The utility of the predictive scores in polytrauma with abdomino-pelvic injuries: a series of 38 patients.

UNLABELLED: Trauma is the principal cause of mortality among the population under 40 years. The aim of our study was to compare predictive trauma scores and demonstrate their utility in the evaluation of the quality of care in polytrauma. MATERIAL AND METHODS: A retrospective study was performed between 2000-2011 including polytrauma patients with abdominal lesions and pelvic fracture who under went emergency laparotomy. We calculated ISS, GCS, RTS,TRISS, ASCOT trauma scores and W score for evaluation of treatment quality. RESULTS: We obtained the necessary data to calculate the predictive scores in 38 cases. Comparing the scores of the survivals and non-survivals we noted the following regarding mortality predictive scores: GCS 13.74 vs. 6.13 (p 0.0001),ISS 28.52 vs. 35 (p=0.0169), RTS 6.96 vs. 3.07 (p 0.0001),TRISS 84.67% vs. 28.7% (p 0.0001), ASCOT 10.34% vs.64.32% (p 0.0001). The W score in TRISS and ASCOT methodology was -2.05 (p=0.7997) and -7.81 (p=0.336),respectively. There was no statistically significant difference between actual and predicted mortality, the former being 39.47%. CONCLUSION: We did not observe differences between the two methodologies TRISS and ASCOT in mortality prediction (p=0.5401). Both of them can be used to predict polytrauma patient evolution. The W score is useful in treatment quality assessment.

Transthoracic versus Transhiatal esophagectomy: a permanent dilemma. our 15-year experience.

OBJECTIVE: Controversy still exists regarding the optimal surgical management of esophageal cancer. This study was performed to determine and compare early and late morbidity,mortality and overall survival after transthoracic (TTE) and transhiatal esophagectomies (THE). METHODS: Between 1997-2011, 100 patients underwent TTE or THE for squamous esophageal carcinoma (90 patients)and adenocarcinoma (10 patients). Assessed parameters included patient demographics, operative data, pathology results, postoperative morbidity and mortality and 1-3 year survival. RESULTS: Thoracic approach was preferred in cases of more advanced tumors, located in the upper and mid-third of the esophagus, in patients with a better cardiopulmonary status. Perioperative blood loss was significantly higher after transthoracic resections (p=0.0004) and these surgeries took significantly longer than transhiatal esophagectomies(p=0.02). We identified complications in 70.7% patients who under went TTE and in 59.3% patients with transhiatal approach. Respiratory complications were statistically significant in the TTE- group (p-0.0003). The 30-day mortality rates were 12.2% for patients in TTE group and 10.1% in THE patients group, respectively. The mortality ratefor the entire period of the study has been calculated at 84.4%.We have identified a survival rate after 1 year of 62.2%, after 2 years of 39.3% and after 3 years - 15.1%. CONCLUSIONS: According to the results of this study, both procedures appear to be acceptable depending on surgeon preference and appropriate patient selection.

Diffusion weighted imaging with background body signal suppression / T2 image fusion in magnetic resonance mammography for breast cancer diagnosis.

INTRODUCTION: Dynamic Contrast-Enhanced Magnetic Resonance Mammography (DCE-MRM) represents the most sensitive examination for breast cancer (BC) diagnosis. However literature data reports very inhomogeneous specificity. The aim of our study was to evaluate the clinical efficiency of a new MRM technique - diffusion weighted imaging with background body signal suppression T2 image fusion in BC diagnosis, compared to DCE-MRM. METHODS: We retrospectively analyzed 50 consecutive DCE-MRM examinations with DWIBS sequence from the archives of the Department of Radiology, Lyon Sud Hospital, (02.2010- 02.2011), summing up to 64 breast lesions. Fusions were created using the Osirix software from the DWIBS images (b=1000 s mm2) and their T2 correspondents. Interpretation was performed using an adapted BI-RADS system. The final histopathological examination or a minimum 6-months follow-up served as gold standard. RESULTS: Out of the 64 examined breast lesions, 35(54.7%) were classified as malignant by DCE-MRM and 24(37.5%) cases by DWIBS T2, respectively. Thus the DWIBS T2 fusion had a Sensitivity of 62.5%(95%CI:35.4-84.8) and a Specificity of 70.8%(95%CI:55.9-83.3) while DCE-MRM had a higher Sensitivity: 87.5%(95%CI:61.6-98.4) but a lower Specificity: 56.2%(95%CI:41.1-70.5). CONCLUSION: DWIBS T2 fusion is an innovative MRM technique, with a specificity superior to DCE-MRM, showing a large potential for improving the clinical efficiency of classical MRM.

Polycystic liver disease with complications: fenestration by laparoscopic approach.

AIM: Isolated polycystic liver disease is a rare congenital cystic liver disease with autosomal dominant transmission. Its main feature is the presence of a large number of cysts of different sizes in the hepatic parenchyma, which have a benign evolution. METHOD: We present the case of an 80 years old male patient with massive polycystic liver disease, diagnosed three years ago by ultrasound examination and abdominal computed tomography scan. The evolution of the disease had been complicated by compressive symptoms, caused by the large dimensions of the cysts. The patient presented with abdominal pain, nausea, vomiting and lost weight. Cyst fenestration through laparoscopic approach resolved the symptoms. RESULTS: The patient was mobilized on the day of the surgery, and was discharged on the 9th postoperative day, after drainage tube removal. CONCLUSIONS: Isolated polycystic liver disease is rare. Surgical treatment is indicated only if complications occur. The laparoscopic approach is an alternate treatment method, if needed. The patients benefit from the advantages of minimally invasive surgery.

[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.

[Bleomycin therapy for lymphangioma]. / Tratament cu bleomicina pentru limfangioame.

Lymphangiomas are uncommun congenital malformations of the lymphatic system, that involve the skin and subcutaneous tissues. Of the several types of treatment, surgical excision has been the preferred. There is a high recurrence rate because lymphangiomas tend to infiltrate the surrounding tissues. The bleomycin is a cytotoxic antitumoral antibiotic, that causes modifications of DNA. It has been also successfully used in intralesional injection treatment of cystic hygromas and haemangiomas, based specifically on a high sclerosing effect on vascular endothelium. We report the cases of five patients, with congenital lymphangioma, localized on the leg, in cervical and latero-thoracal region, treated with repeated intralesional bleomycin injections. The treatment indication was given by the location of this lesions and the infiltration of the surrounding vital tissues, that made the complete surgical excision impossible. Intralesional injection of bleomycin into the lymphangiomas was given at a dose, not exceeding 0,5 mg/kg of body weight, at intervals of 4 weeks. Complete resolution (n = 4) or significant improvement (n = 1) occurred in all patients treated. No other treatment was needed. We didn't notice local or general adverse effects. With this method we set the purpose to treat effectively this congenital malformations, obviating the need for invasive primary surgery or systemic treatment regimens. Toward other methods, intralesional bleomycin injections have a minimal risk of side effects (ulceration, pulmonary fibrosis).

A case of a giant sacrococcygeal teratoma.

Sacrococygeal teratomas are congenital tumors of newborns, originate from one or more of the three germinal layers. Most sacrococygeal teratomas are found in newborns, infants and children youger than 4 years. The prenatal ultrasound exams have increased the number of sacrococygeal teratomas presenting in fetuses. Radical resection, including the coccyx must be performed even if the primary lesion is benign in up to 70% of cases. We report a 16 days old baby girl presented with a large, type 111 sacrococygeal teratoma. The tumor was diagnosed only at 36 weeks of pregnancy. The teratoma was disected from the surrounding structures and excised en bloc with the coccyx. The postoperative recovery was uneventful. There are good functional and cosmetic results at six months follow-up.

[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.

[Local recurrence after the sphincter-saving operations and abdominal perineal resection in rectal cancer]. / Recidiva tumorala locala dupa chirurgia conservatoare si rezectia abdominoperineala în cancerul rectal.

By local recurrence we define the appearance of the same anatomopathological type of cancer like the one initially described in the primary tumor, limited at the rectum or pelvis.The study is based on the analysis of all the cases with rectal cancer who undergone surgical procedures in Surgical Clinic No.2 Tg. Mures in the last 5 years. Using the most important parameters for each patient we identified some risk factors for the recurrence of the rectal cancer: surgical procedures--there were no major variations in the local recurrence between the sphincter-saving operations and abdominal perineal resections. The most frequent recurrence tumors appeared after Hartmann I operation; the moderate aggressive adenocarcinomas at the old patients and high aggressive adenocarcinomas in young patients, T3, T4 stages. The recurrent rectal cancer is more frequent in aged patients with high aggressive adenocarcinomas. There were no major differences in recurrence rate between the sphincter-saving operations and abdominal perineal procedures.

[Long-term follow up after surgery for intractable ascites]. / Rezultate tardive ale tratamentului chirurgical pentru ascita netratabila.

The aim of the study is to evaluate the outcome of a selected group of 24 patients who underwent surgery for refractory ascites, in a 10 years period, 1995-2005. CLINICAL DIAGNOSIS: Alcoholic cirrhosis (n=18), inferior cava thrombosis (n=2), splenic vein thrombosis (n=1), cryptogenic cirrhosis (n=3), with association of variceal bleeding and refractory ascites. The surgical procedures consisted of porto-sistemic shunts (n=12), peritoneo-saphene shunts (n=10), mesenterico-caval shunt (n=1), mesenterico-right atrium shunt (n=1). Early results were very good: no postoperative mortality, no general haemo-dinamic failure, no renal fonctional failure, no encephalopathy. 7 of 10 peritoneo-saphene shunts had an excelent evolution, but in three cases the results were unsatisfactory, the patients continuing the medical treatment. Except one patient who died after 2 years, for B virus and alcoholic abuse, all the patients survived 5 or more years. There was not evidence of digestive hemorrhage or uncontrolable encephalopathy and thrombocytopenia. The grade of esophageal varices was mantained lower than II, ascites remained minimum or absent, and biological parameters were normal or slightly elevated. CONCLUSIONS: In the absence of the technical and economical possibilities of TIPS and liver transplantation, surgery for intractable ascites is a good option in selected patients, especially in the absence of viruses and alcohol consumption, and can improve complications in the natural evolution of the disease.

Two-step hepatectomy with right portal branch ligature for a right lobe metastasis.

AIMS/BACKGROUND: Hepatic resection is the only treatment with possible curative effect both for primary and secondary tumors. An increase of the rate of resectability for tumors considered inoperable at first and a decrease of the postoperative morbidity and mortality can be realized by right portal branch ligature and two-step hepatectomy. METHODOLOGY: This paper presents the case of a patient with left bowel cancer with a hepatic metastasis. A right portal branch ligature was performed followed by systemic postoperative chemotherapy. RESULTS: The right portal branch occlusion was followed by right lobe atrophy and left lobe hypertrophy, confirmed by CT scan. Three months after the portal occlusion a right lobe hepatectomy was performed. The postoperative evolution was favorable; eight days of hospitalization were necessary. CONCLUSIONS: Portal branch ligature can be performed in certain cases of hepatic tumors to increase the resectability rate.

Two-step hepatectomy with right portal branch ligature for a right lobe metastasis.

Hepatic resection is the only treatment with possible curative effect both for primary and secondary tumors. An increase of the rate of resectability for tumors considered inoperable at first, and a decrease of the postoperative morbidity and mortality can be realized by right portal branch ligature and two-step hepatectomy. We would like to present the case of a patient with left bowel cancer with a hepatic metastasis. Right portal branch ligature was performed which was followed by systemic postoperative chemotherapy. The right portal branch occlusion was followed by right lobe atrophy and left lobe hypertrophy, confirmed by CT scanning. Three months after the portal occlusion the patient underwent a right lobe hepatectomy. The postoperative evolution was favorable, eight days of hospitalization were necessary. The portal branch ligature can be made in several cases of hepatic tumors to increase the resectability rate.

[Spleno-renal distal and proximal shunts for hypersplenism due to hepatic cirrhosis]. / Suntul spleno-renal distal si proximal pentru hipersplenismul datorat cirozei hepatice.

The secondary hypersplenism appears from 30-50% in liver cirrhosis with portal hypertension. The mechanism of the complication is the splenic congestion as the result of the progress of the portal hypertension. Between 1997-2005, 16 patients with hypersplenism due to liver cirrhosis were operated in the service. The aim of the operation was to decompress the portal hypertension, by spleno-renal shunt (Warren), in 6 patients, truncular shunts in 2 patients, and splenectomy with spleno-renal shunts in 8 patients. No postoperative death was noted on the series. The platelets number and the white blood cells, destroyed by the reticuloendothelial system of the spleen, were counted in the first month and the first year, as well as the spleen volume. In patients with non-splenectomy operations the improvement of the blood elements number was remarked in the first week, but the volume of the spleen remained increased during 1-6 month. In patients with splenectomy the platelets and the white cells dramatically increased, with the risk of coagulation disfunction. The survival rate at five years was 12 patients.

[Cervical anastomotic fistula in surgery of the esophagus]. / Fistulele anastomozelor cervicale din chirurgia esofagului.

Cervical anastomotic fistula are reported in the surgical literature in 10-30% of the patients, providing a much longer hospitalisation, a higher morbidity and in some cases even mortality. Between 1997-2003, 91 patients underwent surgical treatment for esophageal cancers and 14 patients for chemical burns. In the cancer group the rate of resection was 67,03% (61 patients). In 8 patients with non-resection tumours a retrosternal esophageal by-pass with stomach was carried out. Cervical anastomosis were performed in 68 patients, by hand sutures. Anastomotic fistula were noted in 9 patients (13,24%). In 6 cases temporarily fistula occurred, with spontaneous healing by local treatment, in 8-28 days. 2 patients required reoperation and one patient a definitive feeding jejunostomy. Most common causes of fistula are technical problems, ischemic gastric or colonic tube, postoperative respiratory failure, with prolonged hypoxia. An anastomosis in the neck results in less postoperative complications than one of the lower level.

[Telescopic anastomosis in colorectal surgery]. / Anastomoza prin telescopare in chirurgia colonului.

UNLABELLED: The most frequent postoperative morbidity and mortality in the colorectal surgery is caused by the failure of the anastomosis. On the base of the statistics the postoperative mortality caused by the failure of the anastomosis can rise up to 20%. In the last decade a lot of types of anastomoses was initiated, for example: telescopic anastomosis, mechanical anastomosis with stapler, anastomosis with a bio-fragmentary ring. In the technique of the telescopic anastomosis, introduced from the beginning of 20th century, many changes had made. The experimental and the operative results shown that the telescopic anastomosis is a secure, fast and cheap procedure in the surgery of the colon. CONCLUSIONS: the telescopic anastomosis is applicable also in emergency, with a short septic time , easy procedure and doesn't need special instruments.

[Clinico-statistical evaluation study of the quality of life after gastrectomies for cancer]. / Studiu clinicostatistic de evaluare a calitatii vietii dupa gastrectomiile pentru cancer.

The study compares the quality of post-operatory life after total gastrectomy with that after subtotal gastrectomy for gastric carcinoma. The routine use of "de principe" total gastrectomy remains controversial. Most surgeons believe that the routine use of it increases both postoperative morbidity and mortality and also the nutritional deficiencies, without improving the 5-year survival rate. It is also associated with a poorer outcome in terms of postoperative quality of life, the evidence of which is still under study. At the Surgical Clinics I and II in Targu Mures 414 patients have undergone, during January 1997 January 2004 subtotal gastrectomies (241) respectively total gastrectomies (173) for gastric carcinoma, of which 133 were resections performed with a curative intent, using radical D2-lymphadenectomy. Quality of post-operatory life at the moment of study was evaluated using our own questionnaire, developed upon studying and in accordance to those internationally in use by the de EORTC (European Organization for Research and Treatment of Cancer) and ECOG (Eastern Cooperative Oncology Group). The results of the study show that the quality of life of patients who underwent subtotal gastrectomies is significantly better than of those with total gastrectomies (without pouch). The imposing conclusion is that subtotal gastrectomy is recommended as the treatment of choice (when oncologically feasible) for tumors of the stomach, dismissing the "de principe" total gastrectomy.

[Multivisceral operations for carcinoma of the upper stomach and cardia]. / Operatii multiviscerale pentru cancerul gastric al polului superior si al cardiei.

In this study are noted technical problems regarding "en bloc" multiple organ resections and the anatomic and functional reconstruction for carcinoma of the upper stomach and cardia. From 1997 to 2002, a total of 264 patients with cancers of the stomach were operated in the service. 75 patients presented cancers localized at the proximal stomach and cardia (97.33% adenocc.). The rate of resectability was 27.77% (27 pt.). Types of operations in this series were: standard esophagogastrectomy in 7 patients; total gastrectomy with regional lymphadenectomy in 9 patients; 11 patients underwent "en bloc" multiple organ resection, with the removal of the stomach, partial or total esophagectomy and, occasionally, ablation of the spleen, pancreas, left hepatectomy, resection of the diaphragm and an extensive lymphadenectomy. Surgical mortality for the complex multivisceral resections was noted in 3 patients (8.88%). The global 5 years survival in the service is poor: 15.9%.

[Peritoneo-saphenous shunt for the treatment of ascites]. / Suntul peritoneosafen în tratamentul ascitei.

UNLABELLED: The life quality of the patient suffering from hepatic cirrhosis is affected by ascites refractory to drugs treatment. In the last 30 years, in the ascites treatment there were performed peritoneo-jugular shunts through synthetic prosthesis with unidirectional valve-LeVeen, Denver. The siliconated prostheses are expensive and in the process of time complications are registered consisting of clogged valve or obstruction, requiring thus their replacement. The unidirectional drainage of the ascites can also be performed through peritoneo-saphenous shunt. In our clinic, the peritoneo-saphenous shunt was applied for the first time in 2004, in three patients with hepatic cirrhosis with ascites refractory to drugs treatment. The postsurgical evolution was favourable, a gradual increase of diuresis and reduction of abdominal diameter being registered in all the three cases. CONCLUSIONS: the peritoneo-saphenous shunt is a simple procedure, it does not require special devices and it can be applied with success in the treatment of refractory ascites.

[A simplified method of diverting colostomy]. / O metoda simplificata pentru colostomia pe bagheta.

The diversion of the fecal stream is necessary in some situations, to protect lower anastomosis, or in emergency operations on the colon. Several techniques of colostomy were described, in order to improve the sustaining bridge to the skin level, for the immediate placement of a colostomy bag. A simplified method of diverting colostomy is presented: a plastic tube bridge is passed subcutaneously, extraperitoneally, under the colon loop, permitting an immediate opening of the loop and the placement of the colostomy bag.