Pancreaticoduodenectomy In Patients With Hepatic Artery, Anatomic Variants: Tailoring, Perioperative Care and Surgical Outcomes.

Introduction: Pancreaticoduodenectomy (PD) is the procedure of choice in patients with tumors of pancreatic head or periampullary region. Hepatic artery anatomic variants (HAav) are frequently encountered during PD. Aim: To evaluate the incidence of HAav in a series of PDs and their consequence on technical tailoring and outcome. Material and Methods: Forty-five patients with HAav were identified in a consecutive series of 140 PDs for periampullary and pancreatic head tumors performed between January 1, 2007 and December 31, 2015. The groups with or without HAav were compared in terms of operative approach, complications and survival. Results: All patients underwent Whipple procedure, with right posterior approach for those having HAav. HAav was spared without damage in 41 cases. Four patients in whom the HAav were either sacrificed (2) or damaged (2) required arterial reconstruction. Conclusions: HAav are frequently encountered during PD. Its safeguarding is mandatory but in malignancy it can be damaged or sacrificed, hence arterial reconstruction is required. HAav have no negative impact on surgical morbidity and outcome.

Appendicular Mucocele: Possibilities and Limits of Laparoscopy. Brief Series and Review of the Literature.

INTRODUCTION: Appendicular mucocele, a cystic dilatation of the appendix, is a rare disease, but unfortunately about 1/10 of cases evolves into pseudomyxoma peritonei. METHODS: We performed a prospective study between 1 January 2010 to 31 December 2014 in order to track the incidence, symptoms, and circumstances of diagnosis, treatment and evolution of these rare tumors. RESULTS: A total of seven patients underwent curative surgery for a mucocele of the appendix: one woman and six men with an average age of 59.71 years. Clinical signs, present in two cases, were uncharacteristic. Ultrasound performed in all cases, could guide diagnosis in 5 cases. CT performed in 5 cases diagnosed only two cases. All cases were operated on: the open approach was used in four cases and a minimally invasive in three cases. We performed two right colectomies, an open appendectomy associated to anterior resection of the rectum, two laparoscopic appendectomies and two appendectomies and cecum resection with stapler, one by open approach and one by a minimally invasive approach. Intraoperative spillage of mucinous tumor did not occur in any case. The mean hospital stay was 5.7 days. Postoperative complications were present in 1 case (14.2%): wound infection. The average follow-up period was 40.28 months. (Range 6 to 48 months). No tumor recurrence or readmission, such as pseudomyxoma peritonei, has occurred. CONCLUSIONS: Appendicular mucocele is a rare entity; it can be found incidentally and it can mimic acute appendicitis, appendicular plastron or cecum tumor. Once diagnosed, surgical treatment is required for fear of perforation, tumor evolution and the emergence of the rule of complications. Laparoscopic approach in selected cases can be used, accompanied by safety measures to avoid iatrogenic perforation and peritoneal and parietal seeding.

Rare Tumors, Rare Association: Ovarian Strumal Carcinoid - Retroperitoneal Cystic Lymphangioma.

INTRODUCTION: Strumal carcinoid is a rare neoplasm of the ovary containing thyroid (struma) and carcinoid component revealed by immunohistochemistry. Case present: A 55-years-old woman with hysterectomy and right oophorectomy for uterine leiomyoma and right ovarian cyst, performed 12 years ago, was referred to the First Surgical Clinic, St. Spiridon University Hospital Iasi with pain in hypogastrium present for 2 months. Laboratory tests are normal and serum testing for tumor markers is unchanged. Ultrasound and CT finds for topography of the left ovary a well-defined 63 57 71 mm cystic mass, with a non-uniform wall thickness. Exploration laparoscopy, after adhesiolysis, identifies a cystic tumor developed in mesosigmoid which was excised and auterine tube with cystic dilatation and left ovary with intactcapsule, for which we performed left adnexectomy and extracted pieces of tumors in endobag. Evolution is simple, the patient being discharged after 3 days postoperatively. Histopathological exam and immunohistochemistry reveal edovarian strumal carcinoid and cystic lymphangioma. After one year follow up the patient is disease free. CONCLUSION: This association between an ovarian strumal carcinoid with mesosigmoidian cystic lymphangioma is unusual and rare, not cited in the literature. A laparoscopic approach for the two conditions is safe with good immediate and distant postoperative course.

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.

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.

Laparoscopic adrenalectomy for large solid cortical tumours--is it appropriate?

BACKGROUND: Laparoscopic adrenalectomy, the procedure of choice for small benign adrenal tumours, is also used for large tumours. Our study aims to assess the outcome of large adrenal tumours laparoscopically resected. METHODS: All patients with laparoscopic adrenalectomy performed in between 2002 and 2009, without preoperative or intraoperative malignant characteristics, were reviewed. Clinical, biochemical and CT follow-up data were reviewed for evidence of recurrent disease. RESULTS: Fifty patients underwent laparoscopic adrenalectomies in our unit, 18 of them having solid cortical tumours > or = 7 cm without preoperative or intraoperative malignant features: 6 Cushing's syndrome tumours, 8 non-secreting tumours, 4 aldosteronomas. The mean age of the patients was 46.89 years (range 22-64 years), and the mean tumour size 7.57 cm (range 7-9.1 cm). Histology identified 10 cortical adenomas, 4 malignant tumours, and 4 indeterminate tumours. The mean - follow-up was 28.94 months (range 4-58 months). Three patients died of systemic recurrent disease (liver and lung metastases) at 12, 19 and 21 month, respectively, after operation. One patient underwent a left hepatectomy for liver metastases, 33 months postoperatively. Fourteen patients have no evidence of recurrence. CONCLUSIONS: Adrenal tumours > or = 7 cm without pre- or intraoperative evidence of malignancy are resectable laparoscopically. This approach is unlikely to worsen the long-term outcome. The mortality is related to the malignancy.

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).

Laparoscopic management of gastrointestinal stromal tumours.

UNLABELLED: Gastrointestinal stromal tumours (GISTs) represent the most common non-epithelial tumour of the digestive tract. Laparoscopic approach may be considered ideal for the resection of these tumours. Their particular biological behaviour allows for a curative resection even without large resection margins and extensive lymphadenectomies. METHOD: Over a period of five years, eight patients benefited from laparoscopic resections (six patients with primary gastric GIST and two patients with small bowel GIST). Pathological features were analyzed including tumour size, surgical margin status, immunohistochemical staining profile, and tumour mitotic index. All cases were confirmed GISTs by immunohistochemical staining. RESULTS: The mean age of the patients was 61.6 years (range 48-71 years). Of these patients, five initially presented to hospital with acute gastrointestinal haemorrhage (four cases) or occult bleeding (one case). Gastric or small bowel tumours were identified during subsequent investigation. A presumptive diagnosis of gastric GIST was made in gastric lesions based on endoscopic, ultrasonic, and CT scan characteristics. Small bowel tumours were identified and presumed to be GIST based on information gathered from video capsule endoscopy, enteroscopy and CT scan. Complete resection was obtained with laparoscopic approach in six cases, while in two cases resection was laparoscopically assisted, with added oncology safety margins as preoperative definitive diagnosis was not available. Tumours varied in dimension from 2.5 cm to 9 cm and their malignant risk score using Fletcher criteria was low in three cases, intermediate in three cases and high in two cases. Mean postoperative stay was 3.8 days and there were no complications, nor postoperative mortality. After a mean follow-up of 26 months (range 1 to 60 months) all patients are symptom free and free of recurrent disease. CONCLUSIONS: A selective approach to laparoscopic resection of gastro-intestinal GISTs allows safe resection and very good results, on the condition that a clear diagnosis of GIST has been established on preoperative assessment. The laparoscopic feasible and safe considering the biological particularities of GIST, and it carries no additional risks.

Acute appendicitis--open or minimally-invasive approach?

BACKGROUND: Although laparoscopy has become the standard approach in other procedures, this technique is not generally accepted for acute appendicitis. AIM: To evaluate the results after minimally invasive appendectomies. METHODS: All medical records of patients operated for acute appendicitis during the last year were retrospectively reviewed. We considered only patients with diagnosis of acute appendicitis confirmed by histopathology. We designed two groups: operated by open approach (OA) and operated by minimally-invasive approach (MIA). The two groups were compared for differenced in homogeneity and main end results: morbidity, mortality, hospital stay. RESULTS: The men/women ratio was 112/88 (1.27), with a mean age of 31.83 +/- 1.06 years. There were more women in the MIA and more men in the OA group, p = 0.001. The Alvarado score was significant lower in MIA group (5.69 +/- 0.24 versus 6.57 +/- 0.23, p = 0.009). Comorbidities were noted in 51% from the patients, most of them in MIA group: 58.8%; N = 60, p = 0.016. Mean operation time was similar in both groups: 36.96 +/- 1.48 in OA versus 37.03 +/- 1.39 minutes in MIA. The postoperative mortality rate was 0.5%. The postoperative morbidity rate was 12%. Even though the number of cases with postoperative complications were double in OA group (16 cases versus 8 cases in MIA group) it did not reach statistical significance, p = 0.073. Histopathological examinations revealed early acute appendicitis in 45.5% cases (N = 91), suppurative appendicitis in 46.5% (N = 93) and gangrenous appendicitis in 8% (N = 16); early acute appendicitis was more frequent in MIA group and suppurative appendicitis in OA group: p = 0.017. The hospital stay was similar in both groups: 4.34 +/- 0.39 in OA versus 3.58 +/- 0.25 days in MIA group; p = 0.103. CONCLUSIONS: MIA is a safe procedure and can be performed even in the patients with comorbidities. We didn't find any statistical significant difference from point of view of postoperative morbidity; however more postoperative complications were find in OA vs MIA group. The postoperative hospital stay was similar in both groups.

Peritoneal tuberculosis in laparoscopic era.

UNLABELLED: Peritoneal tuberculosis is uncommon in developed countries, but as the general incidence of tuberculosis is on the rise in Romania so is the case with peritoneal localization of the disease. The present study retrospectively analyzed 18 patients (8 males and 10 females, mean age 50 years, range 17-74 years) diagnosed in our department with peritoneal tuberculosis between 1995 and 2007. RESULTS: Ascites was present in all but one case. Other common findings were weight loss (12 cases), weakness (5 cases), abdominal pain (16 cases), anorexia (6 cases) and night sweat (3 cases). Abdominal ultrasound has been used to demonstrate ascites in 16 cases. Only two patients had chest radiography suggestive for active tuberculosis. Laparotomy was performed in four cases, laparoscopy in 14 cases (two conversions). Intraoperative findings included multiple diffuse involvements of the visceral and parietal peritoneum, white "miliary nodules" or plaques, enlarged lymph nodes, ascites, "violin string" fibrinous strands, and omental thickening. Biopsy specimens showed granulomas, while ascitic fluid showed numerous lymphocytes. We conclude that the symptoms of abdominal tuberculosis vary greatly, and laparoscopy can be essential for diagnosis and management. The operation is safe, reliable with few complications and permits a prompt diagnosis, necessary to cure the patient.

[Pyogenic liver abscesses]. / Abcesele hepatice piogene.

BACKGROUND: Pyogenic liver abscesses were a relative rare disease. In the last decades the management of the liver abscesses was changed due to the new imaging and surgical techniques. AIM: To evaluate the clinical features, imaging techniques and treatment of the liver abscesses. METHODS: We performed a retrospective study during the last twenty years (1987-2007). The patients were divided in two groups: group I treated during the period 1997-2007 and group II, 1987-1996. We compare the clinical features, biological tests, imaging techniques and the treatment. RESULTS: Of the 71 patients with liver abscesses, 39 (54.9%) were included in group I and 32 (45.1%) in group II. The male/female ratio was 49/22; liver abscesses were more frequent to the males, in group I (63.3%) and more frequent to the women, in group II (63.6%) (p = 0.035). The mean age was 47.49 +/- 2.09 years old (range 18-85) with no difference between the groups (p = 0.059). The symptoms were similar in the two groups. We noted, as associated disease: diabetes--16% (N = 12), liver cirrhosis--7% (N = 5), malignancies--4.2% (N = 3). White blood cells were higher than 10000/mm3 in 51 patients (71.83%); a severe anemia with hemoglobin levels less than 10 g/dL was found in 25 cases (35.21%). All cases were investigated by ultrasound exam, but CT scan was performed in only 25 cases (19.71%). The abscesses were situated into the right lobe in 53 cases (74.6%), into the left lobe in 13 cases (18.3%) and into the both lobes in 5 patients (7%). The etiology was diverse: 25.4% after hepatic hydatid cysts, 12.7% with biliary origin, 22.5% with hematogenous and phlebitis origin and 39.4% with unknown origin (cryptogenetic). Treatment of the liver abscesses was surgical, by open (87.3%) or laparoscopic approach (8.5%), and percutaneous (ultrasound guided punction)--2.8%. One case was medical treated (antibiotherapy). Bacteriological exam found aerobic germs in 45 patients (64.28%), anaerobic germs in 3 patients (4.28%); the pus was sterile in 22 patients (31.43%). The intraoperative mean dimension of the liver abscesses was 74.26 +/- 4.35 mm (range 30-160), similar with dimensions measured by echography 72.29 +/- 4.84 mm (range 12-179)--p < 10(-3). Intraoperative bleeding was noted in 29 patients (40.8%). Univariate analysis revealed as prognosis factors for intraoperative bleeding, diameter of the liver abscess (p < 10(-3)), dimension of the residual cavity (p < 10(-3)) and the pus volume (p < 10(-3)). The multivariate analysis, by logistic regression, revealed as prognosis factors for intraoperative bleeding, pus volume (p = 0.006) and hemoglobin level (p = 0.035). Postoperative morbidity was 43.7%. Univariate analysis and logistic regression revealed the pleural effusion as prognosis factors for postoperative complications (p = 0.046) and, respectively, intraoperative hemorrhage (p = 0.010) and splenomegaly (p = 0.007). Postoperative mortality rate was 2.81%. CONCLUSIONS: Pyogenic liver abscess is a challenging disease with high rate of postoperative morbidity. Most of the abscesses are unique and situated in the right lobe of the liver. The imaging techniques, especially ultrasound exam and CT-scan, are essential for the diagnosis and the treatment of liver abscesses. The treatment is usually surgical, by open or laparoscopic approach; in selected patients the percutaneous approach can be performed.

[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.

[Fibrin-collagen patch (TachoComb) in general surgery. Indications and results]. / Foliile de colagen impregnate cu fibrinogen (TachoComb) in chirurgia generala. Indicatii si rezultate.

UNLABELLED: Adequate hemostasis is an important part of any surgical procedure, by open or minimally-invasive approach. The aim of this study was to evaluate the indications and the effect of absorbable fibrin-collagen patch--FCP (TachoComb). METHODS: We performed a retrospective study in the First Surgical Clinic Iasi, during 2000-2006. We evaluated the use and the results of FCP in different types of surgical procedures. RESULTS: A total of 245 patients underwent local hemostatic treatment during surgery. FCP was used in biliary surgery (50 patients), hepatic surgery (39 patients), surgery of the spleen (20 cases), pancreatic surgery (14), colo-rectal surgery (28), surgery of the thyroid gland (20), digestive sutures (39), thoracic surgery (3), surgery in retroperitoneum region (6), gynecologic and urologic procedures (7) and other types of surgical procedures (15). The results of the FCP use were: "very good" in 143 cases (58.4%), "good" at 64 cases (26.1%), "adequate" in 31 cases (12.6%) and "inadequate" at 7 patients (2.9%). CONCLUSIONS: The efficacy of FCP in local hemostasis is excellent. The use of FCP decrease the rate of conversions in laparoscopic surgery and is essential for spleen preserving surgery. The use of FCP in the treatment of digestive fistula is inadequate. FCP (TachoComb) is too expansive for some surgical units.

[Pancreaticoduodenectomy with or without pylorus preservation: a retrospective analysis of 137 patients]. / Duodenopancreatectomia cefalica cu sau fara prezervarea pilorului: analiza retrospectiva a 137 pacienti.

OBJECTIVE: We performed a retrospective study to assess the postoperative results, long-term survival and quality of life after pylorus preserving pancreaticoduodenectomy (PPPD) versus standard Whipple pancreaticoduodenectomy (WPD). METHODS: A retrospective study was performed in a nonselected series of 137 patients who were operated in the Surgical Clinics of "St. Spiridon" University Hospital Iasi, Romania, from January 1st, 1995 till December 31, 2005. Demographics, preoperative and intraoperative data, as well as postoperative morbidity, mortality and follow-up were analyzed. Quality of life, after to at least six months after discharge, was also studied. RESULTS: There were no significant differences noted in demographics data. Jaundice was more frequent in the PPPD group as for WPD patients (p=0.047). For the most patients the digestive reconstruction after resection were performed as in Child technique: the first anastomosis was pancreaticojejunostomy (end-to-end or end-to-side), the second anastomosis was hepaticojejunostomy (end-to-side) and the last anastomosis was gastrojejunostomy end-to-side (duodenojejunostomy in PPPD group). For 31 cases a pancreatico-gastrostomy were performed. We also noted 14 cases with pancreatico-gastrostomy and duodenojejunostomy end-to-end, and a Roux jejunal loop for 3 patients with previous gastrectomy and gastrojejunostomy (Reichel-Polya). The operating time was shorter in the PPPD group as in WPD (p < 10-3), but the mean blood loss was the same. Postoperative morbidity rate was 46.8% in PPPD group vs 39.2% in WPD (p > 0.05), but the reintervention rate was significant higher in PPPD group (30.6% vs 15%; p = 0.027). We also noted no significant differences of Delayed Gastric Emptying, postoperative mortality rate (14.5% in PPPD group vs 10.1% in WPD group) and mean survival time (42.42 months (24.94 - 59.89; 95% CI) in PPPD group vs 46.78 months (28.07 - 61.50; 95% CI) in WPD group; log rank test p = 0.643). Pathological exam diagnosed a malignancy in 109 cases (54 cases with pancreatic cancer); we noted chronic pancreatitis in 22 cases. Quality of life was also the same in the two groups. CONCLUSIONS: PPPD and WPD were associated with comparable results, but, there is a tendency of increase rate of postoperative morbidity and mortality for PPPD patients. We also noted that postoperative quality of life is the same for both procedures.

[Incidence and management of the ovarian fibroma and thecoma. Experience of The First Surgical Clinic Iasi]. / Fibroamele si tecoamele ovariene in experienta Clinicii I Chirurgie Iasi. Incidenta si conduita.

The ovarian fibroma, thecoma and fibro-thecoma are a rare benign tumors growing from the connective tissue of the ovarian cortex. The general surgeon may confront in his practice solid ovarian mass, sometimes in emergency. Between 1995 and 2005, we report thirteen cases of ovarian fibroma (two bilateral) and two ovarian thecoma with mean age 53 years operated in First Surgical Clinic Iasi. Four of them were operated on as emergencies. Clinical ascites are found in three patients with large tumors. The early symptoms were pelvic pain and abnormal uterine bleeding. Patients with large tumors or ascites were admitted with compression symptoms or abdominal distension. Ultrasonography showed a solid uniformly hypo-echogenic mass, with very marked sound attenuation. We performed oophorectomy in six cases (laparoscopic approach in four cases) and salpingo-oophorectomy in nine cases (using laparoscopic stapler in three cases). There were no conversions to laparotomy. In all cases the diagnosis was established by histological examination. Laparoscopic approach is associated with significantly less operative morbidity, less postoperative pain, shorter hospital stays and shorter recovery periods, best cosmetic results.

Laparoscopic wedge resection of gastric leiomyoma.

Gastric leiomyoma is a rare gastric neoplasia. The laparoscopic method may treat various gastric tumors, including benign leiomyoma by wedge resection without opening the gastric cavity. The laparoscopic approach to submucosal tumors of the stomach is technically feasible, is safe, and has good postoperative results. It should be considered a viable alternative to open surgery. Herein, we describe a case of laparoscopic wedge resection of gastric leiomyoma.

[Laparoscopic surgery of the liver, in 92 cases]. / Chirurgia laparoscopica a ficatului consideratii asupra 92 cazuri.

We analyze the experience in laparoscopic hepatic surgery of the Research Center of Laparoscopic and Open Surgery from Iasi between 1993-2006. This study includes 92 patients (0.9% from 10,367 laparoscopic operations) with liver pathology considered for laparoscopic treatment. We performed 42 Lin procedures (wide fenestration technique) for serous hepatic cysts, 32 cystectomies for hepatic hydatid disease, 10 non-anatomical hepatic resections (for 2 adenomas, 4 haemangiomas, 4 metastasis) and 8 steam water thermo-necrosis (for multiple hepatic metastasis). Conversion to open surgery rate was 8.7% (hepatic hydatid cysts--6 cases, serous hepatic cyst--1 case with associated acute cholecystitis, thermo-necrosis--1 case). We had no postoperative mortality and morbidity rate was 6.5%. The follow-up was available in all patients for a mean time of 12 months, by abdominal ultrasound exam and/or computed tomography. No evidence of disease recurrence was registered. We are at the beginning of the laparoscopic hepatic surgery and these results need to be confirmed. For the hepatic serous cysts the laparoscopic fenestration is the best treatment, but for the hepatic hydatid cyst, the laparoscopic approach is indicated only in selected cases: uni-vesicular hydatid cyst, noncomplicated, localised into the "laparoscopic" segments of the liver. Albendazole treatment is also necessary in these cases. For all types of benign liver tumours, the best indication remains small, superficial lesions, located in the anterior or the lateral segments of the liver. When performed by expert liver and laparoscopic surgeons using an adequate surgical technique, the laparoscopic approach is safe for performing minor liver resection for malignant tumours and is accompanied by the usual postoperative benefits of laparoscopic surgery.

[Conversion in laparoscopic cholecystectomy]. / Conversia in colecistectomia laparoscopica.

Laparoscopic cholecystectomy (LC) has become the gold standard in the treatment of symptomatic cholelithiasis. Some patients require conversion to open surgery and several preoperative variables have been identified as risk factors that are helpful in predicting the probability of conversion. The aim of this study was to analyze the factors that make LC difficult and determine conversion to open approach: Our study includes: 6985 cases which underwent LC and 1430 cases with open cholecystectomy, between March 1993 and April 2005 in our clinic of general surgery. The overall conversion rate was 5.1% (deliberate conversion--299 cases, conversion of necessity--62 cases). The conversion rate has decreased from 17.5% in 1993 to 3.2% in recent years. The most conversion happen after a simple inspection or a minimal dissection caused by the existence of perforation (105 cases), the discovery of a difficult anatomic situation (63 cases) or of another pathology (14 cases); more rarely, the conversion was necessary in the principal time, doing to hemorrhage (26 cases), impossible dissection (41 cases), visceral injury (1 case) or even at the end of the operation, doing to hemorrhage, loss piece or stone (10 cases), and other situations (101 cases). Significant predictors of conversion were acute cholecystitis , choledocholithiasis, past history of acute cholecystitis, male gender, gall bladder wall thickness exceeding 6 mm. In conclusion, based on our experience, we suggest limiting OC to patients with proven contraindications to LC (i.e., Mirizzi syndrome or systemic illness incompatible with general anesthesia or pneumoperitoneum), attempting LC in all other cases. Decision to convert to open approach is a proven of surgical maturity. Conversion must be decided from the beginning, in the moment of the recognition of a difficult situation and not after the occurrence of a complication.

[Cholelithiasis after gastric surgery--possibilities and limits of laparoscopic approach]. / Litiaza veziculara dupa chirurgia gastrica. Posibilitatile si limitele laparoscopiei.

An increased incidence of cholelithiasis has been widely reported after gastric surgery. In the early phase of patient selection, previous gastric surgery has been considered a relative contraindication to laparoscopic cholecystectomy. Between 1999-2003, in our clinic, laparoscopic cholecystectomy was attempted on 3145 patients. Of these patients, 37 patients had gallstone, which occurred several years (mean 17.9 years) after gastric surgery for peptic ulcer (34 cases), gastric cancer (1 case) and hiatal hernia (2 cases). Surgical procedures that had been performed included Billroth I gastrectomy (14 cases), Billroth II gastrectomy (15 cases), truncal vagotomy and piloroplasty (6 cases), and Nissen (2 cases). On this group there were 19 chronic cholecystites, 17 acute cholecystites and one cholesterolosis with gallbladder polyps. One patient was diagnosed with gallstone in common bile duct, successfully removed preoperatively after endoscopic sphincterotomy. The laparoscopic approach was possible in 26 cases. The technical difficulty after Cuschieri was level III--26 patients and level IV--11 patients (reconversion). The mean operative time was 75 minutes. The postoperative evolution of the patients was good in 36 cases. One case had a biliary fistula. The mean postoperative hospital stay was 3.6 days for laparoscopic cholecystectomy and 9 days after conversion. The postoperative adhesions determine the main technical difficulty, but it proved to be a relative contraindication for laparoscopic cholecystectomy for gallstones after gastric surgery. Clear visualization of anatomic structures and landmarks, and scrupulous hemostasis are needed to perform a safe laparoscopic cholecystectomy in these patients.