Microscopic Positive Margins in Gastric Adenocarcinoma Following Oncological Resection: Prognostic Factors and Long-Term Survival.

BACKGROUND: In the context of gastric cancer, surgical resection stands as the sole curative treatment. Central to influencing overall survival are the resection margins. This research aims to identify the factors influential in determining microscopically positive resection margins (R1) and to evaluate overall survival. METHODS: Our study encompassed 549 patients diagnosed with adenocarcinoma of the stomach who underwent curative-intent surgery between January 2011 and December 2021 in our Surgery Department. We investigated the incidence of positive margins (R1) and their impact on survival rates, as well as the determinants of R1. The standardization of R1 involved ensuring a margin distance of less than 1 mm from the tumor line to the margin. RESULTS: The incidence of R1 margins was 13.29% (73 patients). Among these, proximal R1 margins were observed in 29 patients (39.72%), while 49 cases (67.12%) presented circumferentially positive margins, with 20 cases (27.39%) exhibiting distally positive margins. Nineteen patients (26.02%) had two R1 margins, and 3 patients had all resection margins microscopically positive (4.10%). Factors such as tumor dimension, invasion of other organs, pT stage, pN stage, pL1 stage, pV1 stage, pPn stage, Lauren type, and tumoral grading demonstrated significance (p < 0.01) in the occurrence of positive R1 margins. CONCLUSION: Tumor dimension, invasion of other organs, pT stage, pN stage, pL1 stage, pV1 stage, pPn stage, Lauren type, and tumoral grading could be regarded as factors for predicting microscopically positive margins. Moreover, positive resection margins have a detrimental impact on overall survival.

A novel step-by-step training program for transanal endoscopic surgery.

BACKGROUND: The objective of our study is to develop an effective training platform for transanal endoscopic surgery and to validate a step-by-step training program for learning the basic skills necessary for this approach. METHODS: We have designed a two-part study: an experimental study (with the aim to design the training platform and the training exercises - on synthetic and biological material) and a prospective analytical study, in order to validate the training program by enrolling as participants general surgery residents and specialists, without previous experience in transanal endoscopic interventions. The performance of the participants was assessed based on the time of completion, as well as the quality of the execution. RESULTS: We have developed three different diameter platforms (5 cm, 7.5 and 10 cm), that can be used with both the TEO and TAMIS platforms; specific exercises were developed to train different surgical skills like manipulation of tissue, cutting, dissection and suturing. Forty participants were enrolled for the validation of the proposed training program (12 young residents, 16 senior residents and 12 specialist surgeons). A statistically significant improvement of the performance time, from round to round, was observed for all participants in all exercises. The time of completion for the exercises, considering the correct technical execution, was the shortest for more experienced surgeons: specialist surgeons, followed by senior residents and young residents. The biological material exercises, that closely recreate intraoperative conditions and had more strict technical requirements, were difficult to be performed by young residents; better completion rates were seen in senior residents, while all the participants in the specialist surgeons group have completed these exercises. CONCLUSIONS: Our training program is an effective simulation based educational model for recreating intraoperative conditions particular to transanal endoscopic surgery. The proposed step-by-step training program has demonstrated to be useful in developing the important basic skills needed for transanal endoscopic surgery and assured the progress of all the participants, regardless of their surgical experience.

Trends in Minimally Invasive Approaches for Liver Resections-A Systematic Review.

BACKGROUND: SILS (single incision laparoscopic surgery) and NOTES (natural orifice transluminal endoscopic surgery) are considered breakthroughs in minimally invasive surgery, the first consisting in the surgeon working via a single entrance site and the second via a natural orifice (e.g., oral cavity). METHODS: Since 2000 until 2022, the original articles published in the online databases were analyzed. Eligible studies included information about the current therapy of patients with liver surgical pathology and how the two new techniques improve the surgical approach. RESULTS: A total of 798 studies were identified. By applying the exclusion criteria, nine studies remained to be included in the review. Two out of nine studies examined the NOTES approach in liver surgery, whereas the other seven focused on the SILS technique. The age of the patients ranged between 24 and 83 years. Liver resections for hepatocellular carcinoma or colorectal metastases were undertaken and biliary or hydatid cysts were removed. The mean procedure time was 95 to 205 min and the average diameter of the lesions was 5 cm. CONCLUSIONS: When practiced by multidisciplinary teams, transvaginal liver resection is feasible and safe. The goals of SILS and NOTES are to be less intrusive, more easily tolerated and aesthetic.

Duodenopancreatectomy for PDAC Associated with MALS: A Case Report.

Introduction: Pancreatic ductal adenocarcinoma (PDAC) is an aggressive form of pancreatic malignancy which occurs in over 90% of such cases. Pancreaticoduodenectomy (PD) is used with a curative purpose for localized PDAC. Case presentation: A 68-year-old woman presented to our service through a transfer from another service, to be investigated and treated for a head of the pancreas tumor in a tertiary referral hospital. After a complete clinical and paraclinical evaluation, the patient was diagnosed with a PDAC and also with a median arcuate ligament syndrome (MALS). The surgical treatment was considered adequate, therefore, the patient underwent a PD with transmesocolic hepaticojejunostomy, pancreaticogastric anastomosis, precolic end-to-side gastrojejunostomy, Witzel jejunostomy and with the help of the cardiovascular surgery team from the Heart Institute, Cluj- Napoca, an aortohepatic bypass using saphenous vein graft was performed. Conclusion: Bypass was essential because the blood flow in the proper hepatic artery was not restored after sectioning the median arcuate ligament and clamping the gastroduodenal artery. The patient had a favorable outcome. The particularity of the present case consists of the complete occlusion of the celiac trunk by MALS and the total vascularization of the supramesocolic organs due to the superior mesenteric artery through the gastroduodenal artery.

Stapled Hemorrhoidopexy: Technique and Long Term Results.

Background: Stapled hemorrhoidopexy (Longo operation) is a infrequent technique in our area. A different concept from hemorrhoidectomy, a proportionally important raise in cost and a special training may have contributed to it. We report our long-term results with the standard technique. Methods: The data of 35 patients with symptomatic second- and third-degree hemorrhoids who had stapled hemorrhoidopexy using a PPH03 stapler, from 01 January 2012 to 04 December 2020, were retrospectively collected. The sex ratio male: female was 3:4 and the mean age 45 (range 28-60) years. The follow-up consisted in a rectal exam and evaluated anatomical recurrence or prolapse. Results: The mean operative time was 42 (30-70) min. The mean parenteral analgesic doses during the first 24 h were 1,52. The mean postoperative hospital stay was 1.55 (1-2) days. A single patient needed reoperation for a staple line bleeding, two patients had a thrombosis of internal hemorrhoids and in one patient a small prolapse was diagnosed at 3 months follow-up. No hematoma, anastomotic stenosis, persistent anal pain, tenesmus, or impaired anal continence was recorded. One patient mentioned discomfort related to the presence of staples. Patients were followed-up for 6 (1-9) years. Global satisfaction rate was 94%. Conclusion: Stapled hemorrhoidopexy procedure is a safe and feasible procedure, which necessitates few analgesics and allows an early discharge. A rigorous selection of cases and a correct surgical technique allow to obtain good long-term results and offer a high level of patients satisfaction.

Greyscale and contrast enhanced ultrasonography for characterization of gastric malignant tumors.

AIMS: To evaluate the utility of grey scale ultrasonography (US) and contrast enhanced ultrasonography (CEUS) for characterization of malignant gastric tumors. MATERIAL AND METHODS: The study was conducted prospectively and it included a number of 30 patients with malignant gastric tumors diagnosed through upper tract endoscopy and biopsy: 25 adenocarcinomas, 3 lymphomas, and 2 stromal tumors. All the patients were examined by US, followed immediately by CEUS, using both oral and intravenous contrast agents. CEUS assessed the dynamics of the contrast agent during the arterial phase and the venous phase. The distribution characteristics of the contrast agent inside the region of interest (ROI) were also evaluated. Twenty four patients underwent surgery. RESULTS: Adenocarcinomas presented heterogeneous enhancement with variable pattern, followed by a delayed wash-out in almost all of the situations. Lymphomas presented a variable pattern, intensity and homogeneity of the enhancement, followed by delayed wash-out. Stromal tumors showed early arterial intense and homogenous enhancement followed by moderate wash-out in venous phase. CONCLUSIONS: Grey scale US and CEUS are useful methods in characterizing gastric tumors and contribute to a more adequate evaluation of the lesions. The dynamics of the contrast agent may be suggestive for the anatomopathological nature of the tumor. Larger studies will be necessary in order to determine thepractical value of the method.

Ethical considerations in bariatric surgery in a developing country.

BACKGROUND AND AIMS: Obesity is the fastest growing health problem worldwide. Ethical issues linked to obesity are numerous and still under debate even in countries with a long history in obesity treatment. METHODS: From 2007 to 2015 we performed several types of bariatric surgical approaches on 250 patients with an average body mass index (BMI) of 42. The age range was 12-64 years. No death was recorded. Direct or phone contact was possible with 90% of them during follow-up. Starting from a specific question based approach in ethics we present aspects regarding obesity surgery in Romania. Patients' safety, informed consent, cost cover, the role of bariatric surgery in children and bariatric surgeons' training are discussed. RESULTS: Co-morbidities improved or even disappeared in 90% of our patients. Informed consent is a major problem, due to the lack of public knowledge necessary. The private system in Romania offers bariatric surgery at lower prices than Western Europe but is still out of reach for a person with an average income. Lack of maturity and disharmonic family relations raise a series of challenges in assessing the best interest of children and adolescents. Ethics committees, which operate according to well-defined processes, are more and more active in universities and research centers in Romania, checking that methods and performance of scientific studies meet adequate standards. CONCLUSIONS: A detailed informed consent, thorough preoperative patient assessment and method selection are mandatory for good results in obesity surgery. Insufficient financial resources combined with the long time necessary to acquire the expertise for laparoscopic bariatric surgery may represent an additional pressure on both physicians and patients.

Therapeutic Challenges for Symptomatic Portal Cavernoma Cholangiopathy.

Although transjugular intrahepatic portosystemic shunts are most frequently used for the management of portal hypertension, the surgical approach is preferred for symptomatic portal cavernoma cholangiopathy. We present the case of a 25-year old female patient with a portal cavernoma secondary to catheterization of the umbilical vein at birth. She had had two episodes of esophageal variceal bleeding, successfully treated by endoscopic banding. and an episode of acute cholangitis secondary to portal cavernoma cholangiopathy. Endoscopic sphincterotomy and biliary stenting were performed, and were followed by repeated episodes of biliary stent occlusion. The last biliary drainage procedure triggered a massive hemobilia. Since endoscopic therapy was ineffective, a surgical mesocaval shunt with graft interposition and splenectomy was performed with favorable outcome. In selected cases, the mesocaval shunting plays an essential role in the treatment of portal cavernoma cholangiopathy even in the era of interventional radiology.