[Distal pancreatectomy with spleen preservation in a pseudopapillary pancreatic tumor case]. / Pancreatectomia corporeocaudala cu prezervarea splinei intr-un caz de tumora solida pseudopapilara de pancreas.

Pseudopapillary pancreatic tumors represent about 1-2% of all exocrine pancreatic tumors, studies in the literature about this type of tumor is limited. We present a female patient of 18 years hospitalized for nonspecific abdominal symptoms, diagnosed with corporeal pancreatic tumor approximately 3-4 cm. It takes practice surgical distal pancreatectomy with spleen preservation, pathological examination revealing a pseudopapillary pancreatic tumor. Postoperative evolution was favorable. Distal pancreatectomy with spleen preservation was indicated due to patient age.

[Postoperative digestive fistulas. Etiopathogenic considerations]. / Consideratii asupra etiopatogeniei fistulelor digestive externe postoperatorii.

The digestive fistula is one of the most serious complications that might appear following different types of resectional digestive surgery. This condition still carries a considerable morbidity and mortality rate and therefore all surgical and ICU staff pay a great deal of attention and intensify their care to avoid the fatalities. The postoperative digestive fistulas, through their physiopathological and clinical complexity induce the disturbance of the biological equilibrium with vital consequences. The trend of the last decades is the increasing of digestive fistulas incidence with a variable mortality rate after different authors. A therapeutic algorithm is needed. The mortality rate due to digestive fistulas, two decades ago was, around 60%; at the present there is a decrease of the mortality rate, which is around 10%. The explanation is the introduction of the new methods of treatment such as lactic acid lavage aspiration for alkaline fistulas or total parenteral nutrition, continuous enteral nutrition and antiexocrine chemotherapy. A fistula is a communication between two epithelial or endothelial surfaces, lined by granulation tissue. It can be a life-threatening condition.

[Primary and secondary hepatic cancer--specifics of surgical treatment in correlation with disease stage]. / Cancerul hepatic primar si secundar--posibilitati de abord chirurgical in corelatie cu stadiul evolutiv.

UNLABELLED: Given the necessity of increasing their resectability, there are evaluated the possibilities of surgical treatment for these types of hepatic cancer, in the context of dominant clinical presence of advanced hepatic tumors. MATERIAL AND METHOD: The study comprises 190 patients during 01.01.2000-31.12.2007, in the IIIrd Surgical Clinic, Iasi, with primary and secondary hepatic tumors. RESULTS: There were made typical and atypical hepatic resections, metastasectomies--36 cases, alcoholisation--11 cases, and radiofrequency ablation--19 cases. Mortality was 4.73%. This study makes a critical analysis of the surgical treatment methods use, given the apparition of radiofrequency thermodistruction and the surgical technology evolution.

[General principles of clinical and therapeutic management in postoperative external enteral fistulas]. / Principii generale de management clinico-terapeutic in fistulele enterale externe post-operatorii.

Postoperative enterocutaneous fistulas represent a frequent complication in the emergency or cancerous digestive surgery. As to the high level of mortality and morbidity caused by this type of postoperative complication (4%), efforts are made to establish the principles of therapeutic management, on the purpose of decreasing these indicators and thus lowering the prolonged hospitalisation afferent costs.

[Intraoperative injuries of the biliary tract]. / Leziunile intraoperatorii de cai biliare.

Statistically speaking, the intraoperative lesions of common bile duct are rare clinical cases, but they have a high gravity potential. Our study was made on a lot of 11 operated pacients during 1995-2007 in our Clinic and it shows the tactical and technical approach used in solving these complications. The study also shows the high level of difficulty of these cases, as immediate recognition of this type of intraoperative lesions is needed. The successful evolution of these cases depends on how quickly the lesions are found and solved.

[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.

[Radiofrequency ablation in the multimodal treatment of liver metastases--preliminary report]. / Utilizarea termoablatiei prin radiofrecventa in tratamentul multimodal al metastazelor hepatice.

UNLABELLED: Although the "gold standard" in the multimodal treatment of liver primary and secondary tumors is the surgical ablation, the rate of resection, despite the last decades advances, remains still low (10 - 20%). In addition, the interest for non-surgical ablation therapies is increasing. Among them, regional or systemic chemotherapy, intra-arterial radiotherapy as well as locally targeted therapies--cryotherapy, alcohol instillation and radiofrequency (RF) are the most valuable options as alternative to the surgical approach. MATERIAL AND METHOD: Between February 2005 - January 2007, 9 patients with liver metastases underwent open RF ablation of their secondaries in the III-rd Surgical Unit, "St. Spiridon" Hospital. An Elektrotom 106 HiTT Berchtold device with a 60W power generator and a 15 mm monopolar active electrode was used. RESULTS: Destruction of the tumors was certified with intraoperative ultrasound examination. Pre- and postoperative CarcinoEmbryonic Antigen (CEA) together with imaging follow-up was carried out, in order to determine local or systemic recurrencies. Six patients died between 6 month - 4 years after the RF ablation. Median survival is 29.2 months. CONCLUSION: RF ablation is a challenge alternative in non-resectable liver tumors.

[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.

[Internal hernia--a rare cause of intestinal obstruction]. / Hernia interna--o cauza rara de ocluzie intestinala.

Internal hernia is rare its frequency ranging between 0.6 and 5.8%. It results from the protrusion of one or more abdominal viscera (usually small bowel) through an intraperitoneal opening. The opening can be normal (e.g. Winslow foramen), congenital (paraduodenal fossa, ileocecal fossa), or abnormal anatomical entities (after trauma or surgery). The clinical diagnosis of internal hernia is difficult because of the lack of specific signs and symptoms. There is a 63.6% lifetime risk of strangulation and bowel ischemia. In such cases, computed tomography is essential in the preoperative diagnosis because of the high mortality rate (20%) (which justifies its costs).

[Radiofrequency ablation of malignant liver tumours]. / Ablatia prin radiofrecventa a tumorilor maligne hepatice.

Both primary and secondary liver tumors are common problems. Hepatocellular carcinoma (HCC) is a tumor with rapid progression and poor prognosis. The standard in the treatment of liver tumors is surgical resection. The majority of patients with primary or metastatic hepatic tumors are not candidates for resection because of tumor size, location near major intrahepatic blood vessels precluding a margin-negative resection, multifocality, or inadequate hepatic function due to coexistent cirrhosis. Only 20-30% of patients undergoing potentially curative liver resection will not suffer from tumor recurrence. Radiofrequency ablation (ARF) is an evolving technology used to treat patients with non-removable primary and metastatic hepatic cancers. ARF produces coagulative necrosis of tumor through local tissue heating. Liver tumors are treated percutaneously, laparoscopically, or during laparotomy using ultrasonography to identify their position and guide the ARF needle electrode. The indications, treatmentplanning, and limitations of hepatic ARF must be defined. ARF of hepatic malignancies is a safe and promising technique to produce coagulative necrosis of non-removable hepatic malignancies. Experience with this treatment is not yet rich enough to establish long-term outcomes.

[Spontaneous esophageal rupture in three patients]. / Ruptura spontana de esofag la trei pacienti.

Boerhaave's syndrome represents the most severe perforation of the gastrointestinal tract. The typical clinical presentation is by a sudden onset of pain after a vomiting effort on the background of an alimentary and alcoholic abuse. It usually associates the cervicomediastinal emphysema, altogether forming the Mackler triad. The atypical presentation and the rarity of this entity usually lead to the delay in diagnosis in 50% of the cases. The diagnosis requires native and hydrosoluble contrast radiological examination which may reveal, altogether with the esomedistinal or esopleural fistula, pneumomediastinum, cervical subcutaneous emphysema, pleural effusion or hydropneumothorax. The early diagnosis and surgical treatment in the first 24 hours after the perforation offer the best chances for survival. We present and analyze the cases of 3 patients with spontaneous esophageal rupture with their different evolution and the diagnostic and treatment steps in each case.

[Surgical treatment of hepatocellular carcinoma--indications, limitations, realities]. / Tratamentul chirurgical al carcinomului hepato-celular--indicatii, limite, exigente actuale.

The present study analyzes the importance of the factors in improving the resectability, obtaining morbidity and mortality rates in accordance to the actual exigencies. In The III-rd Surgical Clinic, "Sf.Spiridon" Hospital, Iasi, during 1998-2003, 24 cases of CHC (19 men, 5 women with a median age of 58.5 years), usually developed on a cirrhotic liver, benefited by surgical approach. The tumoral mass (median size 7.8 cm) was situated in the left liver (15 cases--62.5%), right liver--13 cases and for 1 case with multiple localization (the segments VI-VII and III). For 12 cases (50%) various extensions of liver resections have been undergone: left lobectomies II-III--4 cases, left hepatectomy--1 case, segmentectomies VI--3 cases, segmentectomy III + bisegmentectomy VI-III--1 case, atypical hepatectomy--3 cases. Only 2 cases benefited by right portal vein ligation prior to resection. In 12 cases intraoperative exploration and US examination (4 cases) contraindicated the resection. One patient deceased on the entire lot (4.16%); post-resection mortality--8.33%. In conclusion, the early diagnostic of CHC developed on cirrhotic liver, the patients selection, the use of laparoscopy and intraoperative US, the available devices (CUSA dissector), selective ligation of portal branch prior to resection represents imperative elements in improving the resectability in safe conditions for the patient.

[Spontaneous rupture of the esophagus. Case report]. / Ruptura spontana a esofagului. Prezentare de caz.

We present a 50 years old man who was admitted for severe pain in the chest appeared after vomiting, dyspnoea, cardiovascular collapse. The diagnosis of spontaneous perforation of the esophagus (Boerhaave's syndrome) was confirmed by a radiopaque swallow. We performed a laparotomy, mediastinal drainage, cervical esophagostomy and jejunostomy. Postoperatively, the general state was severe--with high fever, important pleurezia, necessitating pleural drainage, mechanical ventilation for 8 days, parenteral and jejunostomy nutrition. It was possible to close the esophagostomy in the 43rd postoperative day. The patient has been dismissed on the 59th day. Five days later he presented in the ER with severe dyspnoea due to tracheal stenosis--emergency tracheotomy was performed, followed by resection of the stenotic cartilages.

[Therapeutical options in partial infected aorto- bifemoral prosthetic grafts]. / Optiuni terapeutice în infectia partiala a grefonului sintetic aorto-bifemural.

PURPOSE: To asses the use of synthetic or autologous conduits for the reconstruction of iliofemural sector in the cases of partial, limited infections of aortobifemural prosthetic grafts. METHOD: We present two cases, both of them with infection recognized at the groin; the first one by a vascular fistula bleeding intermittently, the second by a draining groin sinus with fever and leukocytosis. RESULTS: The PTFE conduit was the material utilized at the first case and the superficial femoral vein in the second case. The patients presented completed resolution of the infectious signs and symptoms and the revascularisation of the legs was successfully done. Evan with an extra-anatomical bridge or an autogenous material, sometimes is possible to resolve a regional infection of the aortobifemural graft only with a partial resection of one leg of the prosthesis and replacing with another sterile material.

The anatomical variants of the profunda femoris artery and of its collaterals.

The profunda femoris artery, the main nutritive artery of the thigh, has a great surgical significance. The high frequency of the occlusive arterial disease in the lower limbs caused by atherosclerosis, imposes as main therapy the reconstructive surgery. Because the profunda femoris artery remains patient in most of the cases of the occlusive arterial disease of the lower limbs, it means the only hope of saving an critically ischemic limb in a desperate attempt of a surgeon to avoid amputation.

[Insulinemia and its evolution over time in obesity]. / Insulinemia si evolutia în timp a obezitatii.

There is a steady-state metabolism of adipose tissue ("adipose state") with a "metabolic signal" significance. It consists of: seric levels of glucose, insulin, free fatty acids. We studied 45 cases with uncomplicated obesity and we correlated seric level of insulin, basal and reactive, with DAM (mean adipocyte diameter), insulin receptor activity and obesity evolution length (age of obesity). Level of insulin has high influence on insulin receptor function (p < 0.01). Reactive insulin level are higher with obesity age (p < 0.0001). Hyperinsulinemia is a constant, continuous and early reference point of obesity.

[Nonocclusive intestinal ischemia]. / Ischemia intestinala nonocluziva.

Acute or chronic intestinal ischaemia can be the consequence of either intrinsic vascular disease, systemic disease, drugs or surgical procedures. In one quarter of the patients with intestinal ischaemia, no major vascular obstructions can be detected. Very rarely, the cause of ischaemia is splanchnic vasoconstriction due to cardiac arrhythmias or sepsis. The bowel becomes ischaemic as a result of underperfusion. The clinical picture resembles the one of occlusive intestinal ischaemia. From the pathological standpoint, the ischaemia is more intense on the antimesenteric border of the bowel an the lesions are more advanced in the mucosal than in the serosal layer. Often, the ischaemia involves other organs too: liver, spleen or gallbladder. The reconstructive vascular procedures are inefficient, the only therapeutical options remains the resection of the infarcted bowel, together with other organs involved in the ischaemia process. The mortality rate approaches 90%.

[Nonobstructive intestinal ischemia]. / Ischemia intestinala nonocluziva.

Acute or chronic intestinal ischaemia can be the consequence of either intrinsic vascular disease, systemic disease, drugs or surgical procedures. In one quarter of the patients with intestinal ischemia, no major vascular obstructions can be detected. Very rarely, the cause of ischaemia is splanchnic vasoconstriction due to cardiac arrhythmias or sepsis. The bowel becomes ischaemic as a result of underperfusion. The clinical picture resembles the one of occlusive intestinal ischaemia. From the pathological standpoint, the ischaemia is more intense on the antimesenteric border of the bowel and the lesions are more advanced in the mucosal than in the serosal layer. Often, the ischaemia involves other organs too: liver, spleen or gallbladder. The reconstructive vascular procedures are inefficient, the only therapeutical options remains the resection of the infarcted bowel, together with other organs involved in the ischaemic process. The mortality rate approaches 90%.

[The clinical, diagnostic and therapeutic characteristics in antral gastric cancer]. / Particularitati clinice, diagnostice si terapeutice în cancerul gastric antral.

This paper is part of a comprehensive study on subphrenic digestive cancer carried out between 1984 and 1988, representing the experience of the III-rd, I-st, IV-th and emergency surgical clinics of Iasi (1530 cases). The peculiarities of gastric cancer with antral site in 231 out of a total of 612 cases, representing the experience of the III-rd Surgical Clinic, are presented. Clinically, the relative early occurrence of the symptoms, the need for an endoscopic examination and biopsy for all gastric ulcer lesions, for the antral ones particularly, are mentioned. The treatment is surgical, but it has to be associated with adjuvant therapy. For the antral site, the oncological subtotal gastrectomy was the surgery of choice (157 cases), the need of restoring the transit in a gastrojejunal manner being underlined. Total gastrectomy was performed in 12 cases.

[The diagnosis and treatment of benign tumors of the subdiaphragmatic digestive tract]. / Diagnosticul si tratamentul tumorilor benigne ale tubului digestiv subdiafragmatic.

One hundred twenty-two benign tumors of subdiaphragmatic digestive tract admitted in the interval 1975-1988 at the III-rd Surgical Clinic of Iasi are reported. Out of these patients 120 required surgical treatment, the remainder of 2 being treated conservatively (diffuse intestinal angiomatosis, Peutz-Jeghers' syndrome). The clinical evolution being atypical, the surgical intervention was required, in most of the cases, due to hemorrhagic and occlusive complications. Histologically, the polyps and schwannomas were prevalent. The diagnostic difficulties, especially in the cases with jejuno-ileal localization, are mentioned.