Breast-conserving surgery in breast cancer.

The breast cancer treatment is based nowadays on new surgical options: breast-conserving surgery, which applies at least for the first and second stage cancer, with radical intention. We have been practicing breast-conserving surgery for the last 16 years and we have performed 303 breast conserving operations from a total of 673. We recorded 12 local recurrences (3,96%) and 2 deaths due to cancer progression. Our protocol includes removal of the primary tumor with enough surrounding tissue to ensure negative margins of the resectable specimen, associated with axillary lymph-node dissection and postoperative breast irradiation. Our oncologist indicated chemotherapy on different postoperative conditions: tumor size, axillary lymph node involvement, patient's age, etc. The purpose of this paper is to emphasize our modest experience, nevertheless to draw the attention on important results, obtained by long-term monitoring of the patients who underwent breast-conserving surgery, in a two prospective protocols, and demonstrate the importance and applicability of breast conserving therapy. The conclusion of this study is that breast-conserving surgery followed by breast irradiation is reliable, as the results are similar with radical mastectomies; the main objective is to obtain a good cosmetic result, which depends on tumor size / breast size.

[Diseases mimicking advanced-stage epithelial ovarian cancer]. / Afectiuni mimând cancerul ovarian epitelial în stadiu avansat.

This paper draws attention towards 3 cases with different pathologies all of which suggesting however both clinically and by imaging means as the most likely diagnosis advanced-stage epithelial ovarian cancer since all these three postmenopausal women had been admitted to the hospital with ascites, pelvic masses and deterioration of the physical wellbeing (fatigue, decreased appetite, weight loss, pallor). Findings during exploratory laparotomy on all these three pacients included ascites (hemorragic in one case) diffuse tumorous implants throughout the abdominal and pelvic peritoneal surfaces (in two cases) and the ovarian tumour. Postoperatively, the final histopathologic diagnoses consisted of primary peritoneal carcinoma (one pacient), peritoneal tuberculosis (TB, one pacient) and hepatic cirrosis with an incidental benign adnexial mass (one pacient). Moreover, nonmalignant ovarian tumours were certified in all three cases under current presentation. The differential diagnosis of the ovarian cancer and a tailored approach to treatment for each of these three pathologic entities will also be described in detail.

[Correlation of adenomatous polyps and early colorectal cancer. Diagnostic and therapeutic implications]. / Relatia polip adenomatos--cancer colorectal precoce. Implicatii diagnostice si terapeutice.

AIM: To detect the patients with colorectal adenomatous polyps or those with adenocarcinoma areas with a view to prevent and to treat the malignant disease. MATERIAL AND METHOD: A prospective study including 309 patients hospitalized between 2000-2005 diagnosed with isolated adenomatous polyps after repeated colonoscopies. The research method was selective screening with identification of risk factors regarding the evolution of colorectal polyps in early cancer, using colonoscopy and histopathological examination. RESULTS: We identified 464 single or multiple isolated polyps of which 399 were adenomas, 59 hyperplastic polyps and 6 other types of lesions. Histologically we recorded 41 (13.27%) polyps with a low grade of dysplasia, 56 (18.12%) with severe dysplasia and 30 (9.7%) intramucosal adenocarcinoma with submucosal invasion. TREATMENT: Colonoscopic polypectomy was used for benign polyps and in situ carcinoma. In case of adenocarcinoma is probable the invasion of submucosal lymphatics being shown a colorectal resection as appropriate. We performed 279 colonoscopic polypectomies and 30 conventional resections. CONCLUSIONS: High grade of dysplasia, the number of polyps, ulceration, bleeding, intraepithelial areas of neoplastic transformation are predictive factors for early colorectal cancer. Depth of submucosal invasion of malignant transformed polyps are important pathological factors to predict lymphatic metastasis and to select the therapeutic procedure.

[Stress urinary incontinence. Diagnostic and therapeutic aspects]. / Incontinenta urinara de efort. Aspecte diagnostice si terapeutice.

OBJECTIVE: The paper analyses the incidence, diagnosis and treatment options available for stress urinary incontinence (SUI) in women with pelvic floor dysfunction admitted to Craiova's Surgery Clinic IV. METHODS: This is a retrospective 10-year study comprising a surgical cohort of 420 patients with significant enough to alter quality of life SUI associated to ureterocele and cystocele and in 353 cases with rectocele too. The highest incidence of SUI was encountered between 50 and 59 years of age (range 39 - 81 years). In 21 of this case series the diagnosis of SUI was established soon after the surgical repair of the urethro-cystocele. The diagnosis of SUI was based on careful history and physical examination with emphasis on the gynecologic survey of the abdomen and pelvis but in the absence (for objective reasons) of urodynamic testing which is especially useful for SUI pathophysiological evaluation and thus surgery success rate prediction. All our 420 severe SUI associated with vaginal wall hernias underwent surgical treatment by either open Burch retropubic urethropexy or anterior colporraphy. RESULTS: Among anterior colporraphy treated patients SUI persisted in 19.3% of the cases (33 patients). Complications of Burch urethropexy procedure (despite its high ability for cure) in our case series include: urinary retention, hemorrhage into the space of Retzius, intraoperative injury to the bladder and long-term postoperative incisional hernia. Moreover, 5 patients (2%) of the group who underwent Burch operation were readmitted with recurrent urinary incontinence between 2 and 6 months after the aforementioned surgical intervention despite its good anatomical results in all of these cases. CONCLUSIONS: SUI is a prevalent disorder of women that can be diagnosed easily with history and physical exam. If symptoms persist and severely affect quality of life, despite modern noninvasive treatments, several surgical procedures are now available.

[Postoperative biliary peritonitis--diagnosis and treatment difficulties]. / Peritonitele biliare postoperatorii--dificultati de diagnostic si tratament.

AIM: To point out the severity of the postoperative biliary peritonitis (PBP) and to established the most proper ways of diagnosis and treatment. MATERIAL AND METHODS: 14 PBP (6 males and 8 females, age between 42 and 76 years) admitted in the last 14 years were analyzed. The PBP occurred after biliary surgery in 13 cases and after gastro-duodenal surgery in 1 case. The delay between the first operation and the establishing of the diagnosis and reoperation varied between 24 hours and more than 3 days. All the patients were operated on; the operation had to fulfill 2 main objectives: the treatment of the peritonitis and to solve the biliary lesions. RESULTS: 6 patients had a fair evolution. We registered 8 complications with a morbidity rate of 57,14% and 2 deaths with a mortality rate of 14,3%. CONCLUSIONS: 1. Postoperative biliary peritonitis is one of the most severe complications of the biliary and gastro-duodenal surgery, due to preoperative unrecognized biliary lesions or occurring as postoperative accidents or complications. 2. The clinical picture, deeply modified by the complex postoperative treatment makes the early diagnosis very difficult and leads to a delay of the re-operation. 3. The treatment is exclusively a surgical one, with two main objectives: the biliary lesion repair and the treatment of the peritonitis. 4. The postoperative biliary peritonitis are charged by a high postoperative morbidity and mortality rate, the delay of the diagnosis and the time of reoperation being the main risk factor.

[The experience at the 4th Surgery Department of the University Hospital C.F. Craiova in the surgical treatment of inguinal hernia]. / Experienta Clinicii Chirurgicale IV a Spitalului Universitar C. F. Craiova în folosirea plaselor sintetice în tratamentul chirurgical al herniilor inghinale.

This paper aim is to present the experience of Surgery Department IV of University Hospital C. R. Craiova in groin hernias treatment using prosthetic meshes, also describing an original technical procedure of mesh-plasty that we have been practicing successfully in our clinic. The study is based on a number of 1757 groin hernias operated in Surgery Department IV of University Hospital C. F. Craiova during a period of 11 years (1993-2003). There have been used prosthetic meshes in a number of 230 hernias operated for the most part in the last years since mesh repair has become habitually. We have been using so far only prosthetic mesh made in Romania (polyester mesh). We had a single recurrent hernia and the immediate complications were minimal. The study refers us to practice prosthetic mesh repair in an extensive way and offers a technical alternative in using of prosthetic meshes by a simple and efficient procedure with good postoperative results.

[The mirage of the first lesion (gallstones) and laparoscopic cholecystectomy are able to defer the diagnosis of colon cancer]. / Mirajul primei leziuni (litiaza veziculara) si colecistectomia laparoscopica pot întârzia diagnosticul de cancer colic.

The study's aim was to analyze a series of colon cancer cases in which the mirage of the first (clinically most obvious) lesion (gallstones) along with its minimally invasive approach - that explored only the biliary disease - had contributed to the delay of large bowel malignancy' diagnosis and treatment. 1327 patients aged between 17 and 83 years and diagnosed with cholecystolithiasis were operated upon laparoscopically in the Department of General Surgery of Craiova CFR University Hospital from 2000 through 2004. Four out of these 1327 patients (0,3%) were readmitted with the diagnosis of colon carcinoma between 1 and 16 months after the laparoscopic cholecystectomy. Our retrospective study gives a full report on these 4 cases insisting upon the links between their clinical - laboratory evaluations and final diagnosis. Despite the low laparoscopic cholecystectomy overlooked colon cancer' incidence it seems reasonable to both improve the technique of peritoneal cavity exploration during this type of surgery and extend the preoperative evaluation whenever the slightest suspicion of associated pathology is raised especially in patients over 50 years of age.

[Primary retroperitoneal tumors--diagnostic and therapeutic difficulties]. / Tumorile retroperitoneale primitive--probleme de diagnostic si tratament.

This paper emphasizes the diagnosis and therapeutic difficulties in primary retroperitoneal tumors. There were analyzed 68 primary retroperitoneal tumors (1992-2002): 16 (23.5%) benign tumors, 39 (57.35%) malignant tumors and 13 tumors with unknown histological structure. The preoperative diagnosis was clinically suggested and confirmed by ultrasound and CT examination; the operability was always established by laparotomy. All cases were operated on: complete resection of tumor was possible in 39 cases (57.35%); partial resection in 11 cases (16.17%) and 18 (26.47%) cases were inoperable. There were 5 major intraoperative vascular lesions: 1 inferior vena cava lesion, 1 superior mesenteric vein lesion, 1 left common iliac vein lesion and 2 lumbar artery lesions. Postoperative mortality was represented by 2 cases. Postoperative complication was represented by 3 postoperative hemorrhages, 2 severe pulmonary infections, 1 postoperative evisceration, 1 postoperative acute pancreatitis and 1 acute myocardial infarction. In conclusion the primary retroperitoneal tumors represent a challenge for all surgeons, especially due to surgical approach difficulties, because of problems in tumors intraoperative exploration and resection and because of difficulties in hemostasis.

[Plastic repair with Plastex-type synthetic mesh in abdominal wall defects]. / Plastia cu plasa sintetica tip "Plastex" în defectele parietale abdominale.

This paper analyses a statistical series of 53 patients suffering from single or multiple abdominal wall defects and who were managed by plastic surgery with Plastex type synthetic mesh. Our results are pleading for the extension of the indications of Plastex mesh buttressing surgery beyond the usual recurrent "hernia" cases to the patients admitted with nonrecurrent either large abdominal wall defects or, and poor-quality musculoaponevrotic parietes of the abdominal wall. Our study recorded recurrence and postoperative morbidity rates have been minimal due to both a correct selection of cases for this type of surgical repair and an adequate patient preoperative management in which antibiotic and thromboembolic prophylaxis have been applied on a regular basis.

[Acute necrotizing enterocolitis in an adult--a clinical study]. / Enterocolita acuta necrozanta la adult--studiu clinic.

The authors retrospectively reviewed 24 cases of necrotizing enterocolitis, in which the diagnosis was made or confirmed intraoperatively. This article points to the complex pathophysiology and preoperative diagnostic difficulties of necrotizing enterocolitis due to its clinical heterogeneity and lack of specificity of the laboratory findings. Given all these preoperative problems quite too often the best operatory moment is los and despite the somehow simple intraoperative diagnosis and the modern, well established surgical principles: resection of the necrotic segment with secondary reanastomosis (whenever possible), the post-therapeutic mortality rate remains disappointingly high (70.8%).

[Tuberculous perforation of the small bowel]. / Perforatii intestinale de cauza tuberculoasa.

The authors present their experience with two cases of acute peritonitis scattered characteristic lesions were secondary to the tuberculous of the bowel. It is noteworthy, as far as these two cases are concerned, the rarity of intestinal tuberculous fistulation occurrence in addition to the peculiarity of both their preoperative course with its related diagnostic and operative timing difficulties and their postsurgical recurrent perforation complicated evolution. This article also pin-points the special management problems due to the gravity of these cases.

[The primitive gastric non- Hodgkin lymphoma]. / Limfomul gastric primitiv non-hodgkinian.

THE PURPOSE: Of this work is to point out diagnostic problems together with the surgical indications in primitive gastric non-Hodgkin Lymphoma (LGNH). THE MATERIAL AND METHODS: Consist of 11 cases of LGNH (3.09% of 350 gastric cancers that underwent surgery between 1991-2000) of which 4 were women and 5 men, of an average 53 years of age. Three of the cases underwent surgery for various complications (HDS, perforation and pyloric stenosis) or for other clinical forms such as the pseudo-ulcerative one (4 cases) and the gastric carcinoma mimicking form (4 cases). Preoperative diagnosis was established by means of endobiopsy in 5 cases. SURGICAL TREATMENT: total gastrectomy (4 cases), inferior polar subtotal gastrectomy (5 cases) and 2/3 gastric resection (2 cases). RESULTS: Complications involving sub-phrenic abscess that triggered re-intervention in 2 cases; no immediately postoperative mortality. THE DISCUSSIONS AND CONCLUSIONS: Are enumerating the difficulties we encountered in diagnosing the cases and especially in the preoperative histologic diagnosis, the staging of the disease and setting the treatment with an emphasis on the surgical treatment. THE COMPLICATIONS: Induced by the disease, the diagnosis uncertainty and the early stages of the disease are as many eligible indications for the first linje surgical treatment in LGNH.

[A plea for the conservative treatment of breast cancer]. / Pledoarie pentru tratamentul conservator al cancerului de sân.

This article is a plea for the implementation of early-stage breast cancer conservative therapy into as many surgical clinics as possible. The aforementioned statement relies mainly on published papers and data (the protocol included) provided to us by Instituti Clinici di Perfezionamento di Milano experts in breast cancer conservative therapy and to a lesser extent on our not too numerous results (30 cases) obtained over the past 2 years since we applied the Milano protocol on a regular basis. Thus we support the view that the breast-conserving treatment is suitable for clinical stage I or II carcinoma whose tumors are 3 cm or less in greatest diameter, provided axillary lymphadenectomy is associated for prognostic and future management guidance reasons, but not for cure. Breast-limited postoperative radiation treatment is foremost aimed at local recurrences rate reduction without significantly influencing survival rate. Postoperative chemotherapy, indicated for node-positive patients and/or primary tumors over 1 cm in greatest, diameter, has been proved to contribute to long-term survival rate. However, both the small sample size and the short period of observation of our study prevented us from drawing firm conclusions directly.

[Urinary infections with hospital germs in general surgery]. / Infectii urinare cu germeni de spital în chirurgia generala.

Nosocomial urinary tract infection is the most common type of sepsis in the post-surgical patient. This paper presents our experience with 218 nosocomial urinary infections (34.93% of our postoperative infections) which complicated the postoperative course of 1002 (21.75%) urethral catheterized patients out of a total of 5950 (3.6%) operated on and under study individuals. Thus we found that urethral catheterization is the most important risk factor for post-surgery urinary infections. Moreover, in our series the postoperative urinary tract sepsis bacteriology is dominated (> 95% of cases) by aerobic gram-negative bacilli that mainly reside in the bowel and also commonly colonize the perineum. Furthermore, we demonstrated that post-surgical urinary infections did not influence directly death rate but they had a significant bearing on care costs. Finally we consider the prevention of postoperative nosocomial urinary tract sepsis as an essential principle of this condition management.

[Post-operative temporary enteral nutrition methods]. / Cai temporare de nutritie enterala postoperatorie.

THE AIM: Of the present work is to promote duodenostomy as the postoperative enteral nutrition way, when surgery ends in an anastomosis in which one of the partners is the esophagus (esophagectomies, esogastrectomies and total gastrectomies). MATERIAL AND METHOD: Consisted of 45 cases 815 total gastrectomy, 14 esogastrectomy, 6 esophageal resections and 10-esophageal plasty) in which we used: nasofaringoesogastric or nasofaringoesojejunal probes (14 cases); Witzel jejunostomy (11 cases); gastrostomy (10 cases); duodenostomy (10 cases). THE CONCLUSIONS: Show the many advantages of duodenostomy as compared to other enternal nutrition methods: technical simplicity, patient's comfort, avoidance of complications involved by the use of nasopharingoesodigestive probe or by jejunostomy, etc.

[Locoregionally advanced rectosigmoid cancer: diagnosis, surgical approach, late results]. / Neoplasmul rectosigmoidian avansat locoregional. Probleme de diagnostic, rezultate la distanta, atitudine terapeutica chirurgicala.

The colorectal cancer continues to be diagnosed in advanced stages in our country, mainly due to unapplying of a programmer of active diagnosis through screening on the population with risk for colorectal cancer, and inefficiency of primary care system. In the department of General Surgery CFR Craiova Hospital between 1991-2001 were operated a number of 231 patients with colon cancer and 104 patients with rectal cancer. The results, showing an increased number of recurrences in cases of resection performed for advanced loco-regional tumors of rectosigmoid, made us to reconsider the attitude of avoiding the abdominoperineal resection even when the distance between the inferior limits of the tumors and the anal edge exceeded the distance considered being standard for a low anastomosis performing. The follow-up of the patients with paraclinic technique that didn't prove efficient led in the most cases to a delaying in diagnosis of local recurrences until the moment of resectability was exceeded. The applying of efficient methods in early diagnosis of colorectal cancer and follow-up could provide in the future better results for anterior resections with low anastomosis.

[False surgical acute abdomen with intermittent acute porphyria]. / Fals abdomen acut chirurgical în cadrul unei porfirii acute intermitente.

This article presents a case of acute intermittent porphyria admitted to the Surgery Department of C.F. Craiova Hospital between 18.08.2003-26.08.2003 then transferred to the Colentina Hospital in Bucharest for diagnosis confirmation and adequate treatment. The purpose of this paper is to bring attention on a rare metabolic inherited disease that, due to its non-specific and often noisy symptoms and limited possibilities of biochemical, enzymatic and genetic diagnosis, could generate potential serious confusions. The presentes case illustrates the fact that sometimes the acute attack may be mistaken for an acute surgical affection which requires an emergency operation with all the aggravating consequences and delay in the real diagnosis. About 1% of acute attacks of porphyria may be fatal. Only the drugs known as safe should be prescribed. Basic treatment consists in oral and intravenous glucose and hematin administration.

[Nosocomial infections in the Clinica Chirurgie CFR, Craiova]. / Infectii nosocomiale în Clinica Chirurgie CFR Craiova.

The authors present Craiova CFR General Surgery Clinic experience on hospital infections from 1991 through 1996. This study shows that the frequency of hospital infections in our clinic is greater than all the other postoperative complications. Over the investigated period of time we witnessed an increase in the incidence of the postoperative septic complications in addition to those directly linked to the operated interventions (e.g. wound infections, postoperative peritonitis) such as: pulmonary infections: urinary tract infections, catheter sepsis etc. Finally, the authors pointed to the consequences of the hospital infections such as: mortality and late morbidity rates, economic implications. Thus, it is worth mentioning that 30 deaths (75%) out of our clinic total of 40 over the studied period of time were due to a postoperative infections and treatments.

[Esophagoplasty with right ileocolon, technical problems]. / Esofagoplastia cu ileocolon drept probleme tehnice.

The authors present their experience with 14 cases of esophagoplasty by right ileocolon interposition which were performed to re-establish the digestive continuity in 12 patients operated on for caustic burns induced esophageal strictures and 2 patients with esophageal neoplasm managed by esophagectomy. The current study aims to pin/point both the anastomotic risk and the technical difficulties related to the colon interposition graft anatomic trajectory and vascular supply. Given the utmost importance of both the preoperative correction of the nutritional deficit and the improvement of pulmonary function the authors suggest that esophagoplasty should bu preceded by a "preoperative intervention", consisting of ileocolic artery ligation, gastrostomy and pleural drainage. The acute respiratory failure was the immediate main threat following esophagoplasty, whereas cervical anastomotic breakdown was the complication which dominated the early postoperative period in terms of frequency and gravity, but the death rate was nil. When esophagoplasty by right ileocolon interposition simplicity and efficacy are taken into account it appears as the surgical therapy of choice whenever the local and general status of the patients allows it.

[Causes of failure in the treatment of postoperative peritonitis]. / Cauze de esec în tratamentul peritonitelor postoperatorii.

The authors analyze a group of 49 postoperative peritonitis, which represent 0.57% of a total of 8550 surgical interventions performed over the last 7 years and 1.19% of 4100 laparotomies carried out in an elective operation orientated general surgery department. The mortality rate was 28.57% (14 patients) among the 49 studied cases, which represents 25% of all deaths recorded in our department over the same time interval. A full account on postoperative peritonitis vital prognostic factors is given, insisting on: specific bacteriology (nosocomial infections), peculiar etiologies (10 out of 14 fatalities were originally operated on for digestive cancers), different associations of postoperative peritonitis with other infectious and noninfectious postsurgical complications (as encountered in all 14 deaths), type of postoperative peritonitis (13 death out of 14 were due to generalized peritonitis), postoperative peritonitis secondary to ignored lesions at the original operation (3 cases--3 deaths), surgical treatment limitation (late operative timing which was responsible of 9 deaths); treatment inadequacies of peritonitis and its cause--5 fatalities.