparoscopy kit to address abdominal hydatid cysts, emphasizing the critical importance of preventing cyst rupture and spillage to avoid recurrence and anaphylactic shock. We discuss considerations for opting for laparoscopy over open surgery, such as reduced postoperative morbidity, faster patient recovery, and lower costs, while also acknowledging limitations like restricted instrument movement and the absence of haptic feedback. We advocate hypertonic saline as the preferred scolicidal agent and strategies to minimize spillage and manage the residual cavity. In conclusion, we assert that laparoscopy offers a viable and effective treatment option for abdominal echinococcosis, emphasizing that optimizing outcomes for this benign condition hinges on careful patient selection and a conservative surgical approach.

Primary Retroperitoneal Hydatid Cyst: A Diagnostic and Treatment Conundrum.

Hydatid cysts are caused by accidental egg ingestion of the Echinococcus granulosus parasite. A 24-year-old female was admitted to our hospital for chronic left lumbar pain. Computed tomography (CT) and abdominal ultrasonography identified an 8/12 cm retroperitoneal cyst. The CT results coupled with enzyme-linked immunosorbent assay tests (positive IgG for Echinococcus granulosus) confirmed that the tumor was a hydatid cyst. Treatment consisted of preoperative chemotherapy with albendazole, intraoperative parasite inactivation, laparoscopic partial cystectomy, and drainage. The drain was removed after three days. Chemotherapy was maintained for two years after surgery. No relapse was observed at the six-month reevaluation. In this article, the diagnostic and therapeutic options and resources are discussed and compared with the published literature.

Axillary Lymphadenectomy: Safe Dissection Through a Correct Technique.

The primary treatment of breast cancer in sentinel-positive ganglia includes axillary lymphatic nodal dissection. The LAD (lymphatic axillary dissection) has decreased in overall numbers but due to the increasing incidence of breast cancer, it is practised on a daily basis, even though there is a myriad of complications such as numbness of the upper limb and chest wall, movement restriction of the upper limb, and chronic pain which appear due to trauma to the nerves which pass through the axilla. However, the utility in the overall survival or DFS (disease-free survival) of the patient is unquestionable.  In our study, through the dissection of cadavers, we exposed the vital structures and the anatomical relations of this region. We aimed to offer a map or technique for the surgeon to follow to decrease the overall morbidity of this procedure.