Esotracheal Fistula in Esophageal Stenoses of Malignant Origin - Case Report.

BACKGROUND: Approximately 80% of acquired eso-tracheal or mediastinal fistulae are of malignant nature. The occurrence of an eso-respiratory malignant fistula is a devastating complication for both patient and doctor, and, if not treated, records a survival time of 1 to 6 weeks. MATHERIAL AND METHOD: We present a patient, aged 51, smoker,with progressive dysphagia, at first to solids, then to semi-solids and liquids, followed by manifestation of post-deglutition cough due to eso-tracheal fistula, incapability of feeding, and decline of the general condition. Surgical intervention consists of esophageal transstenotic endo-prosthesing by transtumoral drilling with prosthetic montage and the occlusion of the eso-tracheal fistulous orifice. RESULTS: The post-operatory evolution is favorable, the feeding per os resumes in 8 hours after surgery, good digestive tolerance. The radiologic examination using contrast medium, performed in 48 hours after surgery, reveals a permeable esophageal endo-prosthesis, without reflux of contrast substance in the tracheobronchial tree. CONCLUSIONS: The laparo-gastroscopic montage of prosthesis through transtumoral drilling, using siliconized semi-rigid prostheses, represents the only efficient palliative treatment of malignant eso-tracheal or eso-bronchial fistula.

Laparoscopic surgical treatment of umbilical hernia and small eventrations with prosthetic mesh using omentum overlay.

INTRODUCTION: Umbilical hernias and abdominal incisional hernias represent current pathologies which require numerous surgical alternative ways of treatment in prosthetic or non prosthetic,open or minimally invasive surgery. The method proposed by us is a less expensive option with no additional risks compared to other similar procedures as surgical technique. MATERIALS AND METHODS: We conducted a retrospective study between 01.01.2008 - 01.06.2013 in which we considered a number of 23 patients with umbilical hernia and eventration, patients who received laparoscopic intraperitoneal polyester mesh covered with omentum, procedure applied at the IInd Surgery Clinic, Clinical County Emergency Hospital Sibiu. RESULTS: Out of 23 patients with postoperative umbilical hernia and eventration cases in which we used this surgical technique,16 were umbilical hernias and 7 post incisional hernias. The average time of surgery was 1 hour and 40 minutes, recording 4 postoperative complications remitted under conservative treatment, with a mean hospitalization of 4.1 days. CONCLUSIONS: Proepiploic laparoscopic treatment using omentum is a reliable alternative to a more expensive and difficult procedure involving Dual Mesh.

Superior socio-medical alternative to feeding gastrostomy and jejunostomy in advanced esophago-gastric junction adenocarcinoma.

INTRODUCTION: The diagnosis of esophago gastric junction adenocarcinoma often occurs when the neoplastic process is surprised in advanced stages and blocks the esophageal-gastric junction causing dysphagia, stages in which curative therapy is more likely impossible to be accomplished. In these cases, the treatment goal is mainly to provide feeding capacity as naturally as possible and to start the adjuvant oncological treatment. The use of endoscopic esophageal prostheses provides the patient with the possibility to be fed orally and with a good social integration, but due to the technical incapacity to cross the tumoral stenosis with the endoscope, or due to the endoscopist s concerns regarding the sensitive areas (poles of the esophagus), there are reluctances in respect to this method (on average 20%). MATERIAL AND METHOD: We conducted a retrospective study aimed to determine the optimal therapeutic modality depending on the evolutive stages of the disease and to analyse the justification of the original procedure of laparogastroscopic esophageal stenting through tumoral drilling as a technical alternative to the reluctances or failures of endoscopic prosthesis and as a biological and social solution to the disabling gastrostomy for patients with advanced esophageal-gastric junction adenocarcinoma. RESULTS AND DISCUSSIONS: Staging was disarming, most patients were diagnosed in advanced stages, fact also supported by literature. Regarding esophageal stenting by transtumoral drilling, the results are significant especially in terms of postoperative morbidity CONCLUSIONS: Although our study regarding laparogastroscopic stenting by transtumoral drilling in esophago-gastric junction adenocarcinoma is limited, this original procedure brought us satisfaction whenever we used this approach.

Pathological evidence in support of total mesorectal excision in the management of rectal cancer.

BACKGROUND: Pelvic recurrence following conventional rectal resection for cancer is common. Preoperative iradiation has been shown in prospective randomized studies to halve this risk. AIM: This multiinstitutional study aimed to assess the necesity of total mesorectal excision in rectal cancer. PATIENTS AND METHOD: Pathological resections from 50 consecutive patients with adenocarcinoma of the rectum within 12 cm of the anal verge who underwent currative resection incorporating total mesorectal excision were examined. The resection specimen was examined by one of two pathologists. Some 50 total mesorectal excision specimens were examined following rectal excision for cancer. Some 38 had total mesorectal excision as a component of a low anterior resection and 12 with abdomino-perineal resection. "Cure" was defined as absence of metastatic disease and the excision of entire macroscopic tumor tissue with negative proximal and distal borders. TME was performed as described by Heald et al. The mesorectum was evaluated for lymph nodes and tumor deposists in three areas: deep to the tumor, in the proximal mesorectum and in the distal mesorectum. RESULTS: Six patients had Dukes A lesions. Of 21 patients with Dukes B tumors, five had discrete foci of adenocarcinoma in the mesorectum, with no evidence of lymph node metastasis. Dukes C lesions were more heterogeneous, but 12 out of 23 patients had distinct mesorectal deposists in addition to mesorectal node involvement. Circumferential margin involvement was rare, but mesorectal tumor deposits were present in 17 of 44 patients with pT3 tumors, and 23 of 44 had mesorectal nodal involvement. No patient with a pT2 tumor had mesorectal involvement. Failure to excise the mesorectum completely has the potential to leave gross or microscopic residual disease that may in theory predispose to local failure. CONCLUSION: Total mesorectal excision is necessary to avoid incomplete pathological evaluation of the mesorectum and understaging of rectal cancer.