Oesophageal stenosis dilatation through retrograde trans-gastrostomal approach in a patient with systemic scleroderma.

AIM: The paper presents the surgical solving of an oesophageal stenosis, using a device of pneumatic dilatation with trans-gastrostomal approach, in a patient with multiple disabling handicaps, secondary severe malnutrition and previously diagnosed with scleroderma. MATERIALS AND METHOD: The patient was admitted with severe cachexia (37 kg, 170 cm), characteristic byzantine face with microstomy, distal phalanges resorption in both superior limbs and complete dysphagia, with limitation of mouth opening.The Barium swallow test revealed distal oesophageal stenosis,with an important dilation of the oesophagus above. RESULTS: A gastrostoma was placed to allow nutrition (Gavriliu procedure), under general anaesthesia with trans-tracheostomal intubation. After 3 years, with her metabolic status improved(59 kg), the patient returned to our clinic asking for a solution for natural feeding. The technical difficulties in solving this case were determined by the limited mouth opening, which made anterograde oro-oesophageal balloon dilatation or bougienage impossible, as well as oro-tracheal intubation.Making use of the presence of the gastrostomal orifice,knowing von Hacker's mechanical dilation procedure and using the metallic Key Med kit with balls offered the possibility of the tactics and strategy of guiding a metallic guidewire introduced via the gastrostoma, then trans-stenotic and pulled out through the oral orifice. A modified Foley catheter (personal procedure) was attached to the initial catheter. The trans-stenotic retrograde traction of the Foley balloon was the pneumatic dilator factor that later allowed easy dilatation with the metallic dilator of the Key Med, to the maximum size. The follow-up showed good results, the patient returned to natural nutrition. CONCLUSIONS: The device of oesophageal pneumatic dilatation allows, using the presented surgical technique, a gentle plasty done under radiological supervision and lowers the frequency of accidents. The dilation permits the following use of Key Med kit. The novelty consists in adapting a well-known technique to a new patented device of pneumatic dilation with bidirectional approach under radiological control, for solving this atypical case.

Specifics of diagnosis and treatment in synchronous colorectal cancers (SCC).

INTRODUCTION: SCC have an incidence of 1,8% up to 12,4% and could have more simultaneous localizations. MATERIAL AND METHOD: Between January 2004 and January 2011, 214 patients with CRC have been operated on in our ward; from those, eight patients had multiple colorectal neoplasms. RESULTS: The majority of SCC (six cases) was hospitalized under emergency status, with incomplete or complete bowel obstruction through colonic obstructive tumour. The favourite localizations were on the sigmoid (six tumours) and the transverse colon (four tumours). The diagnosis was preoperatively assessed in three cases by colonoscopy and barium enema, intraoperative in four cases, postoperative in one case. Curative operations were performed in five cases and palliative operations in three. Immediate postsurgical evolution was good, long time evolution was marked by the complications of the primary disease. Out of five patients that were long term monitored, three have a five year survival, one has survived for three years and one deceased within a nine month period after surgery, with multiple metastases. CONCLUSIONS: Preoperative diagnosis of synchronous lesions can be difficult (emergency hospitalized patient, incomplete bowel preparation, bowel obstruction or intestinal bleeding) and the colonoscopy exam can be incomplete. Rigorous intraoperative colonic examination is necessary in order to diagnose synchronous lesions and avoid surgical reintervention.

[Clinical case--voluminous diaphragmatic hernia--surgically acute abdomen: diagnostic and therapeutical challenges]. / Caz clinic--hernie diafragmatica voluminoasa--abdomen acut chirurgical: dificultati diagnostice si terapeutice.

We present the case of a 58-year old male patient admitted in the surgery section of the University Emergency Hospital of Bucharest and diagnosed with acute abdomen. The minimal clinical-paraclinical investigation (i.e., thorax-pulmonary Xray, biological probes) raises questions as to the differentiated diagnosis and other associated diseases, also suggesting the existence of voluminous diaphragmatic hernia. The CT thorax-abdomen examination confirms the diaphragmatic hernia suspicion, with intra-thorax ascent of the colon up to the anterior C4 level, but does not explain the abdominal suffering; thus we suspected a biliary ileus or acute appendicitis. Medial laparotomy was imperative. Intrasurgically peritonitis was noticed located by gangrenous acute apendicitis, perforated, with coprolite, for which apendictomy and lavage-drainage pf the peritoneal cavity was performed. Post-surgical status: favourable to recovery.

[Clinical and morphological features in a case of recent gastric carcinoma (the signet ring cell carcinoma type)]. / Particularitati clinico-morfologice într-un caz de carcinom gastric incipient (tipul de carcinom în inel cu pecete).

The article presents the case of a male patient, hospitalized due to severe pain in the upper abdomen area, nausea, and vomiting. The patient was diagnosed with surgical acute abdomen, for which emergency surgery is performed. Upon penetration into the peritoneal cavity, stomach inspection shows at the medio-gastric level, on the greater curvature, a callous gastric ulcer, with a central perforation. A large excision is decided up to the healthy (normal) gastric tissue, and the resulting pieces are sent to the pathological anatomy laboratory. The histopathological exam reveals signet ring cell recent gastric carcinoma. The biopsy performed 1 month after surgery, prelevated from the antropyloric zone, reveals antropyloric gastritis with moderate activity and Helicobacter pylori positive. Due to the fact that such cases when this gastric cancer type is diagnosed in recent stages are extremely rare, we considered it useful to present it and look into its macroscopic and microscopic aspects, as well as into the differentiating diagnosis.

[Amyand's hernia--a clinical case]. / Hernia Amyand--caz clinic.

Amyand's hernia, a rare entity in the surgical pathology, presupposes the presence of the vermiform appendix inside a inguinal hernia sac (1). The hernia sac peritonitis by appendix swelling is even more rare, very few cases being presented in the surgical literature (1). The preoperatory diagnosis of Amyand's hernia is therefore very difficult. We herein present the case of a 71-year old male patient, operated on an emergency basis for hernia, which eventually turned out to be Amyand's hernia, a case which determined us to research the literature dedicated to this topic.