Implication of wide surgical excision in minimizing positive margins and consequential secondary excision - a retrospective comparative study involving 106 basal cell carcinoma cases.

OBJECTIVE: The use of current surgical techniques in the management of skin cancers that are not amenable to other treatment options has become the cornerstone of dermatological surgical intervention. Among the many benign lesions and malignant lesions, such as squamous cell carcinomas, melanomas, and Merkel cell carcinomas, the tumors that are commonly excised surgically are the basal cell carcinomas (BCC). Although the majority of BCC lesions spread locally and are rarely metastatic, these lesions may recur, especially, if the excised tissue consists of positive surgical margins. As BCC lesions are more common on the head, face, and neck regions, inadvertent positive margin excisions to help avoid major disfigurement of the regions may contribute to their recurrence. Trichoepithelioma (TE) is a benign tumor that bears a close resemblance to BCC, and therefore, clinicians encounter difficulty in differentiating between TE and BCC lesions. Clinicians have to rely on histopathology and immune-histochemical markers to rule out TE. This differentiation is crucial to make a definitive diagnosis of BCC and subsequently, employ a more aggressive surgical excision approach to treat this invasive tumor as compared with TE. Our focus in this article is to highlight only the surgical excision management of local and or locally invasive BCCs and report the success rate of our hospital's Dermato-venereology clinic (DVC) in Timisoara, Romania. This article highlights the role of an appropriate wide local lesion excision (5 mm) with negative surgical margins in the prevention of further surgical interventions, be it for corrective or esthetic reasons. PATIENTS AND METHODS: This is a retrospective study that summarizes the evaluation of 120 lesions from 106 patients who were treated for BCCs at DVC (University Hospital), using a wide surgical excision method.  Following the Romanian Society of Dermatologists guidelines, local non-aggressive BCC lesions were excised with margins of 5 mm and up to 1 cm for the aggressive sclerosing subtype. RESULTS: The results of the audit of a sample of 120 lesions from 106 patients demonstrated that none of the surgically treated patients had recurrences and only 23 (19.16%) had positive surgical margin lesions. Out of these, 17 (73.91%) lesions underwent second surgical excision, while only three (13.04%) showed the presence of a residual tumor. The evaluation results may encourage dermatologists worldwide to make appropriately sized excision, especially in regions other than the head and neck, to avoid positive surgical margins and eliminate the need for consequent surgery. CONCLUSIONS: For a better post-surgical prognosis of BCC, the authors recommend the practice of a wide margin excision (5 mm) during the primary surgery to avoid secondary surgery, especially if the tissue in the region is not sparse and chances of causing major disfigurement are minimal. As our findings suggest, only a few cases have the presence of residual tumor in the second surgery, hence authors also advocate the necessity to inform the patients about the merits of a second surgery, clearly mentioning the possibility of the absence of tumor even in the presence of positive margin.

Postoperative morbidity and mortality after liver resection. Retrospective study on 133 patients.

INTRODUCTION: Hepatic resection had an impressive growth over time, both by broadening the range of its indications and the occurrence of changes and technical tricks in order to reduce postoperative mortality and morbidity. MATERIAL AND METHODS: This study is a retrospective study presenting an analysis of 133 patients hospitalized in the Department of Hepatic Surgery in City Hospital Timisoara, between January 2000 and November 2011, in which a surgical intervention was performed, either for a primary hepatic tumor (benign or malignant) or a secondary liver tumor. All cases were analyzed in terms of etiopathogenesis, preoperative and intraoperative investigations, indication and type of hepatectomy performed, the surgical technique used and postoperative evolution. RESULTS: The study group comprises 133 patients. From the whole group, 100 patients (75.19%) were diagnosed with primitive liver tumors, in 70 patients (70% of primary tumors) HCC occurring on a cirrhotic liver. Liver disease was secondary in 33 patients (24.81%), colorectal tumors being most commonly involved (19 patients). Of all liver resections, 21 (15.79%) were major hepatectomies. The remaining were minor hepatectomies, including a trisegmentectomy (V, VI, VII), 51 bisegmentectomies and 60 liver resections limited to one segment. Vascular clamping was used in 89 cases (66.92%), pedicular clamping in 65 patients (73.03%) and selective extraglissonian clamping in 24 patients (26.97%) respectively. Of the 33 patients with liver metastases, 12 (36.36%) received synchronous resections. The most common complication in our study group was postoperative liver failure, found in 45 patients (33.83%), being irreversible in one case (2.22%), followed by the death of the patient. In 34 patients (75.55%), hepatic failure was seen in cirrhotic patients and the other cases were patients with major hepatec-tomies. Hepatic failure occurred in 35 patients (77.78%) with vascular clamping, four of them after selective clamping. 31 of the patients (68.89%) with postoperative liver failure were transfused, 25 patients (55.55%) receiving more than 2 units of blood. Of all patients, 3 (2.25%) died postoperatively. CONCLUSIONS: Respecting the principles of liver surgery, hepatic resection can be performed, even in cirrhotic patients, with acceptable morbidity and minimal mortality. The most common complication after hepatic resection, in our study group, was postoperative liver failure, which was mostly reversible.

Spontaneous rupture of gastroduodenal artery aneurysm.

Gastroduodenal artery (GDA) aneurysm is a rare entity, comprising only 1.5% of all 3000 cases of visceral artery aneurysms that have been reported in literature. We report a case of a 55-year-old Caucasian man, diagnosed with right inguinal hernia. He was admitted to our department for surgical treatment. His medical history was remarkable for hypertension, and angina. He was operated the next day. A external oblique right inguinal hernia was diagnosed intraoperative. The Halsted technique was used for primary inguinal hernia. Immediate postoperative evolution was favorable, systolic blood pressure of 120 mmHg, pulse of 68 beats/minute. 16 h postoperative there was a sudden alteration of the general condition with signs of hemodynamic shock, with a systolic blood pressure of 60 mmHg, tachycardia of 110 beats/min. Physical examination revealed a pale, cold, and clammy patient. His hemoglobin had dropped from 14 g/dL on admission to 6 g/dL. A bedside ultrasound identified pelvic free fluid. An exploratory laparotomy revealed hemoperitoneum, and over 2 500 ml of blood and clot, a large hematoma was identified that was occupying the transvers colon mesentery and retroperitoneum. A clot was removed, revealing ruptured gastroduodenal artery aneurysm with active hemorrhage. The opening was isolated and closed. The contents were returned to the abdomen, which was irrigated and closed. Postoperative laboratory evaluation revealed hyperamylasemia (1543 IU/L, Normal Value (NV) = 15-95 IU/L). He remained normotensive throughout his 8-day hospitalization and was discharged home in good condition. In conclusion, gastroduodenal artery aneurysm rupture is a rare and patients can present with nonspecific symptoms. Rapid diagnosis, localization, and surgical or endovascular intervention are necessary to avoid devastating consequences.