INSIGHTS ON AROMATASE IMMUNOHISTOCHEMISTRY: VARIATIONS BETWEEN INTRINSIC MOLECULAR SUBTYPES OF BREAST CANCERS.

CONTEXT: Aromatase is a key enzyme in local estrogen production by androgen conversion, especially in women post-menopause. There have been controversies concerning aromatase localization in breast carcinomas and its association with current histopathological variables. MATERIAL AND METHODS: Using polyclonal antibody immunohistochemistry we assessed (by intensity and percentage scores) the immunolocalization of aromatase in 70 tissue samples, and described particularities within the molecular subtypes of breast cancer. RESULTS: Aromatase was found in all tissue compartments: tumor (95.7%), stroma (58.6%) and adipose tissue (94.3%). Aromatase expression in tumor cells correlated inversely with tumor grading (p=-0.361, p=0.027), and positively with estrogen receptor status (ER, p=0.143, p<0.001). Dividing the study group by intrinsic subtypes, a strongly inversely association between tumor aromatase and grading (p=-0.486, p<0.001), and between stromal aromatase and Ki67-index (p=-0.448, p=0.048) was observed in luminal A breast cancer. Tumor aromatase and ER percentage scores had stronger correlations in luminal B HER2 negative (p=0.632, p=0.002), and positive (p=0.324, p=0.026) tumors. In contrast, in triple negative tumors, a positive association stromal aromatase and Ki67 index (p=-0.359, p=0.007) was observed. CONCLUSION: Local aromatase was linked to better tumor differentiation and proliferation in luminal breast subtypes, and not in triple negative cases, suggesting a potential prognostic role of aromatase in breast carcinomas.

Rectal impalement injury: from cruelty to salvage endeavour.

Massive penetrating trauma by rectal impalement is a very rare form of injury, complicated and potentially lethal. It is even rarer for such injury to result in pelvic, abdominal and thoracic internal damages. We report the case of a 62 year-old man who was admitted in emergency after an aggression with a sharp wooden stake inserted forcibly into his rectum. Clinical examination revealed the blunt extremity of the stake outside the anus and the prominent sharp end reaching his right supraclavicular fossa. Radiographic examination showed the stake extending from the rectum to the right side of the neck.Surgery disclosed penetration through the rectum, retroperitoneum,large bowel mesentery, liver, diaphragm, right lung and right 2nd rib. The patient survived following management by a multidisciplinary surgical team. As similar reported cases are scarce, knowledge of the management of the few cases that have been successfully treated is likely to prepare the emergency teams to act rationally and efficiently in such exceptionally grave circumstances.

Allograft inflow - concern in liver transplantation after intraoperative radiotherapy for cholangiocarcinoma.

UNLABELLED: Patients who underwent local radiotherapy during surgical resection for cholangiocarcinoma are at increased risk of developing extensive thrombosis of splanchnic vessels and secondary biliary cirrhosis on the remnant liver; hence they become liver transplantation candidates. In these recipients, adequate graft inflow cannot be provided by conventional liver transplantation procedures. Cavoportal hemitransposition and renoportal anastomosis alongside complex arterial reconstructions are innovative techniques to restore allograft inflow in such cases. We report two cases of hilar cholangiocarcinoma formerly treated by left hepatectomy-Whipple en Bloc and intraoperative radiotherapy that developed late secondary biliary cirrhosis requiring liver transplantation. During transplant procedure, concern has been raised by the previous radiation-induced peritoneal injury with extended splanchnicthrombosis. Cavoportal hemitransposition and renoportal anastomosis were performed respectively, beside arterial graft reconstructions. Patients survived 57 and 18 days respectively, after transplantation. Cavoportal hemitransposition and renoportal anastomosis likewise complex arterial reconstructions are life-saving procedures to secure allograft inflow in the setting of radiation-induced extensive splanchnic thrombosis. However,this condition adversely affects patient and graft survival owing to high rates of early vascular and biliary complications, so these patients are not good liver transplantation candidates. ABBREVIATIONS: CCA - cholangiocarcinoma, CPHT - cavoportal hemitrans position, Ct - celiac trunk, DSVT - diffusesplanchnic vein thrombosis, HA - hepatic artery, IVC - inferior vena cava, LRV - left renal vein, LT - liver transplantation, PV- portal vein, PVT - portal vein thrombosis, RISC -radiation induced sclerosing cholangitis, RISC-BC - radiationinduced sclerosing with biliary cirrhosis, RPA - renoportal anastomosis.

Radiofrequency ablation device assisted liver resection for hepatocellular carcinoma.

UNLABELLED: The present study aim was to evaluate radiofrequency (RF)-assisted liver resection for hepatocellular carcinoma (HCC). PATIENTS AND METHODS: 35 consecutive patients were enrolled in this study. A Habib®4X RF ablation device (RFAD) was used for liver resection. The patients were divided into two groups: in group A (45.7%; n=16) liver resection was performed using the RFD, whereas in group B (54.3%; n=19), liver resection was performed without RFD. The data were analysed for statistical significance. RESULTS: The study population had a male female ratio of 25 10 and a mean age of 62.6 ± 11.6 years old. The mean overall tumor volume was 161.8 ± 35.5 mL and there were no differences in tumor volume between groups. The operative time and intraoperative blood loss were lower in group A,but without statistical significance [132.5 ± 61.5 vs 167.9 ± 46.3 mins, (P=0.061) and 459 ± 342 vs 716 ± 648 mL (P = 0.135)]. No differences were reported between the two groups in operative accidents (P = 0.508) and postoperative morbidity (P=0.782); a higher rate of late postoperative complications was found in group A (56.3% vs. 16.7%, P = 0.016). The overall postoperative mortality rate was 2.8%. Local recurrence was noted in 32.4%. The three-year cumulative survival rate was 60%. CONCLUSIONS: RFAD allows liver resection with low postoperative mortality and morbidity rates; RFD tends to decrease the operative time and blood loss.

Transarticular approach and retrograde plate osteosynthesis (TARPO) using implants with angular stability -- a series of 17 cases of complex distal femoral fractures type C3/AO.

AIM: The aim of this retrospective study was to evaluate the outcome of distal femoral fractures type C3 AO, using TARPO technique and plates with angular stability. MATERIAL AND METHODS: The study included 17 fractures type C3 AO, with 4 open fractures: 1 type I, 1 type II, and 2 type IIIA with bone loss Gustilo. All patients were operated by TARPO technique using Less Invasive Stabilization System-LISS (4 cases), Locked Compression Plates-LCP (8 cases) and plates with polyaxial stability (5 cases). The excellent stability of the construct allowed fast knee rehabilitation. The follow-up period included at least 12 months. RESULTS: 15 fractures healed within a mean time of 12.6 weeks,while 2 cases with open fractures and bone loss required secondary bone grafting. We recorded no infection or implant failures. The outcome using Neer scale was excellent in 9 cases and satisfactory in 7 cases (1 patient with discontinued follow-up). CONCLUSIONS: This demanding TARPO technique has the advantage of a faster rate of union and improved exposure of the knee joint. The locked plates provide a unique alternative in distal femoral fractures type C3 AO, as well as in osteoporotic and open fractures.

Esophagectomy in esophageal cancer - is there an optimal approach?

INTRODUCTION: Esophageal cancer is a public health problem,with increasing incidence and postoperative morbidity over the past recent years. Although a number of new surgical techniques, including minimally invasive surgery, have been developed, mortality and morbidity have remained elevated.The element that seems to influence the early postoperative morbidity and mortality is the method of approach. MATERIAL AND METHODS: retrospective observational study which is carried out in the period 2003-2012 including esophageal neoplasm patients operated in the First Surgical Clinic -Hospital "Sf. Spiridon", Iasi. 140 patients were included, of which only 33 have received surgery with curative aim. SURGICAL TECHNIQUE: we consider 2 techniques in our study:transhiatal (TH) technique (without opening the chest)followed by esophagoplasty with cervical anastomosis and transthoracic esophagectomy (TT) with intrathoracic or cervical anastomosis. RESULTS: We performed 57.58 % (n = 19) of interventions by TT versus 42.42% (n = 14) by TH. The overall rate of postoperative morbidity rate was 78.8% (n = 26). Overall early postoperative mortality rate was 15.5% (n = 5) caused by pleuropulmonary sepsis (2 cases), lung emboli (1 case) and sepsis caused by anastomotic leak (2 cases). CONCLUSION: TT and TH esophagectomy have precise indications in esophageal surgery for malignancies, the mortality and morbidity rate being strongly influenced by the surgical approach.

Modeling realistic synaptic inputs of CA1 hippocampal pyramidal neurons and interneurons via Adaptive Generalized Leaky Integrate-and-Fire models.

Computational models of brain regions are crucial for understanding neuronal network dynamics and the emergence of cognitive functions. However, current supercomputing limitations hinder the implementation of large networks with millions of morphological and biophysical accurate neurons. Consequently, research has focused on simplified spiking neuron models, ranging from the computationally fast Leaky Integrate and Fire (LIF) linear models to more sophisticated non-linear implementations like Adaptive Exponential (AdEX) and Izhikevic models, through Generalized Leaky Integrate and Fire (GLIF) approaches. However, in almost all cases, these models are tuned (and can be validated) only under constant current injections and they may not, in general, also reproduce experimental findings under variable currents. This study introduces an Adaptive GLIF (A-GLIF) approach that addresses this limitation by incorporating a new set of update rules. The extended A-GLIF model successfully reproduces both constant and variable current inputs, and it was validated against the results obtained using a biophysical accurate model neuron. This enhancement provides researchers with a tool to optimize spiking neuron models using classic experimental traces under constant current injections, reliably predicting responses to synaptic inputs, which can be confidently used for large-scale network implementations.

Emergency pancreaticoduodenectomy for bleeding pancreatic pseudoaneurysm in patient with common mesentery and replaced right hepatic artery.

Pancreaticoduodenectomy is infrequently performed in emergency, so much the less in lack of traumatic evidence.A rare vascular complication of the pancreatic pseudocyst,the pseudoaneurysm, presents as a pulsating malformation which may lead to life-threatening bleeding if left untreated.Its optimal treatment remains controversial. Most authors agree that angioembolization is the first step to stabilize the patient's condition, with further surgery if such be the case.We herein report an unusual case of pancreatic head pseudocyst complicated with a bleeding pseudoaneurysm arising from the inferior pancreaticoduodenal artery, in a patient with multiple comorbid conditions, common mesentery,hepatic artery variant and hemodynamic instability. An emergency early retropancreatic approach pancreaticoduodenectomy was performed with uneventful immediate and long-term outcome. We highlight that emergency surgery allowed both rapid control over the bleeding with hemostasis and removal of the pseudocyst. This is particularly relevant in high-risk patients in whom selective angioembolization is no more of choice.

Atypical hepatic resection technique for hepatocellular carcinoma using radiofrequency Habib™ 4X Device.

INTRODUCTION: The number of liver resections significantly increased worldwide in the last 20 years. In many hepatic tumours, liver resection remains the best therapeutic option. A difficult intraoperative goal is to obtain a safe haemostasis on the transection plane. Technological innovation in recent decades allowed the development of different tools that allow better control of bleeding, faster and easier haemostasis. METHODS: We prospectively reviewed the patients diagnosed with hepatocellular carcinoma who underwent an atypical liver resection using a radio frequency (RF) ablation. SURGICAL TECHNIQUE: We used a Habib™ 4X bipolar, handheld, disposable RF ablation device. The technique is similar to parenchymal approach, but after the operative ultrasound exam to confirm the tumour and resection plane and liver mobilisation, we perform a plane of coagulative necrosis around the tumour using Habib™ 4X. The parenchyme is then sectioned using the scalpel. RESULTS: 19 patients with hepatocellular carcinoma were included in this study. The mean operative blood loss volume was 170±90.7 ml. The mean operation time was 118±58 min. The postoperative morbidity rate was 32% (n=6) and the reintervention rate was 5.3% (n=1). We encountered no postoperative deaths. The overall mean postoperative stay was 11.6±5.1 days. CONCLUSION: Bipolar radiofrequency device Habib™ 4X allows a shorter operative time with minimal blood loss and low rate of morbidity and mortality.

Laparoscopic approach to ovarian dermoid cysts.

INTRODUCTION: Ovarian dermoid cysts (mature cystic teratomas) are a benign type of germ cell tumours and the most common ovarian neoplasms in women of fertile age. The aim of this study was to analyze the safety of the laparoscopic approach in ovarian dermoid cysts. METHODS: We performed a prospective study between 2006 and ' 2010 including 38 mature cystic teratomas treated either laparoscopically or by open access. All preoperative and postoperative data were included in an MS Access database and statistically analysed with SPSS v. 17 for Windows. RESULTS: The study group was divided into 2 subgroups according to the approach: laparoscopic (25 cases - 2 conversions) and classic (13 cases). The mean age of the patients was 40.34 years (range 19-74): 36.92 years for laparoscopic group and significantly higher 46.21 years for open approach group. Twelve cases were admitted as emergencies either because of complications (torsion or rupture of the teratoma) (11 cases) or associated with acute appendicitis (one case). The latter did not influence the decision for open or laparoscopic approach. Only 29 out of 38 cases had preoperative measurement of CA 125. CA 19-9 was performed in 27 cases and elevated levels were found in 21 cases (78%). Cysts over 10 cm presented higher values of CA 19-9. The mean cysts diameter was 11.29 cm (range 2-27 cm): 13.93 cm mean cyst diameter for open approach vs 9.75 cm for laparoscopic approach. The specimen removal required aspiration of the content for cysts bigger the 10 cm in laparoscopic approach. Mean hospital stay was 4.05 days (range 2-6 days) for the laparoscopic group, significantly lower when compared with the open approach group: 6.96 days (range 5-16 days). CONCLUSIONS: Laparoscopic management of ovarian dermoid tumours is a safe and efficient procedure. It does not increase complications rate in comparison with the open approach, offering a shorter hospital stay, a quick recovery and very important, it allows a conservative treatment, especially in premenopausal women who want to be pregnant.

Laparoscopic retrieval of gossypibomas--short series and review of literature.

UNLABELLED: Laparoscopic removal of retained abdominal foreign bodies represents an obscure domain of minimally invasive surgery. Although not an infrequent situation in general surgical practice, there are very few papers presenting laparoscopic approache in these circumstances. An iatrogenic foreign body following surgery, is a serious complication that may lead to medico-legal problem. We present our experience and a literature review. METHODS: In the last 20 years 48 patients with abdominal foreign bodies were referred to us. Out of these four gossypibomas were managed laparoscopically. RESULTS: Retained swabs represent the most common iatrogenic abdominal foreign bodies. Removal of gossypiboma present more problems in laparoscopic environment due to encapsulation and difficulties in localisation, as retained swabs unusually display radio-opaque markings. There was one conversion due to dense adhesion to the gastric wall. Postoperative recovery was uneventful in all cases. CONCLUSIONS: Gossypibomas, among abdominal foreign bodies, represent a certain reality with significant legal implications. Prevention should prevail and all efforts should be made in such respect. Laparoscopic approach is possible in selected cases (small swabs, encapsulated, no complications).

Laparoscopic adrenalectomy for large solid cortical tumours--is it appropriate?

BACKGROUND: Laparoscopic adrenalectomy, the procedure of choice for small benign adrenal tumours, is also used for large tumours. Our study aims to assess the outcome of large adrenal tumours laparoscopically resected. METHODS: All patients with laparoscopic adrenalectomy performed in between 2002 and 2009, without preoperative or intraoperative malignant characteristics, were reviewed. Clinical, biochemical and CT follow-up data were reviewed for evidence of recurrent disease. RESULTS: Fifty patients underwent laparoscopic adrenalectomies in our unit, 18 of them having solid cortical tumours > or = 7 cm without preoperative or intraoperative malignant features: 6 Cushing's syndrome tumours, 8 non-secreting tumours, 4 aldosteronomas. The mean age of the patients was 46.89 years (range 22-64 years), and the mean tumour size 7.57 cm (range 7-9.1 cm). Histology identified 10 cortical adenomas, 4 malignant tumours, and 4 indeterminate tumours. The mean - follow-up was 28.94 months (range 4-58 months). Three patients died of systemic recurrent disease (liver and lung metastases) at 12, 19 and 21 month, respectively, after operation. One patient underwent a left hepatectomy for liver metastases, 33 months postoperatively. Fourteen patients have no evidence of recurrence. CONCLUSIONS: Adrenal tumours > or = 7 cm without pre- or intraoperative evidence of malignancy are resectable laparoscopically. This approach is unlikely to worsen the long-term outcome. The mortality is related to the malignancy.

Laparoscopic surgical education--the experience of the first surgical unit Iasi.

The classic apprenticeship model for surgical training takes place into the operating theater under the strict coordination of a senior surgeon. During the time and especially after the introduction of minimally invasive techniques as gold standard treatment for many diseases, other methods were developed to successful fulfill the well known three stages of training: skill-based behavior, rule-based behavior and knowledge-based behavior. The skills needed for minimally invasive surgery aren't easily obtained using classical apprenticeship model due to ethical, medico-legal and economic considerations. In this way several types of simulators have been developed. Nowadays simulators are worldwide accepted for laparoscopic surgical training and provide formative feedback which allows an improvement of the performances of the young surgeons. The simulators currently used allow assimilating only skill based behavior and rule-based behavior. However, the training using animal models as well as new virtual reality simulators and augmented reality offer the possibility to achieve knowledge-based behavior. However it isn't a worldwide accepted laparoscopic training curriculum. We present our experience with different types of simulators and teaching methods used along the time in our surgical unit. We also performed a review of the literature data.

[Small bowel tumours from barium meal to capsule endoscopy and from open to laparoscopic approach]. / Tumorile intestinului subtire de la tranzitul baritat la enteroscopie, de la abordul clasic la cel laparoscopic.

INTRODUCTION: Tumors of the small bowel are rare and present with nonspecific symptoms. That causes a significant delay in diagnosis and consequently a worse outcome for the patient. METHODS: In a retro-prospective study we evaluated a series of 63 patients with small bowel tumors operated in the First Surgical Clinic Iasi, during 1992-2010: 18 duodenal tumors, 26 jejunum tumors and 19 ileum tumors. There were 18 (28.6%) cases with benign tumors and 45 (71.4%) cases with malignant tumors (41 primary tumors and 4 secondary tumors). We discuss problems related to diagnosis, treatment and prognosis of these tumors in the presence of new explorations (capsule endoscopy, enteroscopy) and minimally invasive approach. RESULTS: Duodenal tumors were malignant in 14 cases (11 adenocarcinomas, 3 malignant GIST tumors) and benign in 4 cases (adenoma, lipoma, GIST tumor, schwannoma) which led to stenosis in 5 cases, upper gastrointestinal bleeding in 3 cases. Positive diagnostic was confirmed with barium meal and endoscopy. The jejunal and ileal tumors were mostly malignant 31 cases (13 carcinomas, 10 lymphomas, 2 malignant GIST and one sarcoma) with only 14 cases of benign tumors (5 GIST). Their tendency was to present as emergencies: 17 obstructions and 5 peritonitis. Modem imagistic proved useful as diagnostic tool: capsule endoscopy, CT-scan and enteroscopy. The benign tumors benefited from local resection (5 cases) and segmental enterectomy (12 cases), while malignant tumors were managed using Whiple's procedures (10 cases), duodenal-jejunal resections (1 case), segmental enterectomy (29 cases), ileocolectomy (2 cases) and three bypasses. Laparoscopic approach was performed in 8 cases. CONCLUSIONS: The incidence of small bowel tumors remains low. For diagnosis, CT-scan, enteroscopy and capsule endoscopy are very useful; unfortunately the last method is not practicable in emergency. Surgery is the best choice plus chemotherapy for some malignant tumors. Laparoscopic approach is feasible in selected cases.

[Gossypiboma--retained textile foreign body]. / Corpi straini textili restanti postoperator.

UNLABELLED: INTRODUCTION, HISTORY: Increasing complexity of modem surgery is accompanied by the emergence of very different possibility of errors; one of the oldest and most obvious errors is the foreign body forgotten inside the patient. Surgeons worldwide have reported this incident since the first record by Wilson in 1884. DEFINITIONS: Over time, different terms have been used for retained textile foreign body (RTFB), with various etymologies, sometimes controversial: gossypiboma is the latest in this line. EPIDEMIOLOGY: Various studies indicate the incidence of RTFB in range of 1:833-1:32.672; this expresses the difficulty to determine precisely due to complex causes. In our unit the incidence is 1:15.047. RTFB occur after operations on any cavity or organ (operations on the abdomen 56%, pelvis 18%, thorax 11%, orthopedic, neurosurgical, cardiovascular, etc.), at all ages and both sexes. DIAGNOSIS IS VARIABLE: from a loud postoperative evolution, with fever, suppuration of the wound, fistula tracks, spontaneous erosion into various hollow organs to a long asymptomatic period. Imaging diagnosis is difficult and requires RTFB inclusion in the differential diagnosis of patients with a history of surgery. Treatment involves a patient's informed consent and an adjustment to a case: removal of RTFB and individualized treatment of any associated injuries (abscess, fistulas, adhesions, remaining cavity, foci of bone lysis) or just monitoring. PREVENTION: From the theory of "bad apple" (mistake of an incompetent doctor) we moved forward to address systems that often contain latent errors whose summation results in the unfortunate incident. Various national authorities have issued regulations to prevent RTFB, based on counting compresses, intra-/postoperative radiography, marking compresses with two-dimensional matrix label or radio frequency identification. CONCLUSIONS: RTFB, no matter how exotic we name it, remains an unfortunate incident with serious consequences for patient and surgeon alike. The introduction of new technologies can help create a safer environment in the operating room, but beyond that the human factor implies the presence of variables difficult or impossible to control.

Treatment of gastrointestinal stromal tumors--initial experience.

BACKGROUND: Gastrointestinal Stromal Tumors (GIST) offered the first opportunity of a specific treatment in neoplasms (tyrosine-kinase inhibitors) and also a new perspective of management of other neoplasms. METHODS: We have prospectively recorded the clinical characteristics, type of surgery, pathologic findings, adjuvant treatment, and recurrence of the patients with confirmed GISTs admitted between January 2004 and December 2008. RESULTS: There were 18 patients. Location of the tumor was gastric (44.44%), duodenal (11.11%), jejunal (16.67%), right colon (5.55%) and rectal (22.22%). None of our patients had clinical, imagistic or macroscopic metastases. All the patients had R0 resections, except a patient with local excision and another with R1 anterior resection for rectal GISTs. Postoperatively, 4 patients received Imatinib therapy. The mean follow-up period is 32 months (range 8-58 months); 2 recurrences, both after rectal GISTs. The rest of patients are tumor-free and subjects of prospective follow-up. CONCLUSION: We present the first 5 years experience of a prospective study of GIST started in 2004. The complete resection and the malignant potential according to Fletcher index are the most significant prognostic factors. Imatinib treatment may improve outcome in incomplete resected or high risk GISTs.

Acute appendicitis--open or minimally-invasive approach?

BACKGROUND: Although laparoscopy has become the standard approach in other procedures, this technique is not generally accepted for acute appendicitis. AIM: To evaluate the results after minimally invasive appendectomies. METHODS: All medical records of patients operated for acute appendicitis during the last year were retrospectively reviewed. We considered only patients with diagnosis of acute appendicitis confirmed by histopathology. We designed two groups: operated by open approach (OA) and operated by minimally-invasive approach (MIA). The two groups were compared for differenced in homogeneity and main end results: morbidity, mortality, hospital stay. RESULTS: The men/women ratio was 112/88 (1.27), with a mean age of 31.83 +/- 1.06 years. There were more women in the MIA and more men in the OA group, p = 0.001. The Alvarado score was significant lower in MIA group (5.69 +/- 0.24 versus 6.57 +/- 0.23, p = 0.009). Comorbidities were noted in 51% from the patients, most of them in MIA group: 58.8%; N = 60, p = 0.016. Mean operation time was similar in both groups: 36.96 +/- 1.48 in OA versus 37.03 +/- 1.39 minutes in MIA. The postoperative mortality rate was 0.5%. The postoperative morbidity rate was 12%. Even though the number of cases with postoperative complications were double in OA group (16 cases versus 8 cases in MIA group) it did not reach statistical significance, p = 0.073. Histopathological examinations revealed early acute appendicitis in 45.5% cases (N = 91), suppurative appendicitis in 46.5% (N = 93) and gangrenous appendicitis in 8% (N = 16); early acute appendicitis was more frequent in MIA group and suppurative appendicitis in OA group: p = 0.017. The hospital stay was similar in both groups: 4.34 +/- 0.39 in OA versus 3.58 +/- 0.25 days in MIA group; p = 0.103. CONCLUSIONS: MIA is a safe procedure and can be performed even in the patients with comorbidities. We didn't find any statistical significant difference from point of view of postoperative morbidity; however more postoperative complications were find in OA vs MIA group. The postoperative hospital stay was similar in both groups.

Palliative gastrectomy in patients with stage IV gastric cancer--our recent experience.

BACKGROUND: Patients with metastatic gastric cancer are usually not good operative candidates. Recent improvements in surgical techniques allowed palliative gastric resection and other surgical procedures. METHOD: We have examined the place of palliative gastrectomy and its impact on survival in stage IV gastric cancer patients admitted in 2003-2008 period. RESULTS: From a total of 295 patients with gastric cancer, we found 140 patients with stage IV disease; 85 of them had no resection (45 received only chemotherapy) and 55 underwent palliative gastric resection with or without postoperative chemotherapy. Mean survival in non-operated patients with chemotherapy alone was 6.4 months, not significantly different to that of the patients with palliative surgery alone (8.9 months). The group with palliative surgery and adjuvant therapy had a significantly better mean survival (17.8 months). Mortality and morbidity rates associated with palliative surgery were 9% and 34.5%, respectively. CONCLUSIONS: These data suggest that palliative surgery associated with adjuvant chemotherapy can improve survival in patients with stage IV gastric cancer.

Peritoneal tuberculosis in laparoscopic era.

UNLABELLED: Peritoneal tuberculosis is uncommon in developed countries, but as the general incidence of tuberculosis is on the rise in Romania so is the case with peritoneal localization of the disease. The present study retrospectively analyzed 18 patients (8 males and 10 females, mean age 50 years, range 17-74 years) diagnosed in our department with peritoneal tuberculosis between 1995 and 2007. RESULTS: Ascites was present in all but one case. Other common findings were weight loss (12 cases), weakness (5 cases), abdominal pain (16 cases), anorexia (6 cases) and night sweat (3 cases). Abdominal ultrasound has been used to demonstrate ascites in 16 cases. Only two patients had chest radiography suggestive for active tuberculosis. Laparotomy was performed in four cases, laparoscopy in 14 cases (two conversions). Intraoperative findings included multiple diffuse involvements of the visceral and parietal peritoneum, white "miliary nodules" or plaques, enlarged lymph nodes, ascites, "violin string" fibrinous strands, and omental thickening. Biopsy specimens showed granulomas, while ascitic fluid showed numerous lymphocytes. We conclude that the symptoms of abdominal tuberculosis vary greatly, and laparoscopy can be essential for diagnosis and management. The operation is safe, reliable with few complications and permits a prompt diagnosis, necessary to cure the patient.

[Present trends in abdominal actinomycosis]. / Tendinte actuale în actinomicoza abdominala.

BACKGROUND: Actinomycosis is a chronic infectious disease caused by bacteria in the Actinomyces genus. The pathologic, clinic and imagistic polymorphism and the rare incidence of this disease make it so frequent misdiagnosed. MATERIAL AND METHOD: Single unit retrospective nonrandomized clinical study on over 40 years of experience in diagnosing and treating abdominal actinomycosis. RESULTS: First case of abdominal actinomycosis was diagnosed in our clinic in 1968. During the next 36 years, between 1968 and 2004, there were registered only 3 cases, all ileo-cecal actinomycosis. In the next 3 years interval, 5 more cases were diagnosed: 4 associated with intrauterine devices (IUDs) and 1 associated with intraperitoneal remnant calculi after laparoscopic cholecystectomy. We present these last 5 cases, the first 3 having been reported elsewhere. CONCLUSIONS: Abdominal actinomycosis is a rare disease, with variable and deceiving clinical and imagistic characters. In Romania we witness a shift in the epidemiology of this disease as a result of the introducing of the IUDs for the first time after 1990. Confronted with a female patient carrying an IUD that has an inflammatory and a pelvic tumoral syndrome of variable intensity, one should consider also the diagnosis of abdominal actinomycosis. Preoperative establishing of this diagnosis may allow, by a long antibiotic therapy, the elimination of the need for surgery or at least the decrease of its limits. A very rare cause of intraperitoneal actinomycosis is intraperitoneal gallstones remnant after laparoscopic cholecystectomy. To our knowledge, our case is the first reported in the medical literature.