Single incision laparoscopic surgery (SILS) cholecystectomy. A novel technique.

INTRODUCTION: Since early nineties, laparoscopic cholecystectomy has become gold standard for cholecystectomy. Also, a high tendency of minimizing surgical trauma encourages the use of new approaches in laparoscopic surgery. A novel approach such as Single incision laparoscopic surgery (SILS) cholecystectomy has been describes. CASE REPORT: We report on a case of a 33-year-old female patient scheduled for elective laparoscopic cholecystectomy due to symptomatic ultrasonography verified cholelithiasis. A single 2.5-cm long semicircular infraumbilical skin incision was used. Pneumoperitoneum was established alter introduction of the predesigned trocar. Antegrade cholecystectomy was performed without stay suture placement. Postoperative course was uneventful. DISCUSSION: This article reports the authors' method of performing SILS cholecystectomy. SILS approach is feasible with new standard devices from the industry that offers slightly modified instruments for standard laparoscopic cholecystectomy. CONCLUSION: Single-incision laparoscopic surgery is a feasible way to perform cholecystectomy. A learning-curve is required and further work in the form of randomized controlled trials is needed to investigate the advantages of this new technique.

[Surgical and anesthetic coordination during tracheal and carinal resections and reconstruction]. / Coordonarea timpilor operatori si anestezici în rezectiile cu reconstructie ale traheei si carinei.

A retrospective study of anesthetic and surgical techniques involved in 55 consecutive cases of tracheal and carinal resections completed from 2001 to 2007, is presented. The anesthetic maneuvers and surgical approach differed in relation with the site of the tracheal lesions (upper, middle, lower trachea or carinal), the degree of the obstruction, the emergency of the surgical intervention and the concomitant presence of the eso-tracheal fistula. Ventilatory support during anesthesia involved special equipment adapted to the particular techniques used in this type of surgery. Cross field intubation of trachea or a mainstem bronchus, and High Frequency Jet Ventilation-HFJV- have been frequently used. Perfect coordination of the anesthetic techniques with every surgical step is mandatory and for good long term results special anesthetic equipment and a good preoperative anesthetic and surgical assessment of the strategy is needed.

Intra operative lesion of the pelvic ureter solved in a minimally invasive manner.

Ureteral lesions during open hysterectomy, vaginal hysterectomy or laparoscopic hysterectomy have a rate of 0.2% up to 6%. Multiple complications may occur if the lesion is not recognised intra operatively: hydronephrosis, anuria (bilateral lesion), ureterovaginal fistula, ileus, peritonitis. The rate of recognition of an intra operative ureter lesion is 30% and it could rise up to 90% when cystoscopy with ureteroscopy is used at the end of the intervention. The article presents the case of a 46-year-old patient with uterine fibromatosis, whose pelvic ureter was sectioned during surgery. The lesion was recognised during surgery because, at the end of each intervention, the diuresis was stimulated by injecting Furosemide in order to detect the lesions of the ureters and urinary bladder.

Laparoscopic myomectomy.

Uterine leiomyoma is the most common benign tumour occurring in women in the reproductive age. It is typically found during the middle and later reproductive years. The prevalence quoted in literature ranges from 20-50% based on post mortem studies. The symptoms usually reported by women with fibroids are the following: abnormal gynaecologic haemorrhage, chronic pelvic pain, dyspareunia, as well as urinary and bowel symptoms, urinary frequency or retention and, in some cases, infertility. During pregnancy, premature labor might be caused, interfering with the position of the fetus or abortion could be induced. However, only 30% of the women develop symptoms, most of them being asymptomatic. It was proved that the factors that can cause fibroids are the following: genetic, hormonal, and growth factors, especially transforming the growth factor beta (TGFb)-related cellular changes. As diagnosis tools, studies are revealing that ultrasound has been shown to be an insufficient method of myoma mapping, and magnetic resonance imaging should be preferred for surgical therapy planning. The contour of the endometrial cavity is delineated by using trans vaginal ultrasound and saline infusion hysterosonography, but hysteroscopy is the gold standard to evaluate the uterine cavity.

Comparative study of conventional urothelial carcinoma, squamous differentiation carcinoma and pure squamous carcinoma in patients with invasive bladder tumors.

PURPOSE: Treatment results evaluation (radical cystectomy and adjuvant chemo/radiotherapy) in patients with urothelial carcinoma, squamous differentiation carcinoma and pure squamous bladder carcinoma. MATERIAL AND METHODS: The study included 361 patients with invasive bladder carcinoma treated between 1990-2013. Histology showed 296 cases of urothelial carcinoma (82% - group A), 52 cases of urothelial divergent differentiation (squamous and urothelial carcinoma 14.4% - group B) and 13 cases of squamous cell carcinoma (3.6% - group C). All patients benefited from radical cystectomy. Adjuvant chemotherapy was undergone in 68 patients. RESULTS: Group A - urothelial carcinoma - had a 44% rate of patients alive with a mean survival period of 73 months. About 56% of the patients died, the mean survival period being 4 years. Group B - urothelial carcinoma with squamous differentiation - had a mean survival period of 36 months (between 1-156 months). 17 patients (33%) are alive at 50 months postoperatively. Group C - squamous carcinoma - had a mean survival period of 9.4 months. DISCUSSIONS: Locally advanced disease was diagnosed in 50% of the patients in group A, while in group B the rate was 84.6% and 70% in group C, respectively. CONCLUSIONS: Squamous pattern detected in the histopathological specimen represents a negative prognostic factor. It seems that the squamous component influences the outcome of the disease due to its biological characteristics in the evolution of squamous carcinoma, with advanced local stage disease at diagnosis - late onset of symptoms and lack of response to adjuvant treatment.

Prostate cancer with neuroendocrine differentiation--case report.

RATIONALE: About 95% of prostate cancers are adenocarcinoamas. Depending on the detection method used, neuroendocrine cells are found in 10% to 100% of prostate cancer specimens. OBJECTIVE: A 64-year-old patient was diagnosed in 2006 with adenocarcinoma of the prostate, PSA 4.1 ng/ml, Gleason 6, T3b, positive PSA immunohistochemistry. METHODS AND RESULTS: The patient was started on hormone therapy: orchidectomy followed by flutamide 750 mg/day for three years, and underwent radiotherapy 6400 R. The patient was asymptomatic for three years. In 2009, the patient complained of perineal and rectal pain, but the PSA remained normal. In 2010, the patient underwent TUR of the prostate for acute urinary retention. Pathological exam revealed Gleason 8 adenocarcinoma of the prostate (different pathologist suggested Gleason 9) and foci of neuroendocrine cells. Immunohistochemistry detected 15-20% positivity for Cromogranin A and 10% for synaptophysin. The patient developed multiple liver metastases in October 2010 and underwent five cycles of etoposide, carboplatin. The patient died of liver failure in March 2011. DISCUSSION: Regarding prevalence, neuroendocrine differentiation is the second phenotype after prostate adenocarcinoma, but still remains undiagnosed. It is resistant to radiation therapy and chemotherapy. Detection of the neuroendocrine differentiation is recommended during the clinical, biochemical, histopathological and immunohistochemical follow up of prostate cancer patients treated by EBRT and / or androgen deprivation.

Whole lung lavage for pulmonary alveolar proteinosis after surgery for spontaneous pneumothorax.

INTRODUCTION: Pulmonary alveolar proteinosis (PAP) is a relatively rare lung disorder, probably under diagnosed, characterized by the accumulation of lipoproteinaceosus material in the lung alveoli. The primary (acquired or idiopathic) form occurs in more than 90% of all cases. Whole lung lavage is considered the golden standard of treatment. In this report, we describe a rare case of pulmonary alveolar proteinosis with severe and incapacitating respiratory, in which whole lung lavage followed the thoracotomy for spontaneous pneumothorax. CASE PRESENTATION: A 34-year-old white male patient presented at the respiratory intensive care with severe respiratory failure, aggravated in the last two months, cough, night sweats and important weight loss and left spontaneous pneumothorax. The initial diagnosis of diffuse interstitial pneumopathy was revised to Pulmonary Alveolar Proteinosis after bronchoalveolar lavage. Active pleural drainage of the pneumothorax was unsuccessful and after two months, surgical suture of the lung was performed under general anaesthesia. One month later a whole left lung lavage was performed. The same procedure was also performed on the right lung. Eight months later the patient had a good exercise tolerance, normal arterial blood gas (ABG) values, and persistent ground-glass opacities in some of the pulmonary segments on CT scan. CONCLUSIONS: The most severe forms of pulmonary alveolar proteinosis, in which hypoxemia and cyanosis occur, have a high mortality risk during anaesthesia and whole lung lavage. When a rare complication like spontaneous pneumothorax occurs, the suturing of the pulmonary apical blebs seems to be the only viable solution, despite the high risk of dehiscence of the sutures due to the poor pulmonary tissue integrity at the time of the whole lung lavage and during postoperative care.

[Rare case of multiple pulmonary nodules--a case report]. / Cauza rara de noduli pulmonari multipli--caz clinic.

The article presents the case of a 44 years old female patient admitted in the hospital for a solitary pulmonary nodule discovered through a chest X-ray performed for left thoracic pain. Despite the young age, a lot of comorbidities were present: severe dyslipidemia, ischemic right cerebellar lesion, degenerative periventricular lesions, chronic autoimmune thyroiditis, uterine fibroma, fibrocystic mastitis, polyglobulia of uncertain etiology and Rendu-Osler disease. The investigation which showed the nature of the pulmonary nodule was the CT scan with intravenous contrast, which demonstrated that the nodules were in fact arterial-venous malformations as part of the Rendu-Osler disease. This case offers the opportunity to discuss about etiopathogeny, morphopathology, criteria of diagnosis and treatment principles in Rendu-Osler disease.

Management of small renal masses--update 2011.

RATIONALE: The management of renal parenchymal tumors has known many changes over time, a trend that continues today, as a result of technological advances, clinical research and improved diagnostic and therapeutic tools. Unfortunately, conventional cancer treatments--chemotherapy and radiotherapy have proven ineffective and modern approaches such as immunotherapy, angiogenesis inhibitors, though they enjoyed an initial enthusiasm, subsequent studies have shown limited and controversial effects. Thus, surgery remains the gold standard therapy for this type of cancer. The options for the treatment of RCC are numerous, with options that have advantages and disadvantages, with oncological results, in most cases, positive at five years and with different impact on cancer specific survival. It is difficult to compare the results, as these are different techniques with various instruments and intraoperative steps, with more questionable inclusion criteria, selection biases and prosecution, with a tendency for preferential enrollment, different reasons to why randomized prospective studies have not been performed until today. OBJECTIVE: This article is a review of the diagnosis and methods of treatment of small renal masses 2011. CONCLUSION: At the beginning of the new millennium, kidney cancer, with all the arsenal of techniques and methods of ablative surgery, remains a potentially fatal disease for a high percentage of patients, and the decision to choose a treatment or another should be taken with responsibility, depending on currently existing medical records, the degree of expertise and not based on subjective or other non-standard parameters.

Minimally invasive treatment for female stress urinary incontinence - Romanian highlights.

RATIONALE: Stress urinary incontinence is still a "battlefield" for many minimally invasive therapies, but, unfortunately, few can restore the anatomical and functional background of this disorder. OBJECTIVE: Assessing the latest minimally invasive procedures of intra and perisphincterian injection of autologous stem cells. METHOD AND RESULT: The first stem cell implantation (myoblasts and /or mature fibroblasts grown and multiplied in the laboratory from biopsy samples taken from the pectoralis muscle) in the urethral sphincter was performed on October 18, 2010, in "Fundeni" Clinic of Urology and Renal Transplantation, in Romania. DISCUSSION: The follow-up at six weeks with the quality of life questionnaires, micturition diary and clinical examination revealed a decrease of urine loss from six pads/ day at one per day, which significantly improved the patient's quality of life according to visual analogue scale. Clinical and urodynamic evaluations will continue and will be future scientific topics.

Highlights in the minimally invasive treatment of SUI in women.

OBJECTIVE: Treatment of stress urinary incontinence consists of a wide range of options, from conservative therapies like lifestyle changes, medication, pelvic floor muscles exercises, electro-stimulation, to minimally invasive procedures--injection of collagen, suburethral slings TVT/TOT and last but not least, invasive surgical treatment reserved for recurrent and complex cases. Among the latest minimally invasive procedures reported in literature, the injection of intra-and perisphincterian of autologous stem cell (mioblasts and/or mature fibroblasts grown and multiplied in the laboratory from biopsy samples taken from the pectoralis muscles). MATERIAL AND METHOD: On October 18, 2010, in 'Fundeni' Clinical Institute of Uronephrology and Renal Transplantation was performed the first stem cell implantation procedure in the urethral sphincter, in Romania. RESULTS: Assessment at 6 weeks, the quality of life questionnaires, micturition diary and clinical examination revealed a stunning decrease of urine loss from 6 pads/day at one per day, which significantly improved the patient's quality of life. CONCLUSIONS: Stem-cell-mioblasts therapy may represent in the future an every-day intervention in the urologist's armamentarium. The effectiveness of this treatment can change the course of therapy and last but not least, the accessibility to urological evaluation of patients with stress urinary incontinence. Clinical and urodynamic evaluations will continue and will be future scientific topics.

[Non-Invasive Mechanical Ventilation in COPD exacerbations]. / Ventilatia mecanica non-invaziva în exacerbarile BPCO.

Non-Invasive Mechanical Ventilation (NIMV) is often considered as first indication of ventilatory support in COPD exacerbations. Controlled studies with NIMV performed in specialized centers report avoidance of endotracheal intubation in more than 70% of patients with COPD and ventilatory support, a reduction of time spent in ICU and a mortality of less than 10%. These good results are obtained with a proper selection of patients needing NIMV a well trained personnel, familiarized with the technique of NIMV and the availability of the necessary equipment. The most frequent techniques of NIMV are with facial or nasal masks. For hypoxemic patients oxygen-therapy with helmet can be a good option. The most popular modes of ventilation are those with pressure or volume support. The initial settings of the ventilator (pressure, tidal volume, respiratory rate, PEEP) are dependent on the patients' respiratory pattern, the type of ventilator and the skills of the respiratory therapist.

[Metachronous bronchial carcinoma--three years after right upper lobectomy. A case report]. / Carcinom pulmonar drept metacron--trei ani dupa lobectomie superioara dreapta. Prezentare de caz.

The emergence of a secondary pulmonary neoplasm at some time after the primary one raises diagnostic and therapeutic issues especially in patients with functional respiratory capacities at the limits of resectability. We present the case of a 53 years old patient which suffered a right upper lobectomy three years before for a moderately differentiated squamous carcinoma and in which a second cancer was discovered in the right main bronchus. Para-clinic explorations demonstrated the lack of local and systemic invasion of the second cancer. The optimal therapeutic way is presented and its result, discussing also the means for long term follow-up of the patients operated for non-small cell lung cancer.

[Pulmonary manifestations in a case of toxic shock syndrome]. / Manifestari pulmonare într-un caz de sindrom de soc toxic.

The evolution of a toxic shock syndrome in a young adult has yielded particular pleural and lung lesions concomittantly with phenomena of insufficiency of other organs and systems (kidney, digestive, CNS a.o.). X-ray aspect of bilateral bronchopneumonia with small diffuse infiltrates are noted, together with an aspect of bilateral spontaneous pneumothorax, which appeared successively with a tendency to relapse. Hemodynamic alterings during the acute phase of the syndrome initiated by staphylococcal exotoxin are similar to those during the initial phase of the septic shock, requiring a careful monitoring during the treatment.

[The plurality of risk factors in a case of right-sided pneumonectomy]. / Cumul de factori de risc într-un caz de pneumonectomie dreapta.

A right lung cancer case is presented, aged 65 years, obese, submitted to a right lung resection. Stress is laid on the difficult evolution concerning the haemodynamics and particularly the breathing owing to the association of risk factors.

Biologic variation of human immunoglobulin concentration. I. Sex-age specific effects on serum levels of IgG, IgA, IgM and IgD.

Data on a large, randomly selected population of apparently health subjects, aged 10 to 73 years, of both sexes were used to derive estimates of the reference intervals for serum levels of IgA, IgG, IgM, and IgD. The main effects of age and sex on the mean values were studied by the use of a two-way ANOVA model. Except for IgG that showed no sex dependencies, statistically significant sex and age-related differences in mean levels were found for each of the immunoglobulins studied. The mean concentrations of both IgA and IgD were higher in males than in females; an inverse relationship was identified for IgM. Serum levels of both IgG and IgA rose gradually with advancing age in either sex; by linear-regression analyses these age dependencies were found to be statistically significant for IgG in males and IgA in both sexes. The age-related changes in either IgM or IgD serum levels were more complex and fitteda quintic function better than a linear one. These results indicate that any interpretation of immunoglobulin values without appropriate consideration of the subject's age and sex is likely to be misleading.

[Congenital transdiaphragmatic hernia with a late manifestation]. / Hernie transdiafragmatica congenitala cu manifestare tardiva.

A case of diaphragmatic pathology is presented consisting in transdiaphragmatic penetration of abdominal viscera. It raised problems of differential diagnosis with other intrapleural pathology. X-ray aspects should not be interpreted without including them into the general clinical and laboratory data in order to avoid errors of diagnosis and treatment.

[Treatment methods in multiple hepatic, pulmonary and pleural hydatidosis]. / Particularitati de tratament în hidatidozele hepato-pleuro-pulmonare cu localizare multipla.

The modern treatment of hepato-pleural-pulmonary hydatidosis is based on surgical excision and medical treatment with drugs like: Mebendazol, Albendazol or Praziquantel. There are presented 23 patients with multiple hepato-pleuro-pulmonary hydatidosis, operated in the last 4 years. Surgical excision in pleuro-pulmonary hydatidosis is adapted to cysts topography, aiming to eliminate the intact cysts and to close the remaining cavities.

[First experiences of non-invasive positive-pressure ventilation at home in chronic respiratory failure in Romania]. / Primele experimente de asistenta ventilatorie la domiciliu în insuficienta respiratorie cronica (IRC) din România.

The authors are describing the first two cases of noninvasive positive pressure ventilation at home from our country, applied for chronic respiratory failure, demonstrating the advantages and modalities of approach to tackle this new concept of treatment.

Concentration of serum immunoglobulins in acute and chronic hepatic diseases. I. Serum-levels of IgG, IgA, IgM and IgD in young patients with viral hepatitis.

Concentrations of IgG, IgA, IgM and IgD were measured against WHO Reference Preparation 67/97 and British Standard 67/37 in sera from 105 patients with viral hepatitis and 110 "current" controls. To allow comparison at different ages and between sexes, constants previously determined on sera from a large "laboratory" group of controls were used to calculate "scores" for all Ig values. The patients' IgM scores were remarkably higher than those of controls and were bimodally distributed. About 68% of the patients had IgM scores more than 2 SD above the expected mean for laboratory controls. The distribution of IgG and IgA scores appeared unimodal, but schifted to the right of controls. The mean values of IgG and IgA scores were significantly greater in patients than in controls, and in female patients compared with males. Moreover, 16% (12 of 73) of the male and 47% (15 of 32) of the female patients had Ig G scores more than 2 SD above the expected mean. With regard to IgD, no significant difference between patients and controls was observed.