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.

What Can We Find Behind a Parietal Abscess? Case Report.

We report a rare case of a 71-year-old female who presented to the First Clinic of Surgery from "Sf. Spiridon" Hospital Iasi, Romania with a mass in the left iliac fossa that started to discharge a feculent secretion five days prior to presentation. The patient had a history of constipation, several episodes of hematochezia associated with significant weight loss over the past 6 months. Following evaluation, a diagnosis of enter cutaneous fistula secondary to a locally advanced sigmoid cancer was made. The patient underwent semi-elective resection of the sigmoid tumor (measuring 20 cm) with 10 cm safe margins, and of the involved lymph nodes and abdominal wall. A termino-terminal colo-rectal anastomosis was performed. The patient was discharged the 10th postoperative day after an uneventful evolution for oncological evaluation. The authors presented this case in order to illustrate the challenges associated with diagnostic and therapeutic management of advanced colorectal cancer that has been discovered through a parietal abscess.

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.

LIVER METASTASIS OF A GASTROINTESTINAL STROMAL TUMOR OF LARGE BOWEL: CASE REPORT.

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal malignancies of the digestive tract. We present the case of a 61-year-old male patient liver metastasis of a GIST with primary location at the level of sigmoid colon. Like in the majority of cases, the symptomatology in this patient has long been faint and when it became manifest, it was nonspecific. Imagery wise, the computer tomography (CT) scan was the most efficient, showing the origin of the tumor from large bowel, its dimensions, as well as the relations with the other abdominal viscera and the liver metastasis. Surgery in this patient was en-bloc, according to the principles of GIST and for the metastasis he followed treatment with Imatinib. The histological aspect is characterized by a proliferation of spindle cells positive for CD117 and CD34. Despite complete microscopic resection, the exhibit of liver metastasis remains an important relapse factor.

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.

I. Juvara (1913-1996), a surgeon for all seasons.

Ion Juvara is a creator of a genuine Romanian school of surgery. If I. Juvara had lived and worked in a country that had been the proud owner of a Pantheon, undoubtedly he would have rested there to the end of time, among the eternal ones i.e. those who triumphed against time and who had never been defeated. If the first generation of Romanian surgeons represented mainly by Thoma Ionesco (1860-1926) was educated mainly abroad, the next generation was trained professionally at the Romanian school of surgery. Despite of the hostile period he lived in, I. Juvara kept intact his freedom of thinking and opposed with all his powers abuses of any kind, always preserving his integrity, avoiding with elegance the traps of the totalitarian regime. But even so nobody can state that the professor, who came from -Moldavia, as his master, N. Hortolomei, could not say at the end of his life that he hadn't had a fulfilled professional life, as he is considered even today the greatest surgeon of Romania in the latter half of the 20th century. He was, after all, a surgeon for all seasons.

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.

Parastomal hernias -- clinical study of therapeutic strategies.

UNLABELLED: Parastomal hernias are parietal defects adjacent to the stomasite, after ileostomy and colostomy. Their incidence is variable and they are generally underestimated. METHODS: Between 2001 and 2010 at the First Surgical Clinic Iasi, we treated 861 incisional hernias, of which there were 31 parastomal hernias in 26 patients (3%), 5 of which were recurrent parastomal hernias. Parastomal hernias have been explored clinically, through imaging and intraoperatively.Because our experience and literature review have demonstrated that a mesh repair is a safe procedure in the treatment of parastomal hernia, in 2010 we initiated a prospective randomized trial on the use of prophylactic polypropylene mesh at the time of stoma formation to reduce the risk of parastomal hernia. We enrolled in the study 20 patients with mesh implanted at the primary operation and 22 patients without mesh. The inclusion criteria were: patients with low rectal cancer, stage II-III, irradiated, obese, with a history of hernias, patients who do physical work. RESULTS: Most parastomal hernias were asymptomatic; only six cases with parastomal hernias required emergency surgical treatment. We performed local tissue repair in 16 cases (4 cases with recurrent parastomal hernia, stoma relocation in one case), sublay mesh repair in 15 cases (one case with recurrent parastomal hernia; stoma relocation in 5 cases). Postoperative morbidity registered included 4 wound infections (one case after mesh repair which required surgical reintervention) and stoma necrosis in one case with strangulation parastomal hernia with severe postoperative evolution and death. After local tissue repair recurrences were seen in 6 cases, after mesh repair we registered recurrence only in one case and no relapse after the relocation of the stoma. The patients with prophylactic mesh at the time of stoma formation to reduce the risk of parastomal hernia were followed for a median of 20 months(range 12 to 28 months) by clinical examination and ultrasound exam every 3 months. We registered 6 recurrences(27,2%), all in the no mesh cohort. We have not seen any morbidity in patients from the mesh group. CONCLUSIONS: Parastomal hernia is a relatively rare disease compared to the number of incisional hernias. With increasing life expectancy stands we noted increased incidence of parastomal hernia as well. Prophylactic use of mesh during the primary operation is a safe procedure and reduces the risk of parastomal hernia.

Corelation of lymphocytic infiltrates with the prognosis of recurrent colo-rectal cancer.

BACKGROUND: Recent studies are focusing on complementary prognostic and predictive markers that could complete the predictive TNM staging and one of the most promising directions is the study of tumor immune infiltrates. MATERIALS AND METHODS: Our 2-year retrospective study includes resection specimens from the primary tumors of 23 patients presenting to our clinic for a local or a distant relapse after colon or rectal cancer. From every primary tumor specimen we obtained immunohistochemically stained slides in order to assess cd3, cd4, cd8, cd45ro and cd68 infiltrates. Digital analysis assessed the density and percentage of positively stained cells in the normal peritumoral tissue, invasive margin and center of the tumor. RESULTS: A small density of cd8 positive cells in the peritumoral region was strongly correlated with a longer disease-free interval (p=0.009) and the Kaplan-Meier survival analysis showed that the percentage of cd8+ T cells could be used to stratify patients in terms of relapse risk (p=0.006). We found no correlation between invasion front infiltrates and intra tumoral infiltrates and the disease-free interval. CONCLUSION: Our study concludes that cytotoxic T-cell infiltrates in the normal peritumoral tissue could be used to predict a more aggressive tumor in terms of the relapse risk.

Total necrotizing colitis proximal to obstructive left colon cancer: case report and literature review.

BACKGROUND: Necrotizing colitis (NC) is a rare complication of the obstructive cancer of the left colon and it is the result of intramural ischemia due to impairment of blood supply secondary to increased endoluminal pressure. CASE PRESENTATION: A 70 years old patient with significant comorbidities (ASA 4) was admitted for intestinal obstruction.The extensive necrosis of the entire proximal colon secondary to an obstructive sigmoid colon cancer has been diagnosed intraoperatively. Total colectomy and terminal ileostomy have been performed. The postoperative course was uneventful and the ileostomy closure with ileo-rectal anastomosis was performed 7 months later. A review of the literature discussing the epidemiology, pathogenesis, diagnosis and therapeutic approach of this type of colitis, was performed. CONCLUSIONS: NC implies diagnosis and therapeutic difficulties,especially from point of view of surgical strategy. We advocate of large colic resections, beyond the macroscopic limits of the necrosis in order to avoid the postoperative complications. We also consider seriate surgical procedures as a good choice for the high risk patients.

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.

Early retropancreatic lamina dissection during pancreaticoduodenectomy: how, when and why?

UNLABELLED: Pancreaticoduodenectomy is the procedure of choice for tumors of the pancreatic head and periampullary region. During pancreaticoduodenectomy, early neck division may be inadequate in case of hepatic artery anatomic variants, suspected involvement of the superior mesenteric vessels or intraductal papillary mucinous neoplasms. MATERIAL AND METHODS: We describe our early approach to the superior mesenteric vessels during pancreaticoduodenectomy, by retroportal lamina dissection before pancreatic transection. RESULTS: We used this approach in 41 patients. There were 28 patients with abnormal hepatic artery, which was spared in 26 cases. Hepatic artery reconstruction was required in 2 cases. Nine patients with intraductal papillary mucinous neoplasms underwent 6 pancreaticoduodenectomies extented to the body and 3 total pancreaticoduodenectomies. Four patients with adenocarcinoma involving the portomesenteric vein required pancreaticoduodenectomy with venous resection and reconstruction. CONCLUSIONS: Early retropancreatic lamina dissection is useful way to tailor a pancreaticoduodenectomy which is recommended in selective indications.

Laser microdissection--a novel approach for accessing the molecular basis of cancer.

BACKGROUND AND AIM: It has been known for quite a lot of time that tumours are cellular aggregates of different cells, mainly malignant cells but also immune cells--of which the most well-known are the tumour infiltrating lymphocytes (TIL) and the tumour associated macrophages (TAM). By observing hematoxylin--eosin stained or immunohistochemical stained slides belonging to different areas of the tumour it is clear that there are clusters of malignant cells within the tumour itself that seem to behave differently from the rest of the tumour. Another fact is that different areas of the tumour contain different inflammatory cells which may promote carcinogenesis or may help to confine it. Whereas different immune cells can be recognised by using immunohistochemistry, a satisfactory characterization of the molecular characteristics of the malignant clusters of the tumour cannot be made without further use of different molecular techniques such as different PCR techniques or microarray methods. Laser microdissection thus comes as a valuable aid in choosing exactly which cells will be analyzed further on. PRINCIPLE OF THE METHOD: Laser microdissection is based on using the energy of a focused laser beam to cut through the thickness of the tissue that is placed on a microscope slide in order to obtain cell samples previously selected by the pathologist through special software. CONCLUSIONS: To be able to cut the cells that you want and analyze them further without having them contaminated with other cells means that you can get more insight into the progression of the mutations that occur in these malignant cells, mutations that cause them to become more aggressive or multidrug-resistant. This could in time lead to the discovery of new molecular targets for cancer therapy.

Retrosternal goiters.

UNLABELLED: The term of retrosternal or substernal goiter means that more than 50% of thyroid gland descends in the thorax. MATERIAL AND METHODS: There is a retrospective study on retrosternal and substernal goiter and its patological features among 2482 patients who underwent thyroidectomy between 2000 and 2010 in the First Surgery Clinic of Iasi. Retrosternal goiter was identified 54 patients (2.17%). All patients were refered to surgery from the Clinic of Endocrinology. RESULTS: Mean age at diagnosis was 55.3 +/- 3.58 years, and most cases were found in women (83.3%). The clinical pictures of retrosternal goiter was dominated by compressive disorders. Thyroid function abormalities were identified by hormonal assays performed on Endocrinology Clinic lasi in 15 cases (27.7%). The diagnosis of retrosternal goiter was suggested by clinical examination and confirmed by imagery: thorax X ray, ultrasonography, CT scan. The cervical approach was being safely performed. Only in 8 cases (14,8%), sternotomy was necessary. There was no mortality and morbidity was 5.5% (3 cases). The length of stay in the hospital was 4.3 days. We compared our recent data with a previous report on retrosternal and thoracic goiter treated in First Surgery Clinic of lasi during 1950 to 1979 and published in the journal "Chirurgia" in 1981. CONCLUSIONS: Retrosternal goiter is a particular form of thyroid surgical pathology presentation with declining incidence. Diagnosis and treatment of retrosternal goiter involve a multidisciplinary team. The endocrinologist has an important role in diagnosis and postoperative follow-up. Surgery is the treatment of choice for substernal goiters, but there are still some controversies on surgical approach, and complication rate. The cervical approach can be safely performed in almost all cases but when required, sternotomy should be performed without hesitation.

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.

[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.

[The porcelain gallbladder-laparoscopic approach]. / Vezicula de portelan--abord laparoscopic.

A long time porcelain gallbladder was considered a relative contraindication to laparoscopic cholecystectomy, because of a high incidence of gallbladder cancer. From 12,000 patients underwent cholecystectomy in First Surgical Clinic of Iasi, 5 (0.04%) patients had porcelain gallbladder. All patients underwent ultrasound examen. Patients with porcelain gallbladder were classified as Type I to II according to preoperative ultrasound findings: three cases with porcelain gallbladder type I and two cases with porcelain gallbladder type II (in one case we found associated gallbladder carcinoma). We describe a three cases with porcelain gallbladder type I (complete calcification of gallbladder wall) treated by laparoscopic approach. Laparoscopic cholecystectomy was difficult because of adhesions and problems with grasping the thick gallbladder wall, but the postoperative course was uneventful. The histopathologic result of the specimen established the diagnosis of porcelain gallbladder type I and no cancer in the calcified wall of the gallbladder. We conclude based on cases presented and the literature review, although there is a high conversion rate, that patients with a type I porcelain gallbladder should be considered for laparoscopic cholecystectomy using a preoperative selection based on the ultrasound findings.