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.

Radiofrequency ablation device assisted liver resection for hepatocellular carcinoma.

UNLABELLED: The present study aim was to evaluate radiofrequency (RF)-assisted liver resection for hepatocellular carcinoma (HCC). PATIENTS AND METHODS: 35 consecutive patients were enrolled in this study. A Habib®4X RF ablation device (RFAD) was used for liver resection. The patients were divided into two groups: in group A (45.7%; n=16) liver resection was performed using the RFD, whereas in group B (54.3%; n=19), liver resection was performed without RFD. The data were analysed for statistical significance. RESULTS: The study population had a male female ratio of 25 10 and a mean age of 62.6 ± 11.6 years old. The mean overall tumor volume was 161.8 ± 35.5 mL and there were no differences in tumor volume between groups. The operative time and intraoperative blood loss were lower in group A,but without statistical significance [132.5 ± 61.5 vs 167.9 ± 46.3 mins, (P=0.061) and 459 ± 342 vs 716 ± 648 mL (P = 0.135)]. No differences were reported between the two groups in operative accidents (P = 0.508) and postoperative morbidity (P=0.782); a higher rate of late postoperative complications was found in group A (56.3% vs. 16.7%, P = 0.016). The overall postoperative mortality rate was 2.8%. Local recurrence was noted in 32.4%. The three-year cumulative survival rate was 60%. CONCLUSIONS: RFAD allows liver resection with low postoperative mortality and morbidity rates; RFD tends to decrease the operative time and blood loss.

Laparoscopic Transabdominal Pre-Peritoneal (TAPP) procedure - step-by-step tips and tricks.

UNLABELLED: Minimally invasive approach for groin hernia treatment is still controversial, but in the last decade, it tends to become the standard procedure for one day surgery. We present herein the technique of laparoscopic Trans Abdominal Pre Peritoneal approach (TAPP). The surgical technique is presented step-by step;the different procedures key points (e.g. anatomic landmarks recognition, diagnosis of "occult" hernias, preperitoneal and hernia sac dissection, mesh placement and peritoneal closure) are described and discussed in detail, several tips and tricks being noted and highlighted. CONCLUSIONS: TAPP is a feasible method for treating groin hernia associated with low rate of postoperative morbidity and recurrence. The anatomic landmarks are easily recognizable. The laparoscopic exploration allows for the treatment of incarcerated strangulated hernias and the intraoperative diagnosis of occult hernias.

Atypical hepatic resection technique for hepatocellular carcinoma using radiofrequency Habib™ 4X Device.

INTRODUCTION: The number of liver resections significantly increased worldwide in the last 20 years. In many hepatic tumours, liver resection remains the best therapeutic option. A difficult intraoperative goal is to obtain a safe haemostasis on the transection plane. Technological innovation in recent decades allowed the development of different tools that allow better control of bleeding, faster and easier haemostasis. METHODS: We prospectively reviewed the patients diagnosed with hepatocellular carcinoma who underwent an atypical liver resection using a radio frequency (RF) ablation. SURGICAL TECHNIQUE: We used a Habib™ 4X bipolar, handheld, disposable RF ablation device. The technique is similar to parenchymal approach, but after the operative ultrasound exam to confirm the tumour and resection plane and liver mobilisation, we perform a plane of coagulative necrosis around the tumour using Habib™ 4X. The parenchyme is then sectioned using the scalpel. RESULTS: 19 patients with hepatocellular carcinoma were included in this study. The mean operative blood loss volume was 170±90.7 ml. The mean operation time was 118±58 min. The postoperative morbidity rate was 32% (n=6) and the reintervention rate was 5.3% (n=1). We encountered no postoperative deaths. The overall mean postoperative stay was 11.6±5.1 days. CONCLUSION: Bipolar radiofrequency device Habib™ 4X allows a shorter operative time with minimal blood loss and low rate of morbidity and mortality.

[Right colon cancer--clinicopathological findings]. / Cancerul colonului drept--particularitati anatomo-clinice.

BACKGROUND: The right colon cancer (RCC) has some particularities from point of view of epidemiology, clinical aspects, therapy and prognosis. MATERIAL AND METHODS: We retrospectively analyzed the patients operated in the First Surgical Unit Iasi during 2004 until 2009, for right colon cancer. The patients' data from the medical files were digitally encoded and included into a MS Access database, and statistically analyzed. RESULTS: 219 cases were included into the analysis, which represents 24.17% from all the patients with colorectal cancer. The median age was 66 years old. A palpable mass into the right abdominal quadrant was founded in 41.5% and anemia in 65.3%. Abdominal ultrasound exam has been performed in all the patients, with 71.3% sensitivity for primary tumor positive diagnosis. Resectability was 89.5% but without multivisceral resections. The intraoperative complication rate was 6.8%; postoperative morbidity was 19.4% with an incidence of anastomotic leak of 1.38%. The postoperative mortality rate was 2.77%. The mean overall survival was 40.13 +/- 1.93 months (median: 49.26). The prognosis factors for the survival rate were: histologic type of the tumor, stage and tumor grading, vascular and perineural invasion. The presence of metastasis in more than 3 lymphnodes as well as resection of fewer than 11 lymphnodes were found as negative prognosis factors for the survival rate. CONCLUSIONS: RCC has an increasing incidence and it is associated especially with elderly patients. The RCC resectability is about 90% with acceptable rates of morbidity and mortality. Perineural and vascular invasion as well as rate of positive lymphnodes and count of resected lymphnodes are prognosis factor for overall survival rate.

[Small bowel tumours from barium meal to capsule endoscopy and from open to laparoscopic approach]. / Tumorile intestinului subtire de la tranzitul baritat la enteroscopie, de la abordul clasic la cel laparoscopic.

INTRODUCTION: Tumors of the small bowel are rare and present with nonspecific symptoms. That causes a significant delay in diagnosis and consequently a worse outcome for the patient. METHODS: In a retro-prospective study we evaluated a series of 63 patients with small bowel tumors operated in the First Surgical Clinic Iasi, during 1992-2010: 18 duodenal tumors, 26 jejunum tumors and 19 ileum tumors. There were 18 (28.6%) cases with benign tumors and 45 (71.4%) cases with malignant tumors (41 primary tumors and 4 secondary tumors). We discuss problems related to diagnosis, treatment and prognosis of these tumors in the presence of new explorations (capsule endoscopy, enteroscopy) and minimally invasive approach. RESULTS: Duodenal tumors were malignant in 14 cases (11 adenocarcinomas, 3 malignant GIST tumors) and benign in 4 cases (adenoma, lipoma, GIST tumor, schwannoma) which led to stenosis in 5 cases, upper gastrointestinal bleeding in 3 cases. Positive diagnostic was confirmed with barium meal and endoscopy. The jejunal and ileal tumors were mostly malignant 31 cases (13 carcinomas, 10 lymphomas, 2 malignant GIST and one sarcoma) with only 14 cases of benign tumors (5 GIST). Their tendency was to present as emergencies: 17 obstructions and 5 peritonitis. Modem imagistic proved useful as diagnostic tool: capsule endoscopy, CT-scan and enteroscopy. The benign tumors benefited from local resection (5 cases) and segmental enterectomy (12 cases), while malignant tumors were managed using Whiple's procedures (10 cases), duodenal-jejunal resections (1 case), segmental enterectomy (29 cases), ileocolectomy (2 cases) and three bypasses. Laparoscopic approach was performed in 8 cases. CONCLUSIONS: The incidence of small bowel tumors remains low. For diagnosis, CT-scan, enteroscopy and capsule endoscopy are very useful; unfortunately the last method is not practicable in emergency. Surgery is the best choice plus chemotherapy for some malignant tumors. Laparoscopic approach is feasible in selected cases.

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.

Treatment of gastrointestinal stromal tumors--initial experience.

BACKGROUND: Gastrointestinal Stromal Tumors (GIST) offered the first opportunity of a specific treatment in neoplasms (tyrosine-kinase inhibitors) and also a new perspective of management of other neoplasms. METHODS: We have prospectively recorded the clinical characteristics, type of surgery, pathologic findings, adjuvant treatment, and recurrence of the patients with confirmed GISTs admitted between January 2004 and December 2008. RESULTS: There were 18 patients. Location of the tumor was gastric (44.44%), duodenal (11.11%), jejunal (16.67%), right colon (5.55%) and rectal (22.22%). None of our patients had clinical, imagistic or macroscopic metastases. All the patients had R0 resections, except a patient with local excision and another with R1 anterior resection for rectal GISTs. Postoperatively, 4 patients received Imatinib therapy. The mean follow-up period is 32 months (range 8-58 months); 2 recurrences, both after rectal GISTs. The rest of patients are tumor-free and subjects of prospective follow-up. CONCLUSION: We present the first 5 years experience of a prospective study of GIST started in 2004. The complete resection and the malignant potential according to Fletcher index are the most significant prognostic factors. Imatinib treatment may improve outcome in incomplete resected or high risk GISTs.

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.

[Surgical treatment of hyperparathyroidism]. / Tratamentul chirurgical al hiperparatiroidismului.

BACKGROUND: Hyperparathyroidism (HPT), the result of excessive secretion of the parathormone, is one of the most common endocrine disorders. In most forms of HPT, surgical parathyroidectomy is the best choice. AIM: This paper aims to examine patients with hyperparathyroidism operated in First Surgical Unit Iasi, in terms of indications, surgical technique and postoperative results. MATERIAL AND METHOD: We performed a retrospective study, in First Surgical Unit Iasi, during 2000-2008. Clinical, laboratory, intraoperative and histopathological data were included in a MS Access Office XP database. Statistical analysis was performed with the SPSS ver. 15.0 for Windows (Statistical Package for the Social Sciences, Chicago, Ilinois). RESULTS: There were examined 34 patients with HPT: 32 cases were primary HPT (94.12%), and two cases with secondary HPT (patients with renal failure). The men/women ratio was 6/28 and mean age was 50.09 +/- 2.23 years old. Clinical presentation was variable: the dominant symptoms were osteoarticular (67.6%) followed by neuropsychological (64.7%), digestive (17.6%) and renal (11.8%). Associated diseases were recorded at 47.06% of patients: arterial hypertension--32.4%, coronary heart disease--23.5%, heart rhythm disorders--17.6%, diabetes--11.8%, biliary lithiasis--5.9%, renal lithiasis--8.8% and thyroid hypertrophy--55.9%. In 8 cases, primary hyperparathyroidism was associated with other diseases of the endocrine glands: 4 cases with Multiple Endocrine Neoplasia (MEN) type 1; a patient with von Recklinghausen disease; a patient with associated hypothyroidism and diabetes; two cases that with papillary thyroid carcinoma. Positive diagnosis was supported by determining serum calcium, phosphorus and serum concentration of the parathormone (PTH). All patients were evaluated by ultrasound exam; the sensitivity of the investigation was 88.23%. 99Tc-sestamibi scintigraphy was performed in 32.35% of patients with a sensitivity of 72.72%. Parathyroidectomy was performed by Kocher's incision in 88.23% and minimally-invasive open approach in 11.76%. The following types of interventions have been performed: tumor resections (73.53%), subtotal parathyroidectomies (17.6%), total parathyroidectomies (8.82%). In patients with associated thyroid disease total thyroidectomies (26.5%) and subtotal thyroidectomies were done (11.8%). The postoperative morbidity rate was 2.9% (transient hypocalcemia). Histopathological examination revealed the presence of parathyroidian adenoma in 67.6% of patients (N=23), parathyroidian hyperplasia in 26.5% (N=9) and parathyroidian carcinoma in the others 5.9% (N=2). CONCLUSIONS: The diagnosis of HPT involves positive determination of calcium and PTH. The most useful imaging techniques, are 99Tc-sestamibi scintigraphy and ultrasonography, which locates in most cases, the parathyroid pathological glands. Surgical treatment is the only curative treatment of HPT, with medical treatment only role in preoperative preparation. The precise site of the parathyroidian lesion facilitates minimally-invasive approach. The postoperative follow-up is mandatory because of the increased potential for recurrence and for diagnosis of other endocrine tumors (in patients with MEN).

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.

[Parathyroid glands involvement in multiple endocrine neoplasia]. / Interesarea paratiroidelor in neoplaziile endocrine multiple.

UNLABELLED: Multiple endocrine neoplasias are syndromes characterized by the involvement of at least two endocrine glands. Parathyroid gland involvement is usually noted in Multiple Endocrine Neoplasia (MEN) type I and type II. Parathyroid glands tumor associated with endocrine pancreatic tumor, as well as pituitary tumors is the typical pattern of MEN I. The parathyroid gland is the most frequent abnormality in MEN I. CASES REPORTS: We presented five cases with MEN I and parathyroid glands involvement. In three cases with young ages (28-33 years old) and familial setting, the MEN I syndrome was "complete" (parathyroid adenoma, gastrinoma or insulinoma and pituitary adenoma--prolactinoma or GH-secreting tumors), and, in the other two cases, with 57 and 68 years old respectively, the MEN I syndrome was "incomplete" with parathyroid glands and pituitary gland involvement. The cases with gastrinomas were operated in emergency for complication of peptic ulcer (perforation associated with peritonitis and gastro-intestinal bleeding); then the pancreatic tumors were diagnosed and left pancreatectomy with spleen preservation and respectively, tumor resection have been performed. Hyperparathyrodism was then diagnosed and subtotal parathyroidectomy has been performed in both cases. Unfortunately one patients died due to severe endocrine disorder. During the necropsy, the pituitary adenoma has been diagnosed. The third case with "complete" MEN was a women of 33 years old, admitted for severe hypoglycemia. The imagistic and laboratory test diagnosed a tumor situated into the pancreatic body, and an parathyroid adenoma. The resection of pancreatic tumor associated with resection of the parathyroid adenoma, in the same time, were performed. The other two cases with "incomplete" MEN were older then the first patients, and were diagnosed with hyperparathyrodism and pituitary gland tumor. The resection of parathyroid gland adenoma has been performed in both cases, with uneventful postoperative course. The literature data was also discussed. CONCLUSIONS: The parathyroid glands involvement in MEN is common. There are two kinds of MEN associated with parathyroid gland involvement: the "complete" form, especially in young patients, with diffuse involvement of the parathyroid glands, and the subtotal parathyroidy is the best choice, and the "incomplete" form, especially in elderly, with the involvement of a single parathyroid gland; in this way, the resection of the adenoma associated with biopsy from the other parathyroid gland is the best approach. The presence of gastrinomas, complicate the disease prognosis and the surgical approach. The treatment of these patients is challenging and has to be done in multidisciplinary team.

Training on a virtual reality simulator--is it really possible a correct evaluation of the surgeons' experience?

UNLABELLED: Laparoscopic simulators provide a safe and efficient means of acquiring surgical skills. It is well known that virtual reality training improves the performance of young surgeons. Most of the virtual reality simulators have construct validity and can differentiate between novice and expert surgeons. However, for some training modules and trainees categories the possibility to distinguish the real surgeon's experience is still discussed. METHODS: A total of 14 young surgeons were evaluated during a 5 days postgraduate laparoscopic course using a LapSim Basic Skills, v. 3.0 simulator and a Virtual Laparoscopic Interface (VLI) hardware. The best performances of the surgeons were included in a MS Access database and statistical analyzed. RESULTS: There were 6 males and 8 women with a mean age of 30.21 +/- 1.01 years old (range 26-38). Nine surgeons (64.28%) were young residents without any laparoscopic surgical experience (group I), and the other 5, had some laparoscopic surgical experience (10 to 30 laparoscopic procedures) (group II). During the instrument navigation task we found that both hands performances were significant better in group II--the navigation time was 12.43 +/- 1.31 vs 19.01 +/- 1.40 seconds for the left hand--p = 0.006 and 13.57 +/- 1.47 vs 22.18 +/- 3.16 seconds for the right hand--p = 0.032); the right instrument angular path degree was also shorter for experienced surgeons (153.17 +/- 16.72 vs 230.88 +/- 22.6 - p = 0.017). The same data were noted for the lifting and grasping module. However, the suturing module tasks revealed contradictory results: the group I residents recorded better performances then the group II surgeons: total time--677.06 +/- 111.48 vs 1122.65 +/- 166.62 seconds; p = 0.043; right instrument path (m)--15.62 +/- 2.47 vs 25.73 +/- 3.13; p = 0.028; right instrument angular path (degree)--3940.43 +/- 572.54 vs 6595.5597 +/- 753.26; p = 0.017. CONCLUSIONS: Laparoscopic simulators are useful to evaluate the surgeons' experience; the parameters of the instrument navigation and lifting and grasping modules, which require a higher degree of eye-hand coordination, were better for residents with previous surgical experience and revealed a good transfer of training (TOT). The suturing module is less influenced by surgeons' experience. This result is probably explained by a lack of TOT.

[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.

[Surgical treatment of gynecomastia]. / Tratamentul chirurgical al ginecomastiei.

BACKGROUND: Gynecomastia describes a benign increase of the mammary gland in men. When medical treatment fails, the surgical procedure is the treatment of choice. There are two main surgical procedures: subdermal mastectomy and liposuction. AIM: To evaluate the results after surgical treatment (mastectomy) performed in a general surgery unit. METHOD: We performed a retrospective study; all the patients operated for gynecomastia were reviewed. The clinical, imaging, biological, intraoperative and histological data were included into a MS Access database and statistical analyzed. RESULTS: From 1990-2007, 114 patients were admitted in the First Surgical Clinic Iasi for gynecomastia. Only 12.6% from the patients were with bilateral gynecomastia. The mean age was 40.54 +/- 1.83 years old (range 12-84). Mean body mass was 26.72 +/- 0.46 kg/m2 (range 18.5-41), and about 20% from the patients had a BMI of over 30 kg/m2. We also noted that 46.5% were smokers. Simon classification was used for preoperative staging: 2.6% from the cases (N = 3) were included in stage I, 16.7% (N = 19) in stage IIa, 50% (N = 57) in stage IIb and 30.7% in stage III. The patients included in stages IIa and I are younger then the patients included in stage III (p = 0.024). Mastodynia was noted in 46 cases (40.4%). Ultrasound exam was performed in all the cases, and the larger diameter of the nodule measured was 3.75 +/- 0.18 cm (range 0.5-9.7). Only three cases were preoperatively treated with tamoxifen. Most of the cases were operated using general anesthesia (53.5%). Mastectomy was performed by peri-areolar (70.2%), elliptical (28.9%) or radial (0.9%) incisions. The subdermal mastectomy using peri-areolar approach was performed especially for the cases included in stages I, IIa and IIb--p < 10(-3). The epi-pectoral vacuum drainage has been used in 79.8%. The postoperative morbidity rate was 15.8%--4 cases of hematoma, 13 cases of seroma and 1 case complicated with skin necrosis. No specific risk factors for postoperative complications were found by univariate and multivariate statistical analysis. The pathological exam revealed pseudo-gynecomastia in 6 cases; the other cases presented dilated ducts. We also noted intraductal papillary hyperplasia in 87 cases and chronic inflammation in 35 cases. The histological exam also revealed intraductal papilloma--9 cases, fibro-adenoma--1 case, papillary ductal carcinoma--1 case and mucinous carcinoma--1 case. From all these data, the etiological diagnosis in presented series was: pseudo-gynecomastia--5.3% (N = 6), idiopathic--64.9% (N = 73), endocrine--7.9% (N = 9), drug induce--5.3% (N = 6), metabolic--7.9% (N = 9), tumoral--8.8% (N = 10). The postoperative hospital stay was 4.04 +/- 0.26 days (range 1-12). A literature review has also been performed. CONCLUSIONS: The management of gynecomastia has to be performed by a multidisciplinary team. Gynecomastia it is possible to be associated with a breast cancer, even in younger people. The surgical treatment, especially the type of incision, will be chosen from point of view of Simon stages. Liposuction can be associated in selected cases.

[Unusual forms of liver abscesses]. / Forme particulare de abces hepatic.

UNLABELLED: Liver abscess is a rare disease. In this paper we present five unusual cases of liver absceses. These cases represents 5.68% from all patients with liver abscesses treated in the First Surgical Clinic Iasi, from 1977 to 2007. The ethiology of the abscesses was different: intrahepatic biliary duct migration of Ascaris lumbricoides, migration of a foreign body (toothpick) from stomach into the liver, infected hydatid cyst with a large biliary leak and cholangitis and, residual cavities after surgical treatment of hepatic hydatid cyst associated with foreign bodies. Another case was a patient with a very large, multilocular liver abscess (2000 mL) with biliary ethiology. In all cases a surgical drainage was performed. In the cases with hydatid cysts and biliary leakage, ERCP procedures were performed. The postoperative course was uneventful. CONCLUSIONS: Surgical treatment remains a valuable option in the treatment of pyogenic hepatic abscesses especially in unusual form.

[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.

[Abdominal tuberculosis--a surgical reality]. / Tuberculoza abdominala--o realitate chirurgicala.

Abdominal tuberculosis is a rare disease, with non-specific findings. Peritoneal tuberculosis is a frequent cause of low gradient ascites. The records of 22 patients (Il males, 11 females, mean age 41,17 years, and range 17-74 years) diagnosed with abdominal tuberculosis (TBC) in First Surgical Clinic, "St. Spiridon" University Hospital Iasi between 1995 and 2006 were analyzed retrospectively and the literature was reviewed. From these 22 patients diagnosed with abdominal tuberculosis, there were: peritoneal TBC in 16 cases, intestinal TBC in 5 cases, mesenteric lymph nodes TBC in 1 case. The patients with intestinal TBC, were presented with complications, 2 perforations with peritonitis, 1 intestinal obstruction, and 2 as ileo-cecal "tumors" solved by right colectomy, 4 enterectomy (3 entero-enterostomies and 1 ileo-colic anastomosis). The patients with peritoneal TBC were diagnosed by laparoscopy and peritoneal biopsy in 13 cases, and by laparotomy in 3 cases. In peritoneal tuberculosis ascites was present in 15 cases. Other common findings were weight loss (12 cases), weakness (5 cases), abdominal pain (15 cases), anorexia (5 cases) and night sweat (2 cases). Only two patients had chest radiography suggestive of a new TBC lesion. In those patients with peritoneal tuberculosis, subjected to operation, the findings were 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. Post operatory evolution and management were applied by the TBC Medical System and the patients were treated 6 months by tuberculostatics, with favorable evolution. Abdominal tuberculosis should be considered for diagnosis, in patients with non-specific symptoms of abdominal pain, fever, loss of appetite, abdominal distension and even symptoms of acute abdomen. Laparoscopy is the best approach for peritoneal tuberculosis, and emergency surgery is necessary for acute complication like obstruction and peritonitis. Specific antituberculosis drugs are indicated in postoperative period.

[Thermo-necrosis in nonresectable colorectal hepatic malignant tumors. Preliminary results]. / Termonecroza metastazelor hepatice nerezecabile de origine colorectala cu vapori de apa sub presiune. Rezultate preliminare.

MATERIAL AND METHOD: We report the 19 months followup results after thermo-necrosis with steam water of non-resectable colorectal liver metastases. The studied group included 24 (18 men + 6 women) cases, aged 39-85 (mean age = 61), that were subjected to thermo-necrosis procedure between 2004-2006. Thermo-necrosis was performed per primam (1 case with non-resectable primary tumor), or either synchronous (8 cases) or at up to 53 months (15 cases) after primary tumor resection, and implied delivering of 6.7 - 87 kiloJoules to targeted lesions (for a median of 5 targets per patient liver). Concomitant with thermo-necrosis, in 8 cases some metastatic lesions were also resected (for tumor mass reduction). Followup consisted in echographic, CT, clinical and laboratory evaluation each 1-2 month. RESULTS: The thermo-necrosis procedure was completed within 3 to 20 (median = 10) minutes, and no peri-operatory deaths or complication were recorded. After procedure, the treated lesions either shrunken or were stationary under imaging explorations; increasing images marked the time to tumor progression. Tumor progression was recorded in 12 cases, time to tumor progression ranging from 1 to 14 (median = 5) months; the follow up time for the remaining 12 cases ranging 3 - 18 (median = 8) months. Nine cases died at 6-15 (median = 9) months after thermo-necrosis; for the remaining 15 cases the followup time ranged 4-19 (median= 10) months. One year survival was 61%; median survival (50%) time was 9 months. CONCLUSIONS: Thermo-necrosis with steam water of non-resectable colorectal liver metastases associate low invasiveness, good compliance, and time interval for tumor progression and survival comparable or better than other thermo-necrosis techniques, representing a promising palliative therapy in secondary liver cancer.