Anterior transperitoneal laparoscopic approach of retroperitoneal tumour - clinical case.

We present our personal experience in the anterior transperitoneal laparoscopic approach of a retroperitoneal tumour.The case we have in view is that of a 48-year old female patient P.V., with congenital single left kidney. The patient has a retroperitoneal tumour mass of the right flank. Following investigations (ultrasound, CT with contrast), the tumour appeared well defined, of small dimensions (approximately 6-7cm diameter) and without anatomical relationships with large retroperitoneal vessels (inferior vena cava). For the laparoscopic excision of the tumour, we used an operating device adapted from the one used in right hemi-colectomy. After the coloparietal dissection, the access into the right retroperitoneal flank by means of laparoscopy is achieved by applying our procedure.The surgical intervention was quick and of a minimally invasive nature. Postoperative evolution was favourable, without any complications; the patient was discharged after 48 hours. In anatomic situations where the tumour anatomy is well defined and its size is acceptable, without dangerous anatomic relationships with large retroperitoneal vessels, attempted laparoscopic transperitoneal removal is the preferred option.

Lethal gastric hemorrhage from a caliber-persistent artery of the antrum - a branch of the right gastric artery.

AIM: To present a rarely diagnosed case of gastric Dieulafoy lesion. DESCRIPTION OF CASE: A 62-year-old male was hospitalized with hematemesis. Laparoscopic ligature of two gastric ulcers located in the antrum was performed but the upper gastrointestinal bleeding was not stopped. The patient was transferred to another surgical clinic and he underwent an emergency abdominal laparotomy with re-suture of gastric ulcers. Considering his general condition and another recurrent bleeding, he was transferred to our hospital and a total gastrectomy of necessity was performed. The patient died four days after surgery because of sepsis. At autopsy, we identified diffuse peritonitis, hypertrophic cardiomyopathy and chronic pancreatitis with expanded fibrotic areas. Histological examination of the surgical specimen showed oversized tortuous vessels in the gastric submucosal layer with expansion into mucosa. Some of the vessels presented acute and/or organized thrombi with recanalization, in the others, lipid-rich atherosclerotic plaques were observed. Based on these criteria, the 'caliber-persistent artery', also known as 'Dieulafoy's lesion', was diagnosed. CONCLUSION: Dieulafoy's lesion should be suspected in every case of gastrointestinal bleeding in both adults and children.

Using the galactomannan antigen assay in the diagnosis of invasive aspergillosis after hematopoietic stem cell transplantation.

Invasive aspergillosis (IA) is the most common life-threatening infections after hematopoietic stem cell transplant (HSCT). The serum galactomannan (GM) is recognized as an indirect mycological criteria for an early diagnosis of IA. Starting January 2011, we implementing in Fundeni Clinical Institute, Bucharest, for the first time in Romania, the detection of GM antigen (Platelia Aspergillus EIA, Bio-Rad). In 2011, patients undergoing HSCT were screened with the galactomannan ELISA; we performed a retrospective chart review of 162 SCT patients who underwent galactomannan testing. Thirteen of the patients (8.02%) had at least one positive galactomannan ELISA, and four had multiple positive tests. When calculated in reference to a proved or probable diagnosis of aspergillosis, the galactomannan ELISA had a sensitivity of 0.857 and a specificity of 0.913. The positive predictive value was 0.46, and the negative predictive value was 0.993. The Platelia Aspergillus galactomannan antigenemia assay may assist physicians in making an early diagnosis of IA, in correlation with clinical and radiological criteria. The test has a high sensitivity and specificity and a very good negative predictive value. We found the screening of GM ELISA to be a highly specific diagnostic tool in detecting IA manifested in patients undergoing HSCT.

Mena, a new available marker in tumors of salivary glands?

Mena (mammalian Ena) is an actin regulatory protein involved in cell motility and adhesion. Based on its potential role in malignant transformation revealed in other organs, we analyzed the Mena expression in normal salivary glands (SG) and salivary tumors. Mena expression was determined in normal SG (n=10) and also benign (n=20) and malignant (n=35) lesions of SG. For the immunohistochemical staining we used the anti-Mena antibody. All normal SG and the benign lesions (10 pleomorphic adenomas, 10 Warthin's tumors) were Mena negative. Salivary duct carcinomas (n=5), carcinomas in pleomorphic adenoma (n=5), acinic cell carcinomas (n=5), squamous cell carcinomas (n=10) and high-grade mucoepidermoid carcinomas (n=2) were positive. The lymphomas (n=5) and low-grade mucoepidermoid carcinomas (n=1) were Mena negative. In one case the lymphoblastic cells stained positive for Mena. Some of the endothelial cells, in the peritumoral vessels, were Mena positive. To the best of our knowledge, this is the first study in the literature about Mena expression in salivary tumors. Our study suggests that Mena protein seems to play a role in malignant transformation and its intensity is correlated with the type and grade of tumor and also with vascular invasion. Its positivity in endothelial cells may suggest its potential role in tumor angiogenesis.

Practical value of the complex analysis of sentinel lymph nodes in colorectal carcinomas.

BACKGROUND: Despite modern factors, which seem to predict outcome, lymph node (LN) status remain the main prognostic factor, which also shows the need for complex oncotherapy in colorectal carcinomas (CRC). Sentinel lymph nodes (SLNs) mapping is a very controversial method, which can increase the number of identified LN. MATERIALS AND METHODS: In 28 patients who underwent surgical intervention between December 2009 and December 2010, we performed in vivo SLNs mapping followed by ex vivo examination at 1, 10, and 48 hours. All blue nodes were separately included. In cases without LN metastases (pN0) five multilevel sections and immunohistochemical stain with cytokeratin 20 were performed in SLNs. RESULTS: Two cases were excluded because they were in pT4 stage. In one case the diameter of lymph nodes was about 10 mm and we obtained a false negative result (negative SLNs with positivity in the non-SLNs). From the other 25 cases, 13 do not presented LN metastases or micrometastases, nine had metastases only in the SLNs and the other three in both SLNs and non-SLNs. Mean identified number of LNs was 15. The blue dye intensity increased after formalin fixation and some nodes with metastases were blue stained only after 10 hours. CONCLUSIONS: SLNs mapping is a simple and inexpensive technique, which can improve the management of CRC. All in vivo and ex vivo blue LNs should be considered SLNs. Ultrastaging of SLNs is an expensive method, with uncertain results. High diameter of LNs seems to be an exclusion criterion for SLNs mapping.

[Sentinel lymph node mapping in colorectal cancer]. / Determinarea ganglionului santinela în cancerul colorectal.

UNLABELLED: Colorectal cancer is the most common malignant tumor of digestive tract with high mortality due to local reccurences and metastases. These are due to micrometastases undetected by classical microscopic examination of regional lymph nodes. Sentinel lymph node SLN technique in colorectal cancer may lead to identification of micrometastases using immunohistochemistry. METHODS: We present our experience in SLN mapping in colorectal cancer using a limphofil dye, on 52 patients. We present the patients selection criteria in the study, the technique of SLN detection. RESULTS: Identification of SLN was performed in 48 cases, it failed in 4 cases. In 27 cases, 1 SLN was identified, in 21 cases 2 SLN were found. In 4 cases the SLN were false negative. In 30 cases SLN were negative on histopathology and immunohistochemistry. In 14 cases, SLN were positive, 4 cases presented micrometastases confirmed only by immunohistochemical methods. CONCLUSION: SLN technique in colorectal cancer: - doesn't change the surgical approach regarding the regional lymphadenectomy; - can modify the tumor stadialization by detecting lymph nodes micrometastases; - increase the number of patients who can benefit from the adjuvant chemotherapy and therefore, it may improve the prognosis.

Vascular endothelial growth factor: a possible mediator of endothelial activation in acute respiratory distress syndrome.

AIM: Vascular endothelial growth factor (VEGF) is a potent angiogenic and endothelial factor, which is abundantly found in the normal lung tissue. The objective of the study was to assess the VEGF levels in lung tissue and plasma in acute respiratory distress syndrome (ARDS) patients compared with controls who died from non-ARDS causes. METHODS: Plasma and tissue samples were prospectively collected from 20 patients with ARDS within 6 hours after intubation (VEGF in plasma and tissue samples) and on the day of extubation (plasma VEGF) or postmortem (lung tissue). We used an ELISA to measure the VEGF level in plasma. Lung specimens were obtained by bronchoscopic biopsy or by open biopsy during autopsy. All lung samples were stained for standard histopathological analysis and for immunohistochemical methods. Biomarker levels were compared between survivors (N=12), non-survivors (N=8) and controls (N=10). RESULTS: Compared with the levels in controls, in the early stages of ARDS, plasma VEGF levels rose and intrapulmonary levels fell, but during recovery, these levels went back to normal levels. CONCLUSION: The initial phase of ARDS is associated with a decrease in VEGF in the lung and an increase in the plasma. This down-regulation may represent a protective mechanism aimed at limiting endothelial permeability and may participate in the decrease in the capillary number that is observed during early ARDS. A persistent elevation of plasma VEGF over time predicts poor outcome.

Elastography, progression factor in liver ultrasound.

Elastography is a method which, using ultrasound, obtains images and measurements of tissue elasticity when applying a force on it. As an imaging method it was developed to quantify objectively the pathological changes related to the presence of an abnormal tissue, compared to the surrounding tissues, giving information about the elasticity/stiffness of the examined tissue, the degree of fibrosis, the degree of stiffness compared to tumor free tissue. The tissue analysis can be done through a compression technology "eSie touch elasticity imaging" (with applications for the surface elastography) or ARFI technology--"acoustic radiation force imaging" (the diffusion impulse of the acoustic force). The ARFI method allows valid, accurate and flexible evaluation of liver stiffness and it is correlates with the fibrosis stage. The liver elastosonography, through new technologies available, has reached the level of the fibro-elastoscanner and magnetic resonance imaging. The ultrasound elastography application quickly advances, starting with the researches in this field. At present, it has analised the most various fields of application, from the breast, prostate, thyroid, pancreas imaging to the study of abdominal lymphnodes and peripheral vessels, gastrointestinal stromal tumors, primary and secondary liver tumors, the evaluation of uterine cervix, from cardiology to gastroenterology and urology, both in adults and in pediatrics.

[Gastric stromal tumor with liver and subcutaneus metastasis. Case report]. / Tumora stromala gastrica cu metastaze hepatice si subcutanate. Prezentare de caz.

UNLABELLED: The gastrointestinal stromal tumours expand from the undefine mezenchimal cells of the intestinal wall and the origin is in the Cajal interstitial cells. The agresivity of GIST is difficult to be evaluate. Very importants factors for grading are the tumour localisation, the invasion of serosa or mucosa, the dimensions of tumour and the number of mytosis. We present a case with haemoragic gastric stromal tumour, with small dimensions, which was initially diagnosed as a "benign" tumour. Seven years after the operation, the patient presented voluminous liver metastases. After right hepathectomy and medical treatment with Glivec we followed up the case. Eleven years after the first operation she presented a subcutaneus metastasis in parietal region, which was confirmed with imunohistochemical exam. The patient is still under observation with higher doses of Glivec. CONCLUSIONS: The gastrointestinals stromal tumours represent a very rare group of digestive tract tumors, with malignant potentially evolution; the first choice of treatment is surgery, with complete ablation of the tumour. The medical treatment with Glivec is necessary in case of reccurence or metastases; the stromal tumours present a strange evolution, for this reason all the patients must be under medical observation, for the rest of their life.

Magnetic acupressure for management of postoperative nausea and vomiting: a preliminary study.

BACKGROUND: To assess the efficacy of magnetic acupressure in the prevention of postoperative nausea and vomiting (PONV). METHODS: Fifty-eight patients were included in this randomized, double blind, preliminary prospective study. Thirty-three underwent ear, nose, and throat (ENT) procedures and twenty-five underwent gynaecological procedures. A magnet patch (M) or a placebo patch (P) was applied to patients in each group randomly. The patch was applied 15 min before surgery to P6 a point situated above the wrist, on the medial aspect of the arm between the palmaris longus and flexor carpi radicis (REF point). Anaesthesia was standardized for all patients. Primary study endpoints included PONV scores and number of rescue antiemetic administrations. Secondary endpoints included pain scores, percentage of patients who required rescue analgesics and satisfaction scores. Study variables were measured on arrival in the PACU and 8, 16 and 24 h after surgery. RESULTS: The global incidence of PONV was 50%. We found no significant difference in the incidence of PONV between ENT patients (46%) and gynaecology patients (56%), and no difference between patients who received magnet treatment (47%) and those that did not (54%). Patients receiving the magnet had a similar satisfaction level (75% satisfied) to those receiving placebo (73% satisfied). In addition, magnet-treated patients had similar pain and PONV scores, and a similar percentage of patients in each groups received postoperative rescue analgesics. Finally, there was no difference in the number of rescue antiemetic administrations between the two groups. CONCLUSION: The use of magnetic acupressure as a prophylactic antiemetic treatment prior to ENT or gynaecology surgeries produced no benefit when compared to placebo.

The angiogenesis in colorectal carcinomas with and without lymph node metastases.

UNLABELLED: Many clinical trials revealed that the anti-angiogenic treatment could improve prognosis in patients with metastatic colorectal carcinomas (CRC), when added to standard chemotherapy. In this paper, we tried to find out if the microvascular density (MVD) determined with CD31, CD105 was correlated with lymph node status, and if the intensity of angiogenesis was different in right versus left colon segments. We studied 187 CRC, with and without lymph node metastases, 128 from left and 59 from right colon. RESULTS: In the right colon, the MVD was higher in the cases where the lymph nodes did not present metastases (pN0) but also when four or more lymph nodes were involved (pN2). In the rectum and sigma, the angiogenesis presented the highest intensity in pN0 and pN1 stage (1-3 lymph nodes with metastases), decreasing in pN2 stage. In the descendent colon segment, the MVD did not present differences between the cases with and without lymph node metastases. CONCLUSIONS: Our study reveals that the most indicated cases for antiangiogenic treatment seem to be the pN0 and pN1 cases in the rectum and sigma, respectively pN0 and pN2 cases in the right colon. We tend to believe that the angiogenesis intensity in CRC is higher in early-stages of the tumoral proliferation but it is not an increasing process, having rather an oscillating character. Therefore, the angiogenesis remains an independent prognostic and predictive factor and the antiangiogenic treatment is necessary to be individualized for each patient.

The aspects of angiogenesis in anal canal carcinomas compared with that in colorectal carcinomas.

AIM: To compare the angiogenesis in anal canal carcinomas (ACC) with that in colorectal carcinomas (CRC). METHODS: A number of 507 CRC, surgical specimens, were analyzed, 12 cases (1.97%) being ACC. In 20 cases from left and right colon (CRC) and in the 12 ACC we analyzed the immunohistochemical parameters related to angiogenesis, utilizing the following LabVision antibodies: CD31, CD105 (endoglin) and VEGF1. Morphometrical analysis and positive cell counting were performed in the tumoral and peritumoral tissue. Immunoperoxidase method was used. RESULTS: The average age was 63.17 +/- 10.87 years in CRC, respectively 57.9 +/- 10.05 years in the ACC (p<0.0001). Compared with CRC the ACC occur more frequently at the females (58%). Angiogenesis was expressed in the majority of cases. In CRC, the microvascular density (MVD) was higher than that from ACC. The ratio CD31/CD105 was 1 in ACC and 3 in CRC. VEGF was positive in 25% of ACC and 80% of CRC. In CRC were more mature vessels, marked only with CD31 than immature vessels or endothelial isolated cells marked with both CD31 and CD105. In ACC prevailed the neoformed vessels marked with both CD31 and CD105. CONCLUSIONS: The performed assessments have showed a higher incidence of ACC at females and at younger ages. The angiogenesis in ACC was not so high like in CRC and the immature neoformed vessels was more frequently. In ACC, the antiangiogenic treatment that regards the VEGF inhibition seems to be not as efficient as in CRC. The radiotherapy could stop the angiogenesis and could inhibit the vessels' maturation.

Looking for the best management of myasthenia gravis at the Tg.Mures Clinic of Anesthesia and Intensive Care.

Thymectomy is one of the current management strategies for myasthenia gravis. This is observational study focused on the evolution of the surgical and anesthesiological strategies applied to the patients submitted to thymectomy initially by maximal sternotomy (in the years 1994-1998), followed by unconditioned reorientation towards thymectomy by VATS. A number of 103 patients are included, 51 thymectomy by left VATS. All the thoracoscopic thymectomy were performed in general anesthesia, the lungs were separated by left selective intubation, and the left lung was deflated during the surgical procedure. The surgical complications appeared mainly in the VATS group: one pericardial and one myocardial lesion leading to sternotomy (minimal blood loss, uneventful recovery), contralateral pleural lesion with pneumothorax. The classical approach accounted for one hemothorax. The postoperative mortality was zero in the VATS group vs. 6 out of 52 pts in the sternotomy group. The postoperative evolution confronted the anesthesiologist with the classical crises of myasthenia. Death occurred within the first three weeks following surgery. The demise in 3 cases was due to cardiac complications (preexisting cardiomyopathy complicated by ventricular arrhythmia) and respiratory failure plus sepsis (for the remaining cases that we lost). The treatment options in the ICU are discussed: plasmapheresis, immunosuppression, ventilatory support. VATS is appropriate for almost all thymectomy, but the outcome is heavily based on a team approach: neurologist, surgeon and anesthetist.

[Investigating the possibility of aerosol therapy individualization using the stochastic lung model]. / Investigarea posibilitatii de a individualiza terapia cu aerosoli cu ajutorul modelului pulmonar stochastic.

The aim of our study is to examine the possibility of individualizing aerosol therapy, by determining the ideal diameter of the inhaled particles and the optimal breathing pattern, using a computerized simulation program. In order to find the optimal breathing pattern, we used different variations of the tidal volume and breathing period. We tried to determine the ideal particle diameter by carrying out a series of simulations for particles with diameters ranging from 1 to 10 microns. Our results show that increasing the particle diameter will lead to higher deposition values in the upper respiratory regions and bronchi, and smaller values in the acinary regions of the lung. Repeated simulations have led to two different ideal particle diameters, according to the localization of the desired effect. This way, for the bronchial regions the ideal particle diameter is 10 microns, and for the acinary regions 2 microns.