Robotically performed total mesorectal excision for rectal cancer.

BACKGROUND: Rectal cancer is an important health problem, due to the increasing number of new cases and the quality of life issues brought forth by surgical treatment in these patients. AIM: The aim of the study was to analyse the results of robotic surgery in the treatment of lower and middle rectal cancer,locations in which TME is performed. MATERIAL AND METHOD: Patients diagnosed with and operated on for rectal cancer by the means of robotic surgery between 2008-2012 at the Fundeni Clinical Institute were retrospectively analysed. RESULTS: A number of 117 patients with rectal cancer were operated on by robotic surgery, of which 79 (67.52%) were submitted to total mesorectal excision (TME). The most frequently performed surgery was low anterior resection, followed by rectal amputation through abdominoperineal approach.Anastomosis fistula was observed in 9 (11.39%) patients. Local recurrence was encountered in 2 (2.53%) of the robotically performed surgeries. CONCLUSIONS: 1. Robotically assisted total mesorectal excision is feasible, safe and can be performed with a small number of complications and a low local recurrence rate; 2. The main advantages are oncological safety and quality of life; 3.Conversion to open surgery is rarely encountered; 4. Protection loop ileostomy existence allows avoiding reintervention in case anastomotic fistula occurs in patients with low anterior resection. 5. Robotic surgery may become gold standard in the surgical treatment of rectal cancer.

Robotic surgery for rectal cancer: a single center experience of 100 consecutive cases.

BACKGROUND: Minimally invasive techniques have revolutionized the field of general surgery over the few last decades. Despite its advantages, in complex procedures such as rectal surgery, laparoscopy has not achieved a high penetration rate because of its steep learning curve, its relatively high conversion rate and technical challenges. The aim of this study was to present a single center experience with robotic surgery for rectal cancer focusing mainly on early and mid-term postoperative outcome. METHODS: A series of 100 consecutive patients who underwent robotic rectal surgery between January 2008 and June 2012 was analyzed retrospectively in terms of demographics, pathological data, surgical and oncological outcomes. RESULTS: Seventy-seven patients underwent robotic sphincter-saving resection, and 23 patients underwent robotic abdominoperineal resection. There were 4 conversions. The median operative time for sphincter-saving procedures was 180 min. The median time for robotic abdominoperineal resection was 160 min. The median distal resection margin of the operative specimen was 3 cm. The median number of retrieved lymph nodes was 14. The median hospital stay was 10 days. In-hospital mortality was nil. The overall morbidity was 30%. Four patients presented transitory postoperative urinary dysfunction. Severe erectile dysfunction was reported by 3 patients. The median length of follow-up was 24 months. The 3-year overall survival rate was 90%. CONCLUSIONS: Robotic surgery is advantageous for both surgeons (in that it facilitates dissection in a narrow pelvis) and patients (in that it affords a very good quality of life via the preservation of sexual and urinary function in the vast majority of patients and it has low morbidity and good midterm oncological outcomes). In rectal cancer surgery, the robotic approach is a promising alternative and is expected to overcome the low penetration rate of laparoscopy in this field.

Surface characterization and biocompatibility of titanium alloys implanted with nitrogen by Hardion+ technology.

In this study, the new Hardion+ micro-implanter technology was used to modify surface properties of biomedical pure titanium (CP-Ti) and Ti-6Al-4V ELI alloy by implantation of nitrogen ions. This process is based on the use of an electron cyclotron resonance ion source to produce a multienergetic ion beam from multicharged ions. After implantation, surface analysis methods revealed the formation of titanium nitride (TiN) on the substrate surfaces. An increase in superficial hardness and a significant reduction of friction coefficient were observed for both materials when compared to non-implanted samples. Better corrosion resistance and a significant decrease in ion release rates were observed for N-implanted biomaterials due to the formation of the protective TiN layer on their surfaces. In vitro tests performed on human fetal osteoblasts indicated that the cytocompatibility of N-implanted CP-Ti and Ti-6Al-4V alloy was enhanced in comparison to that of the corresponding non treated samples. Consequently, Hardion+ implantation technique can provide titanium alloys with better qualities in terms of corrosion resistance, cell proliferation, adhesion and viability.

Robotic surgery of locally advanced gastric cancer -- an initial experience.

BACKGROUND: The treatment of gastric cancer is currently based on open gastric resection and regional lymph node dissection. Although the minimally invasive approach is currently being adopted for ever more complex procedures in order to improve post-operative outcomes, the laparoscopic radical D2 gastrectomy has not yet gained a wide acceptance, it being considered one of the most difficult operations in general surgery. Robotic surgery is better than the conventional laparoscopic approach, in that it avoids some of its limitations. Wristed instruments with seven degrees of freedom, the tremor filtering system, the ability to scale motion, and tridimensional vision improve the surgeons' dexterity when a fine manipulation of tissues in a narrow, fixed operating field or handsewn sutures are required. This study will attempt to evaluate the feasibility of robotic total and subtotal gastrectomy for locally advanced gastric cancer. METHODS: Two patients with locally advanced gastric adenocarcinoma underwent robot-assisted gastrectomy with D2 lymph node dissection, with no open or laparoscopic conversion. RESULTS: The post-operative evolution was uneventful and they were both discharged without complications. The number of lymph nodes retrieved was comparable to open surgery. Currently, after a follow-up period of 23 and 26 months respectively, both patients are disease-free. CONCLUSIONS: Robotic surgery can be a simpler way of expanding the indications of minimally invasive surgery so as to include the advanced gastric cancer. However, controlled prospective studies are needed in order to evaluate the role of robotics in the management of gastric cancer.

Robotic surgery of locally advanced gastric cancer: a single-surgeon experience of 41 cases.

The mainstay of curative gastric cancer treatment is open gastric resection with regional lymph node dissection. Minimally invasive surgery is yet to become an established technique with a well defined role. Robotic surgery has by-passed some of the limitations of conventional laparoscopy and has proven both safe and feasible. We present our initial experience with robotic surgery based on 41 gastric cancer patients. We especially wish to underline the advantages of the robotic system when performing the digestive tract anastomoses. We present the techniques of end-to-side eso-jejunoanastomoses (using a circular stapler or manual suture) and side-to-side eso-jejunoanastomoses. In our hands, the results with circular stapled anastomoses were good and we advocate against manual suturing when performing anastomoses in robotic surgery. Moreover, we recommend performing totally intracorporeal anastomoses which have a better post-operative outcome, especially in obese patients. We present three methods of realising the total intracorporeal eso-jejuno-anastomosis with a circular stapler: manual purse-string suture, using the OrVil and the double stapling technique. The eso-jejunoanastomosis is one of the most difficult steps in performing the total gastrectomy, but these techniques allow the surgeon to choose the best option for each case. We consider that surgeons who undertake total gastrectomies must have a special training in performing these anastomoses.

Fractal-like kinetics, a possible link between preconditioning and sepsis immunodepression. On the chemical basis of innate immunity.

In a recent paper the authors hypothesized that the so called fractal-like enzyme kinetics of intracellular reactions may explain the preconditioning effect in biology (Vasilescu C, Olteanu M, Flondor P, Revue Roumaine de Chimie. 2011; 56(7): 751-7). Inside cells the reaction kinetics is very well described by fractal-like kinetics. In the present work some clinical implications of this model are analyzed. Endotoxin tolerance is a particular case of preconditioning and shows similarities with the immunodepression seen in some sepsis patients. This idea offers a theoretical support for modulation of the enzymatic activity of the cell by changing the fractal dimension of the cytoskeleton.

A clinical case of Fournier gangrene.

OBJECTIVE: To present a case of Fournier gangrene and the specific surgical therapy CASE PRESENTATION: A 71-year old patient with a two days history of pain in the perineal region, swelling, developing necrosis and foul-smelling lesions was examined in emergency settings. The swelling of subcutaneous plane involved the flank regions, mainly on the left side. The investigations were performed (full blood count, blood urea, electrolytes, coagulation profile). A Fournier gangrene was diagnosed and surgery performed under general anesthesia. Broad spectrum antibiotics were given concomitantly. The first surgical procedure consisted in surgical debridement and excision of all the necrotic tissue. Cultures were taken. We performed counter incisions bilaterally on both flanks. The communication through the fascial planes was clearly demonstrated, especially on the left side. A loop colostomy was also performed. Multiple re-excisions were further employed. Due to a precarious evolution, the patient were on mechanical ventilation for 13 days. Inotrope medication was given for a total of 19 days and, the antibiotherapy adapted to the antibiogram (Bacterioides eggerthii was identified). The reconstruction of the perineum was later performed and, after 3 months, the colostomy was closed in good conditions without further complications. CONCLUSION: Early recognition and aggressive surgical excision are mandatory for success in patients with Fournier gangrene. Colonic diversion can be very useful if employed from the beginning.

Polymorphisms in SREBF1 and SREBF2, two antipsychotic-activated transcription factors controlling cellular lipogenesis, are associated with schizophrenia in German and Scandinavian samples.

Several studies have reported structural brain abnormalities, decreased myelination and oligodendrocyte dysfunction in schizophrenia. In the central nervous system, glia-derived de novo synthesized cholesterol is essential for both myelination and synaptogenesis. Previously, we demonstrated in glial cell lines that antipsychotic drugs induce the expression of genes involved in cholesterol and fatty acids biosynthesis through activation of the sterol regulatory element binding protein (SREBP) transcription factors, encoded by the sterol regulatory element binding transcription factor 1 (SREBF1) and sterol regulatory element binding transcription factor 2 (SREBF2) genes. Considering the importance of these factors in the lipid biosynthesis and their possible involvement in antipsychotic drug effects, we hypothesized that genetic variants of SREBF1 and/or SREBF2 could affect schizophrenia susceptibility. We therefore conducted a HapMap-based association study in a large German sample, and identified association between schizophrenia and five markers in SREBF1 and five markers in SREBF2. Follow-up studies in two independent samples of Danish and Norwegian origin (part of the Scandinavian collaboration of psychiatric etiology study, SCOPE) replicated the association for the five SREBF1 markers and for two markers in SREBF2. A combined analysis of all samples resulted in highly significant genotypic P-values of 9 x 10(-4) for SREBF1 (rs11868035, odd ration (OR)=1.26, 95% confidence interval (CI) (1.09-1.45)) and 4 x 10(-5) for SREBF2 (rs1057217, OR=1.39, 95% CI (1.19-1.63)). This finding strengthens the hypothesis that SREBP-controlled cholesterol biosynthesis is involved in the etiology of schizophrenia.

[Current problems in surgical oncology: 1. Theoretical models in oncology and their implications in surgical therapy]. / Probleme de chirurgie oncologica: 1. Modele teoretice în oncologie si implicatiile lor în tratamentul chirurgical.

Cancer biology has proven to be far more complex than imagined twenty years ago. While current treatment strategies (i.e., surgery, chemotherapy, and radiation) are successful in many cancers, they all have limitations. In some types of solid tumors some survival progress has been recorded, such in the case of breast and colorectal cancer, but these improvements are probably mainly due to screening programmes and earlier detection than to more-effective treatment. In other tumor types the mortality certainly increased: the death rate from lung cancer rose from 43 to 53 per 100,000 people from 1975 to 2005, the death rate from melanoma has risen nearly 30 percent, and death rate from liver and bile-duct cancer almost doubled, from 2.8 to 5.3 per 100,000. Cancer is commonly viewed as minimally controlled by modern medicine, especially when compared with other major diseases (Sharon Begley, 2008). Either directly from the phenomenological observation or through the biological model, mathematicians and biologists can generate mathematical models aimed at describing the biological phenomenon. The analysis of the solution properties by mathematical methods will give a description of the dynamics resulting in a deeper insight into the problem. The models can be implemented numerically to give rise to in silico models. The quality of the modeling process can be tested, validating the results of the simulations with experiments and clinical data. The theoretical predictions generated from the models may optimize the experimental protocol by identifying the most promising candidates for further clinical investigation. The speed with which large numbers of simulations can be performed may reduce the number of animal experiments and identify new experimental programmes and optimal cancer therapy schedules. However, it is clear that surgical decisions in cancer therapy are strongly driven by the theoretical hypotheses of local tumor evolution and malignant cells dissemination. For 60 years cancer was seen as a disease that arose in one location and spread through the lymphatic system first to nearby lymph nodes and subsequently to other organs. This theory of "contiguous" development of metastases has become known as the Virchow-Halsted theory. After 1954 an alternative theory was formulated by B. Fisher stating "that breast cancer is a systemic disease". Following the therapeutic implications of this "systemic theory," the disease has been attacked in recent years by chemotherapy and hormone therapy to the whole body. In 1994 S. Hellman stated the case for what he calls the "spectrum theory." He observed that there are intermediate tumor states between purely localized lesions and widely metastatic. Such clinical circumstances are not accounted for by either the contiguous (Halsted theory) or the systemic (systemic theory) hypotheses and supports the idea that loco-regional therapies (surgery and radiotherapy) may be useful in some cases. So, it is obvious that the extent and the role of cancer surgery are direct consequences of our theoretical understanding of cancer natural history. The genetical, pathological and clinical heterogeneity of cancers suggest new theoretical approaches based on chaos and fractal theory.

[Current problems in surgical oncology. Part 3. Total mesorectal excision with curative intent. Why are not all patients with rectal cancer treated with minimally invasive procedures (either by laparoscopy or by robotic surgery)?]. / Probleme de chirurgie oncologica. 3. Despre excizia totala a mezorectului, cu sinceritate. De ce nu sunt toate cancerele rectale operate minimal invaziv (nici laparoscopic, nici robotic)?

The main evaluation criterion in rectum cancer surgery is the accuracy of total mesorectal excision (TME). Laparoscopic TME has some advantages (sharp dissection, a better visibility) over open surgery; there are other factors that limited the dissemination of the laparoscopic approach (rigid instruments, with a limited maneuverability). Laparoscopic TME can be beneficial for selected patients. Robotic surgery, with a better view and instrument versatility, may overcome in part the limitations of laparoscopic TME. The excellent results demonstrated by robotic surgery in other types of pelvic malignancies (in urology and gynecology) are expected in the treatment of rectum cancer surgery. However, still remain patients with advanced rectum cancers that can be operated correctly only by open surgery. Laparoscopy and robotics are only tools and not aims of the oncological surgery.

[Current problems in surgical oncology 2. A lesson from Japan. D2 lymphadenectomy in gastric cancer]. / Probleme de chirurgie oncologica 2. Lectia japoneza. Limfadenectomia D2 în cancerul gastric.

At present there is accumulating evidence supporting the D2 lymphadenectomy in gastric cancer performed according the rules of the Japanese school of surgery. The D2 lymphadenectomy by open surgery seems to gain a wide acceptance and to become a standard therapy. The minimally invasive D2 lymphadenectomy (by laparoscopic or robotic surgery) in advanced gastric cancer showed promising results. However, these advanced minimally invasive techniques have still to be performed only in highly specialized surgical centers, with a large experience in oncological surgery. Further clinical trials are needed in order to verify the encouraging data of the few studies published until now in this field.

Analysis of 10 independent samples provides evidence for association between schizophrenia and a SNP flanking fibroblast growth factor receptor 2.

We and others have previously reported linkage to schizophrenia on chromosome 10q25-q26 but, to date, a susceptibility gene in the region has not been identified. We examined data from 3606 single-nucleotide polymorphisms (SNPs) mapping to 10q25-q26 that had been typed in a genome-wide association study (GWAS) of schizophrenia (479 UK cases/2937 controls). SNPs with P<0.01 (n=40) were genotyped in an additional 163 UK cases and those markers that remained nominally significant at P<0.01 (n=22) were genotyped in replication samples from Ireland, Germany and Bulgaria consisting of a total of 1664 cases with schizophrenia and 3541 controls. Only one SNP, rs17101921, was nominally significant after meta-analyses across the replication samples and this was genotyped in an additional six samples from the United States/Australia, Germany, China, Japan, Israel and Sweden (n=5142 cases/6561 controls). Across all replication samples, the allele at rs17101921 that was associated in the GWAS showed evidence for association independent of the original data (OR 1.17 (95% CI 1.06-1.29), P=0.0009). The SNP maps 85 kb from the nearest gene encoding fibroblast growth factor receptor 2 (FGFR2) making this a potential susceptibility gene for schizophrenia.

In vitro biocompatibility and corrosion resistance of a new implant titanium base alloy.

One objective of this work was to study the corrosion resistance of the new implant Ti-10Zr-5Ta-5Nb alloy in physiological fluids of different pH values, simulating the extreme functional conditions. Another objective was in vitro biocompatibility evaluation of the new alloy using human fetal osteoblast cell line hFOB 1.19. Cytocompatibility was assessed by determination of possible material cytotoxic effects, cell morphology and cell adhesion. The thermo-mechanical processing of the new implant alloy consisted in plastic deformation (almost 90%) performed by hot rolling accompanied by an initial and final heat treatment. The new Ti-10Zr-5Ta-5Nb alloy presented self-passivation, with a large passive potential range and low passive current densities, namely, a very good anticorrosive resistance in Ringer solution of acid, neutral and alkaline pH values. Cell viability was not affected by the alloy substrate presence and a very good compatibility was noticed.

[Thomas Ionescu versus Wildhem von Waldeyer. Rectum sheath or fascia propria recti? The story of a wandering idea]. / Toma Ionescu sau Wilhelm von Waldeyer? Teaca rectului sau fascia propria recti? Istoria unei idei calatoare.

Anatomical knowledge of rectum and its fascial relationship is crucial in modem surgery and it represents the basis of total mesorectal excision. Most of the contemporary authors make reference to Waldeyer's description and use the name fascia propria recti. However, there are evidence regarding Thomas Jonnesco's priority in describing this fascial structure 5 years before Waldeyer. Thomas Jonnesco's description was published in a famous anatomy textbook: Traité d'Anatomie Humaine, Paris, Bataille, 1894, editor P. Poirier, where Thomas Jonnesco was the author of volume 4, fascicule 1, containing the anatomy of the digestive system. His description of the rectum sheath precedes Waldeyer's publication (Das Becken, Cohen, Bonn, 1899). The description of the rectum sheath is included also into the second edition of Traité d'Anatomie Humaine (editors P. Poirier and A. Charpy) published again in 1901 at Masson Publishing House. This second version, better known by contemporary authors (Chapuis et al. Dis Colon Rectum 2002;45:1), probably revised by Charpy, is no more so simple and so clear as the first one. In our paper Thomas Jonnesco's original description of rectal fascia (rectum sheath), published in 1894, is facsimiled, the two succesive editions of the book are compared and a comparison with Waldeyer's description of fascia propria recti is done. The priority of Thomas Jonnesco seems to be well proved. In this respect our own research is in line with the observations of Chapuis and Bell si colab.

[Robotic splenectomy--a personal view]. / Splenectomia robotica.

Until now 40 robotic splenectomies were performed in our department, the first case being done on February 25, 2008. Our data show that robotic splenectomy with the DaVinci surgical system is technically feasible and safe, with good results and without complications. The main advantages are a better tridimensional view and an increased versatility of the surgical instruments. The DaVinci system allows an accurate dissection around the splenic hilum and preservation of the splenic remnant vessels in partial splenectomy. Robotic splenectomy will probably not replace the laparoscopic splenectomy for the most common indications like ITP, hemolytic anemia. It may be a very useful surgical tool in difficult splenectomy: partial splenectomy, splenectomy in liver cirrhosis, splenic tumors or malignant hemopathies. In these cases the robotic approach may shorten the operative time, decrease the blood loss and the risk of remorrhagic complications during surgery and even make possible a minimally invasive splenectomy very difficult to be performed by classical laparoscopy.

[MicroRNA's role in sepsis and endotoxin tolerance. More players on the stage]. / Rolul microRNA in sepsis. Noi actori in scenariul tolerantei la endotoxina.

MicroRNAs are non-coding RNA fragments, well characterized and well preserved along the evolution of the species and whose essential role is to regulate gene expression. MicroRNAs perform its action on messenger RNA ("target"). They induce degradation or repression of target translation with a significant decrease in the quantity and the activity of proteins. MicroRNAs are involved in normal cell function. Abnormal levels of microRNA were found in several pathological contiditions such as cancer, autoimmune diseases, viral infections, sepsis. Sepsis appears as a result of an improper inflammatory response after systemic bacterial infection. It remains a disease with a high incidence and mortality despite the evolution of diagnostic and treatment techniques. Sepsis patients have similar features to those found in the endotoxin tolerance phenomenon. Endotoxin tolerance is a state of hyporesponsivness to endotoxin challenge induced by a prior exposure. Due to its important role in repression of the pro-inflammatory cytokines translation, microRNA can be considered a new mechanism of endotoxin tolerance and a new mechanism involved in sepsis pathogenesis. In sepsis patients abnormal levels of the following types of microRNA were found: miR-146, miR-155, miR150, miR-132. Further studies are carried out to demonstrate the potential role of microRNA as biomarkers in sepsis.

[Minimally invasive splenectomy for thrombocytopenia associated with liver cirrhosis]. / Splenectomia minimal invaziva la pacientul cirotic.

Thrombocytopenia is a common complication in patients with chronic liver disease and corelates with the severity of cirrhosis. Severe trombocytopenia can sinificantly increase the risk of spontaneous bleeding, but even if it is not symptomatic it can complicate the medical management of the cirrhotic patient by postponing diagnistic or therapeutic procedures (liver biopsy, interferon therapy, hepatocellular carcinoma resection). In consequence, numerous procedures were imagined to reverse thrombocytopenia associated with liver cirrhosis, among wich splenectomy. Due to the extreme invasiveness of the clasic approach in patients with hipersplenism (risk of bleeding, postoperative pain) especially in those with advanced cirrhosis, minimally invasive splenectomy appears to offer a safe and effective method for reversing thrombocytopenia in a highly selected group of patients with liver cirrhosis (Child A cirrhosis without other significant medical comorbid conditions). In these cases the surgical procedure is associated with low morbidity, blood loss and short hospital stay.

Surgical treatment of chronic pancreatitis--a 14 years experience.

BACKGROUND: Operative treatment of chronic pancreatitis is indicated for patients with intractable pain after failed medical and endoscopic treatment, or in the presence of complications of the disease. AIMS: This study evaluates a single-center experience with operative management of chronic pancreatitis over a period of time of 14 years, regarding indication, surgical technique, early and late results. PATIENTS AND METHODS: The records of 265 consecutive patients who underwent surgery for chronic pancreatitis between 1995 and 2008 were retrospectively reviewed and analyzed. Long-term outcomes were assessed by patient survey, with a median follow-up of 40 months. RESULTS: 265 patients underwent 275 operations for chronic pancreatitis with the main indication abdominal pain (46.8%), followed by suspected malignancy in 24.8% and recurrent episodes of acute pancreatitis in 18.6%. Resection procedures 54.5% (150), drainage procedures 1.09% (3), bypass and denervation procedures 44.36% (122) and exploratory laparotomy 3.27% (9) were performed with an overall morbidity of 22% and an in-hospital mortality rate of 2.64%. After a median follow-up of 40 months survival information was available for 137 patients (51.69%) with a 5-and actuarial survival rate of 74.7% and quality of life improvement in most patients, especially in the resected group. CONCLUSION: Our results suggest that in chronic pancreatitis the type of surgery has to be individualized in each patient (resection VS drainage) and organ preserving operations are safe and effective in providing long-term pain relief and in treating CP-related complications

Robotic spleen-preserving distal pancreatectomy. A case report.

Distal pancreatectomy (DP) is the removal of the pancreatic tissue at the left side of the superior mesenteric vein and it is traditionally approached by an open or laparoscopic exposure. Preservation of the spleen is optional but appears to have a better immunological outcome. We present the case of a 53-year old patient with a 2.4/2.2 tumor located in the tail of the pancreas, with high tumour marker values for whom we decided to perform a robotic spleen-preserving distal pancreatectomy (RSPDP). The postoperative outcome was satisfactory. In conclusion, we recommend this type of approach for small pancreatic tail lesions.

[Portal vein thrombosis after laparoscopy--an underestimated complication]. / Tromboza portala dupa laparoscopie--o complicatie subestimata.

Portal vein thrombosis after laparoscopy became an issue of interest with the technological progress in surgery (the expanding use of minimally invasive approach) and imaging (the higher availability of Doppler ultrasonography and spiral computer tomography). Along with the extensive interest for laparoscopy in our country, a guideline for the prophylaxis and treatment of this potentially deadly complication seems necessary. Portal vein thrombosis (PVT) should be promptly diagnosed and treated to prevent its extension to the superior mesenteric venous system, as it may sometime trigger a potentially life-threatening complication, the entero-mesenteric venous infarction. It is acknowledged that the increasing use of laparoscopy in the last decades represents a major therapeutical progress. The effects of this approach are still to be explored.