Laparoscopic treatment of perforated duodenal ulcer -- a multicenter study.

AIM: The aim of this study is to evaluate the results of the laparoscopic treatment of perforated duodenal ulcer performed in 6 Romanian surgical centres with experience in the field of laparoscopic surgery. MATERIAL AND METHOD: Between 1996 and 2005, 186 patients with perforated duodenal ulcer were operated on in the centers participating in this retrospective study, all patients being ASA I-II. Thirty-nine patients (20.0%) presented mild peritonitis, 120 (64.5%) medium peritonitis and 27 (15.5%) severe (20.0%) simple suture was performed, in 110 (59.1%) suture with epiplonoplasty, for 1 (0.5%) only epiplonoplasty and 1 (0.5%) underwent excision of the perforation and suture. RESULTS: The operative time was between 30-120 minutes, with an average of 75 minutes. No death was noted. Average hospitalization time was 6 days, with periods varying between 3 and 18 days. Postoperative complications included: 5 patients (2,6%) presented infections of the abdominal walls, 1 patient (0.5%) duodenal fistula, 1 patient (0.5%) intra-abdominal abscess, 1 patient (0.5%) a superior digestive hemorrhage by "mirrored ulcer" and 1 patient (0.5%) duodenal stenosis 6 months after operation. The patients were administered 50% less analgesics, used 70% less dressings, 30% less antibiotics and had 60% less complications in comparison with those operated by the classical approach. CONCLUSION: The laparoscopic approach of perforated duodenal ulcer constitutes the first choice for patients without important co-morbidities, allowing a quick recovery and a significant reduction in the consumption of analgesics, antibiotics and dressing materials.

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.

[Right colon cancer--clinicopathological findings]. / Cancerul colonului drept--particularitati anatomo-clinice.

BACKGROUND: The right colon cancer (RCC) has some particularities from point of view of epidemiology, clinical aspects, therapy and prognosis. MATERIAL AND METHODS: We retrospectively analyzed the patients operated in the First Surgical Unit Iasi during 2004 until 2009, for right colon cancer. The patients' data from the medical files were digitally encoded and included into a MS Access database, and statistically analyzed. RESULTS: 219 cases were included into the analysis, which represents 24.17% from all the patients with colorectal cancer. The median age was 66 years old. A palpable mass into the right abdominal quadrant was founded in 41.5% and anemia in 65.3%. Abdominal ultrasound exam has been performed in all the patients, with 71.3% sensitivity for primary tumor positive diagnosis. Resectability was 89.5% but without multivisceral resections. The intraoperative complication rate was 6.8%; postoperative morbidity was 19.4% with an incidence of anastomotic leak of 1.38%. The postoperative mortality rate was 2.77%. The mean overall survival was 40.13 +/- 1.93 months (median: 49.26). The prognosis factors for the survival rate were: histologic type of the tumor, stage and tumor grading, vascular and perineural invasion. The presence of metastasis in more than 3 lymphnodes as well as resection of fewer than 11 lymphnodes were found as negative prognosis factors for the survival rate. CONCLUSIONS: RCC has an increasing incidence and it is associated especially with elderly patients. The RCC resectability is about 90% with acceptable rates of morbidity and mortality. Perineural and vascular invasion as well as rate of positive lymphnodes and count of resected lymphnodes are prognosis factor for overall survival rate.

[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.

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.

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).

[Heterotopic accessory pancreas in surgical pathology: review of 23 years experience]. / Pancreasul accesor heterotopic in patologia chirurgicala: experienta a 23 de ani.

BACKGROUND: The abnormal presence of the pancreatic tissue in other digestive organs is rare but sometimes is the cause of some surgical diseases. MATERIAL AND METHOD: This retrospective study is focussed on heterotopic pancreas cases diagnosed in 2nd Surgical Clinic of "Sf. Spiridon" Emergency Hospital from Iasi between Jan. 1986 and Dec. 2008. RESULTS: 22 patients (15 males/68.2% and 7 females/31.8%) aged between 23 and 76 years were grouped in A group--clinical symptomatic cases (3 patients/13.6%), group B--coincidental cases (17 patients/77.3%) and group C--incidental cases (2 patients/9%). Group A patients presented with obstructing prepyloric polypoid tumors and recquired antrectomy and gastroduodenal anastomosis. 13 patients of group B (76.4%) recquired surgery for pyloroduodenal stenosis and in 4 cases of this group with severe upper-GI bleeding, a subtotal gastric resection (3 patients) or antrectomy (1 case) was performed. In group C patients jejunal HP was histopathologically diagnosed during extensive intestinal resection for colonic malignancies (ascendant colonic and transverse colonic cancers) with jejunal invasion. HP cases were categorized as type I in 40.9% cases (ducts, acini and pancreatic islets), type II in 45.4% cases (ducts and acini) and type III (exclusively with ducts) in 13.6% cases. In 76% patients HP was localized in mucosal and submucosal layers, in 16% intramucosal and in 8% in subserous layer. CONCLUSION: HP is most often an unexpected symptomless coincidental diagnosis during gastrointestinal surgical diseases.

[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.

[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.

[The absence of haptic perception in laparoscopic cholecystectomy--risk factor for biliary lesions]. / Absenta perceptiei haptice în colecistectomia laparoscopica--factor de risc pentru leziuni biliare.

BACKGROUND: Bile duct injuries are the main serious technical complication of laparoscopic cholecystectomy (LC). Each lesion is peculiar in its features as well as the surgeon's reaction when face it. AIM: To reveal the place of the human error according to accepted principles of cognitive psychology, beside other risk-factors involved in biliary accidents during LC. METHOD: Retrospective study on 18 patients treated for severe biliary lesions during LC in 1st Surgical Clinic of "Sf. Spiridon" Hospital, Iasi, Romania, between March 1993 and March 2008. According to Strasberg's classification the lesions were: type C (n=1; 3%), type D (n=13; 39.4%), type E1-2 (n=2; 6.1%) and type E5 (n=2; 6.1%). In the medical records we followed up the technical aspects of the procedure (section, dissection, clips) and the lesional and anatomic factors attended at the moment of LC. We also assessed the concerned surgeons experience based on the number of the LC at time of the biliary accident. RESULTS: In our experience (10046 LC) the incidence of the biliary injuries was 0.1% only. We met four lesional and/or anatomic factors (mean) on each case with biliary lesion. Only five cases (27.7%) were detected intraoperatively, but Spearman's correlation between time of detection and surgeons experience is insignificant. CONCLUSION: Our results, rounded with cognitive psychology data from literature, suggest the role of the absence of haptic perception during laparoscopic procedures, in the occurrence of some errors, even in circumstances with "perfect visibility".

The histopathologic type of the periampullary tumors. Is it important for survival?

BACKGROUND: The ampulla of Vater is a junction with four histologic epithelial types: ampullary, duodenal, pancreatic and biliary. The tumors of this region are named periampullary adenocarcinomas, but the histologic type of these malignancies seems to have an important significance for survival. AIM: Our purpose is to determine whether the histologic type of the resectable vaterian adenocarcinomas is a prognostic factor. METHODS: We reviewed the medical records of 38 patients who underwent RO-R1 pancreatoduodenectomy for periampullary adenocarcinomas between 1998 and 2007 in one single surgical center. The histopathologic reports and the microscopic samples were reevaluated independently by two senior pathologists. Using our database we assessed the overall survival based on histologic type, tumor stage, lymph nodes involvement, tumor size and the level of differentiation. RESULTS: The histologic type of the adenocarcinomas was intestinal in 23 cases (60.5%) and pancreatobiliary in 15 cases (39.5%). The median overall survival was significantly higher in patients with well differentiate intestinal-type in T1-T2 stage without nodes involvement. In a multivariable Cox regression analysis the regional lymph nodes involvement and the differentiation degree remained significant prognostic factors. CONCLUSION: The intestinal type of periampullary adenocarcinomas has a long survival, but the lymph nodes involvement and the lower degree of differentiation are associated with a high risk of death in these malignancies.

Laparoscopic hand-assisted splenectomy for hydatid cyst.

Hydatid cyst of the spleen is a rare location even in endemic areas. From classical splenectomy, surgical treatment has evolved to more conservative and even minimal invasive techniques. The authors report a 44 year old male with a palpable but asymptomatic mass in the left hypochondrium. Ultrasonography and computed tomography confirmed a large round unilocular cystic imagine of 12.5 cm in diameter with a thin regular wall. A total splenectomy was performed laparoscopic, the dissection being directed upward from the lower peritoneal attachments continuing with delivery of the anterior aspect of the hilum and splenorenal ligament, interception of main splenic vessels and finally detachment of the superior pole of the spleen where the cyst is adherent to the diaphragm muscle. The all delivered spleen was partial evacuated of hydatid content and the extraction was done via a mini-laparatomy with a digital lever manoeuvre. The 200 minutes operation has an uneventful postoperative course and the patient is still well 12 and 24 months after surgery without recurrence. The laparoscopic approach of hydatid cyst of the spleen constituted a challenging therapeutic perspective in selected cases and a good expertise of the surgeons.

[Primary hypersplenism due by accessory spleens after splenectomy]. / Hipersplenism trombocitopenic prin spline accesorii dupa splenectomie.

Primary hypersplenism may affect any of the figurative elements of blood, simultaneously or in successive sequences. In function the answers, the therapy may be necessary splenectomy. The authors present the case of a 50-year-old patient what suffered one splenectomy, admitted to the 1st Surgical Clinic for purpuric cutaneous phenomena. 32 years ago, the patient suffered the splenectomy, from a severe autoimmune hemolytic anemia. After 29 years the biologic exam realized for a generalized purple, relieved a severe thrombocytopenia (2,500/mm3) being necessary the administration of thrombocytes transfusion and high doses of corticosteroids in emergency. The spleen sequestration test, ultrasound exam and CT showed the existence of accessory spleens. We practice the surgical intervention for ablation of the accessory spleens. The splenectomy cure disease in 65-80% of cases and the partial remission of manifestation is obtained in 15-20% of cases. The recurrence risk is possible by omission of the accessory spleens. The ablation of these accessory spleens induced recovery in 98-99% of cases.

[Surgical treatment of gynecomastia]. / Tratamentul chirurgical al ginecomastiei.

BACKGROUND: Gynecomastia describes a benign increase of the mammary gland in men. When medical treatment fails, the surgical procedure is the treatment of choice. There are two main surgical procedures: subdermal mastectomy and liposuction. AIM: To evaluate the results after surgical treatment (mastectomy) performed in a general surgery unit. METHOD: We performed a retrospective study; all the patients operated for gynecomastia were reviewed. The clinical, imaging, biological, intraoperative and histological data were included into a MS Access database and statistical analyzed. RESULTS: From 1990-2007, 114 patients were admitted in the First Surgical Clinic Iasi for gynecomastia. Only 12.6% from the patients were with bilateral gynecomastia. The mean age was 40.54 +/- 1.83 years old (range 12-84). Mean body mass was 26.72 +/- 0.46 kg/m2 (range 18.5-41), and about 20% from the patients had a BMI of over 30 kg/m2. We also noted that 46.5% were smokers. Simon classification was used for preoperative staging: 2.6% from the cases (N = 3) were included in stage I, 16.7% (N = 19) in stage IIa, 50% (N = 57) in stage IIb and 30.7% in stage III. The patients included in stages IIa and I are younger then the patients included in stage III (p = 0.024). Mastodynia was noted in 46 cases (40.4%). Ultrasound exam was performed in all the cases, and the larger diameter of the nodule measured was 3.75 +/- 0.18 cm (range 0.5-9.7). Only three cases were preoperatively treated with tamoxifen. Most of the cases were operated using general anesthesia (53.5%). Mastectomy was performed by peri-areolar (70.2%), elliptical (28.9%) or radial (0.9%) incisions. The subdermal mastectomy using peri-areolar approach was performed especially for the cases included in stages I, IIa and IIb--p < 10(-3). The epi-pectoral vacuum drainage has been used in 79.8%. The postoperative morbidity rate was 15.8%--4 cases of hematoma, 13 cases of seroma and 1 case complicated with skin necrosis. No specific risk factors for postoperative complications were found by univariate and multivariate statistical analysis. The pathological exam revealed pseudo-gynecomastia in 6 cases; the other cases presented dilated ducts. We also noted intraductal papillary hyperplasia in 87 cases and chronic inflammation in 35 cases. The histological exam also revealed intraductal papilloma--9 cases, fibro-adenoma--1 case, papillary ductal carcinoma--1 case and mucinous carcinoma--1 case. From all these data, the etiological diagnosis in presented series was: pseudo-gynecomastia--5.3% (N = 6), idiopathic--64.9% (N = 73), endocrine--7.9% (N = 9), drug induce--5.3% (N = 6), metabolic--7.9% (N = 9), tumoral--8.8% (N = 10). The postoperative hospital stay was 4.04 +/- 0.26 days (range 1-12). A literature review has also been performed. CONCLUSIONS: The management of gynecomastia has to be performed by a multidisciplinary team. Gynecomastia it is possible to be associated with a breast cancer, even in younger people. The surgical treatment, especially the type of incision, will be chosen from point of view of Simon stages. Liposuction can be associated in selected cases.

[Abdominal wall endometriosis after gynecologic procedures: an under-appreciated diagnosis in general surgery]. / Endometrioza parietala abdominala dupa chirurgia ginecologica: un diagnostic subapreciat in chirurgia generala.

UNLABELLED: Incisional endometriosis is a clinical entity described in the gynecologic literature but it is not well recognized among general surgeons. The preoperative diagnosis is often mistaken for a suture granuloma, abscess, lipoma, cyst or incisional hernia. MATERIAL AND METHOD: This is a retrospective review of six cases of incisional endometriosis in our hospital aimed at determining which, if any, factors would suggest the diagnosis preoperatively. All general surgery patients with a diagnosis of endometriosis in their pathology specimens from January 1990 to February 2006 were reviewed. RESULTS: All six patients had previous cesarean sections through either a Pfannenstiel (n = 4) or lower midline (n = 2) incision. Ages ranged from 28 to 43 years (mean 34.3 years). All patients presented with a palpable painful lesion located in the area of cesarean section incision. Three of the patients had a change in symptoms with their menstrual cycle. The duration of symptoms ranged between 2 months to 6 years. All patients underwent surgical excision. The size of the excised endometrioma ranged from 3 cm to 9 cm (mean 5.3 cm). CONCLUSION: Incisional endometriosis seems to be common in women with a history of cesarean section. Most patients presented with a painful abdominal mass. Three patients presented cyclic changes in pain and size of the mass with menses, but this may be due to physician's lack of awareness and questioning. The management of choice is to remove the lesion completely even if fascial excision is required.

[Pancreaticoduodenectomy for pancreatic head cancer, 54 cases]. / Duodenopancreatectomia cefalica in cancerul de cap de pancreas--consideratii asupra 54 cazuri.

UNLABELLED: Pancreatic cancer has an increase rate in western countries. From the first pancreaticoduodenectomy (PD) performed by Kausch in 1909, the value of the resection in the treatment of pancreatic head cancer was disputed. AIM: To assess the PD with or without pylorus preservation as surgical treatment for pancreatic cancer. METHODS: Retrospective review of the clinical records of patients undergoing PD for pancreatic cancer. RESULTS: From January 1995 till December 2005, in the First and Third Surgical Units, "St. Spiridon" University Hospital Iasi, Romania, were performed 137 PD. From these, 54 cases were histologic diagnosed with pancreatic cancer; 23 cases underwent pylorus preserving pancreatico-duodenectomy (PPPD) and 31 patients, classical Whipple procedure (PDW). Mean age was 59.07 +/- 1.42 years old (26-75 years old), and male to female ratio was 29 to 25. Jaundice was presented in 51 cases (94.4%), abdominal pain at 39 patients (72.2%) and Curvoisier-Terrier sign at 37 cases (68.7%). Fever was observe only in 4 cases (7.4%). Other biological and imaging parameters (e.g. main diameter of the biliary duct, tumor and wirsung ) were also discussed, but no significant difference was found between PPPD and PDW. Pancreatico-jejunostomy was performed in 41 cases (28 during the PDW and 13 in PPPD) and 13 pancreatico-gastrostomy (3 during PDW and 10 during PPPD). Mean operating time and mean blood loss in the PDW group were 358.22 +/- 10.53 minutes and 587.74 +/- 60.87 mL. After PPPD, these figures were 326.08 +/- 15.04 minutes and 571.74 +/- 90.50 mL, but no significant difference was noted. Delayed Gastric Emptying (DGE) was presented at 15 patients: 8 in PPPD group and 7 in PDW group (p=0.322). Postoperative morbidity rate (excluding DGE) was 33.33% (8 cases in PDW group and 10 in PPPD group). Pancreatic leak has a rate of 5.55% (3 cases--one in PPPD group vs two in PDW group), biliary leak has a rate of 12.96% (4 in PPPD group vs 3 in PDW group)and duodeno-jejunal anastomotic fistula appeared in one cases (PPPD). Acute postoperative pancreatitis is presented in one case (PPPD group) and postoperative hemorrhage appeared in 4 cases (2 in PPPD and 2 after PDW). Hospital stay was 19.91 +/- 2.28 days in PPPD group vs 18.87 +/- 2.24 days in PDW group (p = 0.751). Postoperative mortality rate was 5.5% (one case after PPD and 3 cases after PDW). Histological exam diagnosed ductal pancreatic adenocarcinoma in 51 cases (94.44%). Mean long-term survival rate was 20.98 months (10.52-31.45 months; 95 CI) and no difference was revealed between PPPD and PDW (log rank test - p = 0.796). CONCLUSION: PD should be performed for any pancreatic tumor even without preoperative histologic confirmation. The results after PPPD (postoperative morbidity and mortality, long-term survival) are similar to that following conventional Whipple procedure, if the principles of viable and tumor free margins are observed.

[Torsion and infarction of an accessory liver lobe]. / Lob hepatic accesoriu torsionat si infarctat.

Anatomical abnormalities of the liver are extremely rare. We report a case of a 32 year old female who has admitted with acute epigastric pain and vomiting. Physical exam revealed a mobile mass in right middle abdominal quadrant. Ultrasound and contrast--enhanced CT demonstrated a heterogeneous vascular left mass. Small bowel enema shows left jejunal loops displacement. Surgical findings: twisted, congested swelling, attached by a long pedicle to the liver's third segment. Histological examination showed recent hepatic infarction.

[Long-term results after surgery for colorectal adenocarcinoma, stage I-III. Problems of prognosis]. / Rezultate la distanta dupa tratamentul chirurgical al adenocarcinomului colo-rectal stadiile I-III. Probleme de prognostic.

UNLABELLED: Colorectal cancer is one of the leading causes of cancer-related death worldwide. STUDY DESIGN: Prospective study on 142 consecutively cases with stage I to III colorectal adenocarcinomas (TNM AJCC/UICC) in which patients underwent potentially curative surgery in one single public health service (1st Surgical Clinic Iasi, Romania) between 2004 and 2005. MATERIAL AND METHOD: The mean follow-up was 23.26 +/- 9.78 months (range 2 to 42 months). There were 85 men (59.9%) and 57 women (40.1%) with mean age 63.38 +/- 11.84 years (range 28 to 88 years). The surgical procedures performed were the following: right colectomy (n = 54; 30%); transverse colectomy (n = 2; 1.4%); left colectomy (n = 19; 13.4%); segmental colon resection with anastomosis (n = 5 ; 3.5%); Hartmann procedure (n = 18; 12.7%); anterior rectal resection (n = 11; 7.7%) and abdominoperineal resection (n = 33; 23.2%). With regard to postoperative adjuvant therapy most patients were given chemotherapeutic agents such as 5-fluorouracil and folinic acid. The mean overall survival (months) and 42-months survival rates were calculated. The patients were censored in the survival calculation (Kaplan-Meier method) and Cox regression if they were alive at the endpoint of the follow-up. Some patients were censored because they were "lost to follow-up". Statistical significance is p < 0.05. RESULTS: The factors with a significant negative influence in overall survival and 42-months survival rates were: the age over 70 years, the emergency surgery related to cancer's complications, the advanced AJCC/ UICC stage, vascular invasion, perineural invasion, the recurrence of disease, the moderate and lower differentiated adenocarcinoma and incomplete or not performed chemotherapy. CONCLUSION: Even with a radical surgical approach the advanced stage of colorectal adenocarcinoma has a low prognostic, but some other factors have also a high significance in postoperative outcome. Related to other prognostic factors we performed a review of literature.

[Pancreatic endocrine tumors]. / Tumori pancreatice endocrine.

Incidence of the endocrine tumors of the pancreas is about 4 to 10/1.000.000 peoples. We present 10 cases of endocrine pancreatic tumors which were operated in the First Surgical Clinic Iasi in the last 20 years (1984-2003); these cases represent about 2.21% from all the pancreatic tumors (454 cases). It was 4 insulinoma, 2 gastrinoma, 2 gastrinoma associated with other endocrine neoplasia (Wermer syndrome) and 2 non-functioning endocrine pancreatic tumors. Female/men ratio was 9/1 and median age was about 41.9 yo (27-67 yo). In the four cases of insulinoma (all females) the diagnosis was delayed by two to five years due to misinterpretation of neurological symptoms generated by hypoglycemia. The diagnosis of insulinoma was based on Whipple triad, high plasma insulin levels associated with low plasma glucose levels, as well as the symptomatic relief after intravenous glucose injection. The surgical option was based on biological data, ultrasonography, computed tomography and arteriography. In two cases the localization of the insulinoma was established only by intraoperative ultrasonography. All tumors were localized in the tail of pancreas. In three cases we decided for a distal pancreatic resection with splenectomy and in one case for spleen preserving left pancreatectomy. Postoperative course was uneventful and all the symptoms disappeared. The diagnosis was confirmed on pathological examination in all cases. We also present two cases of gastrinoma with multiple ulcers and multiple surgical interventions for haemorrhage and perforation with peritonitis. Both patients died and diagnosis of pancreatic endocrine tumors was post-mortem. The two patients with Wermer syndrome also had ulcers complicated with haemorrhage and peritonitis and parathyroid adenoma. One case also had ante-hypophyseal and pituitary adenoma and the other had thyroid colloid hypertrophy. We performed left pancreatectomy with spleen preservation in one case and enucleation associated with total gastrectomy in the second case. The two cases of non-functioning pancreatic endocrine tumors had a non-specific symptoms. Diagnostic was established by abdominal ultrasound exam. We performed spleno-pancreatectomy in one case and pancreatectomy with spleen preservation in the other patient. Postoperative course was un-eventful.