The Impact of the COVID-19 Pandemic on Colorectal Cancer Patients in a Tertiary Center in Romania. Single Center Retrospective Study.

Background: The novel coronavirus, SARS-COV-2, was first reported in Wuhan, China in the end of 2019. To curb its spread, social distancing measures and new safety regulations were implemented which led to major disruptions in colorectal cancer care. It is however unknown how it influenced the Romanian colorectal cancer care. Methods and Material: We assessed the demographical, clinical, intraoperative and pathological data of our colorectal cancer patients, 302 in total, between 15.03.2019-14.03.2021. The first year's data was considered as the control group and the second one, the study (pandemic) group. Results: We observed a 12% decrease in colorectal cancer hospitalizations in the first year, 38,6% in the first six months. The rate of emergency admissions, colo/ileostomy formatting procedures, palliative resections, clinical metastasis was higher in the pandemic group. More advanced locoregional invasion, a higher tumor stage, higher rate of vascular, perineural invasion, positive resection margin, and a higher lymph node yield was seen after the restrictions were implemented. Conclusion: The COVID-19 pandemic and the response against it had a major effect on the colorectal cancer care in our country. The outcomes of these worse clinical and pathological findings are unknown, but it is important to do further research in this field. We think colorectal cancer care should have an absolute priority in future pandemics.

Angiomyofibroblastoma mimicking an inguinal hernia: a challenging diagnosis in a male patient.

INTRODUCTION: Angiomyofibroblastoma is a rare benign myofibroblastic neoplasm which mainly occurs in the soft tissues of the pelvi-perineal region of females. AIM: To present an unusual case of angiomyofibroblastoma mimicking an inguinal hernia in a 62-year-old male. MATERIAL AND METHODS: The patient was hospitalized with an irreducible, painless inguinal mass and surgical intervention for inguinal hernia was decided. The well-defined nodular mass was sent for histological examination. RESULTS: Under microscope, proliferation of spindle and oval cells around thin-walled vessels was observed, being intermingled with mature adipocytes. We did not identify necrosis, haemorrhage, cytologic atypia or mitotic figures. The tumour cells displayed positivity for desmin, vimentin, CD34, oestrogen and progesterone receptors, a low Ki67 index and unusual nuclear positivity for c-theta (PKCθ). They were negative for smooth muscle actin (SMA), S100, CD44, maspin, synaptophysin, DOG1 and CD117. The case was diagnosed as angiomyofibroblastoma, the main challenge being the differential diagnosis with aggressive angiomyxoma, which can present a similar histologic aspect and immunophenotype and recurs more frequently. No recurrences were observed 8 months after the surgery. CONCLUSIONS: Angiomyofibroblastoma should be included in the differential diagnosis of inguinal hernia. This is the fourteenth case of angiomyofibroblastoma diagnosed in males.

Sentinel node biospy using intravital blue dye: An useful technique for identification of skip metastases in gastric cancer.

As the lymph node status remains the main prognostic factor of gastric cancer (GC), several lymph node-based staging systems have been recently proposed for an appropriate postoperative therapy. The identification of sentinel lymph nodes (SLNs) might improve the postoperative protocols. The aim of this study was to present our experience in detecting SLNs in GC using methylene blue dye.We have performed an observational study and retrospectively analyzed all of the consecutive cases of GC operated by the same surgical team and managed by the same pathologists during 2013 to 2015. In all of the cases SLN status was determined using the methylene blue that was intraoperatively administered in the peritumoral subserosal tissue. All blue colored nodes were histopathologically examined. In the node negative cases immunohistochemical stains using AE1/AE3 keratin were performed.The blue SLNs were identified in 48 out of the 50 cases included in the study, with a 96% sensitivity and 87.50% specificity. From the 48 cases, 34 (70.83%) presented positive SLNs; in the other 14 cases the SLNs were negative (29.17%). False negativity was observed in 6 of the 14 cases. In 2 of the cases the false negativity of the group 20 was induced by the anthracotic pigment. In other 2 false negative cases, although no regional metastases were founded, sentinel skip metastases in the group 8 and 15, respectively, were identified.Mapping of the SLNs is a simple and cheap method that might improve the accuracy of LN-based staging of patients with GC and favor identification of skip metastases.

Is Awareness Enough to Bring Patients to Colorectal Screening?

BACKGROUND: The aim of the study was to assess the awareness of colorectal cancer (CRC) patients about CRC screening methods and to investigate the relationship between awareness, socio-demographic characteristics and the stage in which patients with CRC are diagnosed. METHODS: The observational cross-sectional study included 275 CRC patients admitted between 2014 and 2016 to two surgical clinics from Tîrgu Mures, Romania. Study variables were collected via face-to-face interview and from patients' observation sheets. RESULTS: Only 41.5% of the patients heard about cancer screening and 6.5% about specific CRC screening methods. Mass-media was the major source of information (85.1%) followed to a much lesser extent (14.9%) by family, friends, and colleagues. Health professionals did not contribute at all to informing patients about screening methods. Awareness about screening methods was statistically associated with the patients' residence, age, and educational achievement, but not with the stage of CRC. CONCLUSION: The level of awareness of CRC screening methods was very low among the CRC patients included in the study but it could not predict the stage in which malignancy was diagnosed, suggesting that awareness alone is not enough to bring patients to undergo early CDC screening procedures.

Modified enteromesenteric bridging operation for primary lymphedema.

BACKGROUND: Primary lymphedema represents a condition which affects the lymph vessels and their cells without any pathologic patient history leading to soft tissue swelling. They are described in the literature three types: congenital primary lymphedema, or Milroy disease, lymphedema praecox, which occurs in puberty, and lymphedema tarda, when, the same symptoms, develop over 35 years old patients. The aim of this paper is to present a modified Kimmoth's original procedure for a praecox lymphedema by introducing an omental flap in the resorptive area. CASE REPORT: We present a case of 18 year-old patient with a significant lymphedema of the lower limbs and genitalia associated with high-symptomatic under-knee and scrotal ulcerative, necrotic and inflammatory lesions. The ultrasound and computed-tomography scans showed bilateral hypertrophic lymph-nodes in the inguinal and external iliac areas. Considering this diagnosis we decided to perform a physiologic lymph drainage by combining the enteromesenteric bridge with the omental transposition. The postoperative course was favorable without wound complications. Three months after, it was resected the remnant scrotal sclero-lymphatic tissue. 3 years after surgery, the clinical follow-up showed a significant reduced lymphedema with 10 cm shank / 15 cm thigh circumference lost. CONCLUSIONS: The enteromesenteric bridge combined with the omental flap proved to be efficient in ensuring the lymphatic drainage in a case with proximal lymphatic occlusion. KEY WORDS: Enteromesenteric bridging operation, Omental flap transposition, Primary lymphedema.

Laparoscopic gastric plication for the treatment of morbid obesity by using real-time imaging of the stomach pouch.

BACKGROUND: Bariatric surgery is a continuously evolving field. Laparoscopic greater curvature plication is a new investigational procedure used to treat patients with morbid obesity. The demand for this operation from the obese patients is also rising. The problem is that during gastric plication the exact dimensions and volume of the pouch are not known so frequently it is too large or too tight thus compromising the results. The aim of the study was to identify the parameters that can improve the outcomes after this procedure. METHODS: We performed laparoscopic greater curvature plication in 75 obese patients during 2013-2015. The last 25 patients underwent surgery with a modified surgical technique using real-time imaging of the stomach pouch. The inclusion criteria for the 25 patients enrolled in this case series were the usual, body mass index higher than 40 or higher than 35 but with comorbidities along with the option of the patients for laparoscopic gastric plication. The operative technique was enhanced by using a computerized device and special intragastric catheters during the procedure that permitted real-time imaging of the gastric geometry. With this new operative approach we obtained the desired volume of the gastric remnant and we avoided strictures, obstruction or irregular shape of the pouch, problems that otherwise could have compromised the outcomes. RESULTS: We found an increased excess weight loss of 55% at six month and 65% over a 12-month follow-up period with alleviation of comorbidities. There were no major complications (gastric outlet obstructions or leaks) and less minor complications (nausea and vomiting) than in the patients operated with classic gastric plication procedure. CONCLUSIONS: This study shows that in case of laparoscopic gastric plication the use of our modified operative technique has better outcomes than in the classical setting. This is a new operative approach in the bariatric literature which can lead to greater acceptance of gastric plication among bariatric surgeons. The target population is represented by the obese patients who want to obtain similar results to those after gastric bypass and sleeve gastrectomy but are concerned about removing a part of their stomach and the postoperative complications that may occur, especially leaks and nutritional complications. KEY WORDS: Gastric geometry, Laparoscopic gastric plication, Morbid obesity, Real-time imaging.

Crossover iliofemoral bypass graft through tension-free abdominal wall-repair mesh.

INTRODUCTION: In vascular surgery the crossover iliofemoral bypass grafting is a well-known surgical technique. In general surgery the repair of an abdominal defect using a Polypropylene mesh is also a standard procedure. A particular technique is defined by the performance of these 2 separate procedures inside a single operation in which the crossover arterial graft is directed from the retroperitoneal space toward the contra-lateral femoral bifurcation through a Polypropylene mesh which closes the musculoaponeurotic layers of the abdominal wall. We present our experience with the use of this particular surgical technique in patients with critical limb ischemia and with indication for extra-anatomic crossover bypass (high-risk patients with contra-indication for the transperitoneal approach, extensive calcified aortic or iliac wall which contraindicated the direct arterial reconstruction or secondary arterial reconstruction after the occlusion of an aorto- femoral graft). METHODS: In principle, the hernioplasty was performed by using the Lichtenstein tension-free hernia repair technique, followed by the crossover iliofemoral bypass. The main feature of this technique is to pass the vascular graft from the retroperitoneal space above the mesh through a calibrated hole in the mesh RESULTS: The 7 patients with inguinal hernia and l limb-threatening ischemia had favorable evolution, without hernia recurrence, limb-threatening ischemia or any graft complication at 3 years. DISCUSSION: Using this particular surgical technique we treated 2 surgical diseases using a single intervention for highrisk patients who had both inguinal hernia and contra-lateral critical limb ischemia. Being encouraged by the initial satisfactory results, we extended this technique even for the patients with indication of crossover iliofemoral bypass but without inguinal hernia. CONCLUSIONS: The particular surgical technique of the crossover bypass in which the vascular graft crosses a tension-free Polypropylene mesh from the retroperitoneal space toward the Retzius space represents an efficient and short procedure which treats simultaneously 2 different surgical diseases (inguinal hernia and contra-lateral critical limb ischemia) in high-risk patients. The results were satisfactory: we had no hernia recurrence and the limb-threatening ischemia was successfully treated. The preferred vascular graft for this particular technique is the reversed autogenous vein because its resistance to infections and the vein long-term patency is better than of a vascular prosthesis. When a prosthetic graft is required, we prefer to use the classic technique in which the crossover graft is placed in an under-aponeurosis site, in order to diminish the prosthesis infection risk. KEY WORDS: Abdominal wall, Iliofemoral bypass, Vascular surgery.

How much does decompressive laparotomy reduce the mortality rate in primary abdominal compartment syndrome?: A single-center prospective study on 66 patients.

Contribution of decompressive laparotomy within the framework of the complex therapeutic algorithm of abdominal compartment syndrome (ACS) is cited with an extremely heterogeneous percentage in terms of survival. The purpose of this study was to present new data regarding contribution of each therapeutic step toward decreasing the mortality of this syndrome.This is a longitudinal prospective study including 134 patients with risk factors for ACS. The intra-abdominal pressure was measured every hour indirectly based on transvesical approach and the appearance of organ dysfunction. Specific therapy for ACS was based on the 2013 World Society of Abdominal Compartment Syndrome guidelines, which include laparotomy decompression. Management of the temporarily open abdomen included an assisted vacuum wound therapy.Of 134 patients, 66 developed ACS. The average intra-abdominal pressure significantly decreased after therapy and decompression surgery. The overall rate of mortality was 27.3% with statistical significance in necrotizing infected pancreatitis. Surgical decompression performed within the first 24 hours after the onset of ACS had a protective role against mortality (odds ratio <1). The average time after which laparotomy decompression was performed was 16.23 hours. The complications occurred during TAC were 2 wound suppurations and 1 intestinal obstruction. Wound suppurations evolved favorably by using vacuum wound-assisted therapy associated with the general treatment, whereas for occlusion, resurgery was performed after which adhesions dissolved. The final closure of the abdomen was performed at a mean of 11.7 days (min. = 9, max. = 14). The closure type was primary suture of the musculoaponeurotic edges in 4 cases, and the use of dual mesh in the other 11 cases.The highest mortality rate in the study group was registered in patients with necrotizing pancreatitis and the lowest in trauma group. Surgical decompression within the framework of the complex algorithm treatment of ACS contributed to the reduction of mortality by 8.7%. It is extremely important that the elapsed time since the initiation of the ACS until the surgical decompression is minimal (under 24 hours).