Clostridium difficile Infections in an Emergency Surgical Unit from North-East Romania.

Background and Objectives: Colitis with Clostridium difficile is an important health problem that occurs with an intensity that varies between mild and severe. Surgical interventions are required only in fulminant forms. There is little evidence regarding the best surgical intervention in these cases. Materials and Methods: Patients with C. difficile infection were identified from the two surgery clinics from the 'Saint Spiridon' Emergency Hospital Iași, Romania. Data regarding the presentation, indication for surgery, antibiotic therapy, type of toxins, and post-operative outcomes were collected over a 3-year period. Results: From a total of 12,432 patients admitted for emergency or elective surgery, 140 (1.12%) were diagnosed with C. difficile infection. The mortality rate was 14% (20 cases). Non-survivors had higher rates of lower-limb amputations, bowel resections, hepatectomy, and splenectomy. Additional surgery was necessary in 2.8% of cases because of the complications of C. difficile colitis. In three cases, terminal colostomy was performed and as well as one case with subtotal colectomy with ileostomy. All patients who required the second surgery died within the 30-day mortality period. Conclusions: In our prospective study, the incidence was increased both in cases of patients with interventions on the colon and in those requiring limb amputations. Surgical interventions are rarely required in patients with C. difficile colitis.

The Influence of Neoadjuvant Treatment on the Number of Lymph Nodes on the Surgical Specimen in Mid and Low Rectal Cancer - A Retrospective Single-Centre Study.

Introduction: In this study, we aim to identify the impact of neoadjuvant radiation treatment upon the number of harvested and positive lymph nodes in the surgical specimen; in addition, we tried to identify the impact of chemotherapy in association with radiotherapy on said structures. Patients and methods: In the study we included patients treated for rectal cancer within a single oncologic surgical Unit serving the north-eastern part of Romania, over a period of 5 and a half years, between May 2013 and April 2018. Firstly, we compared pathologic lymph node status to pretherapeutic staging. Secondly, we compared lymph node values in relation to the treatment scheme. Results: There was a total of 498 patients treated radically through open surgery for low and mid rectal cancer. We saw a decrease in N staging in 218 cases, 65 remaining stationary and 10 increasing their lymph node staging on the surgical specimen. We identified significant differences between the total number of lymph nodes (17.4 vs 24.2, p 0.001), the number of positive lymph nodes (1.4 vs 3.4, p 0.001) and the ratio between positive and total lymph nodes (0.08 vs 0.14, p 0.001) in patients with and without neoadjuvant treatment respectively. However, there was no statistical difference between patients with and without chemotherapy associated to radiotherapy in the neoadjuvant treatment plan (p=0.539, p=0.58, p=0.575). Conclusion: This study shows there are significant variations according to the application of neoadjuvant treatment, between the numbers of positive and total lymph nodes, as well as the positive/total lymph node ratio.

Hindgut and Midgut Neuroendocrine Tumors - Therapeutic Approach.

Introduction: Neuroendocrine tumors of the gastro-entero-pancreatic system have a variety of components, clinical manifestations and prognostic indices according to their anatomical site. Therefore, their diagnostic and management strategies differ a great deal. Prognosis concerning NETs can be poor due to the degree of differentiation, early metastasizing and the high degree of invasiveness. Material and Methods: For the present study, the patient files were evaluated and the parameters of interest were followed. Results: Over the course of 6 years there were 37 patients diagnosed with and treated for NETs, regardless of primary tumor site. There were 9 patients with NETs of the primite mid- and hindgut thusly: 5 cases with colorectal NETs and 4 cases of small bowel NETs. 6 patients benefited from radical surgical treatment, 2 cases with palliative procedures and only one patient with tumor biopsy. The tumors were evaluated according to the 2010 WHO classification based on the number of mitoses and the Ki67 proliferation index. Adjuvant treatment was adapted according to staging and histopathological parameters. Conclusions: Despite recent progress in managing NETs, there are still many controversial aspects regarding the management of these cases, mainly about timing the right sequence of therapy.

Impact of Surgery and Early Postoperative Outcomes After Radical Gastrectomy for Cancer.

Background: Surgery remains one of the most important part of the multimodal treatment of patients diagnosed with gastric cancer. Due to the fact that the consequences in terms of postoperative morbidity can delay the onset of postoperative chemotherapy or even can make the patient unfitted for adjuvant treatment, a thorough clinical evaluation of patient prior to surgery is mandatory. Methods: We performed a retrospective study, which included all the patients diagnosed with gastric cancer in which radical surgery was performed during a 5-year period in a single center. All the patients, tumour and surgery characteristics were used for a risk analysis for the occurrence of overall, medical and surgical complications. Results: There were 189 patients in whom radical surgery was performed, 100 (52.9%) total gastrectomies and 89 (47.1%) subtotal gastrectomies, without difference in term of postoperative morbidity. There were 25 (13.2%) cases of duodenal stump fistula, 15 (15%) cases of esojejunal fistula. On multivariate analysis albumin levels (OR 1.9, p=0.035), hypertension (OR 4.22, p=0.0311) and splenectomy (OR 3.91, p=0.048) were independent factors for overall complications, albumin levels (OR 1.91, p=0.0405), hypertension (OR 3.54, p=0.0444), neoadjuvant treatment (OR 3.97, p=0.01657) and splenectomy (Or 1.66 p=0.05) for medical complications; age (OR 1.71,p=0.044), hypertension (OR 2.22, p=0.045) and albumin levels (OR 1.92, p=0.041) for surgical type complications. Conclusions: Postoperative morbidity after gastrectomy remains one of the most important factors that can impair the effectuation of a multimodal treatment protocol. Comorbidity factors, nutritional status and surgical technique are the key factors that can influence the amount and the consequence of a surgical complication.

Evaluation of circulating tumor cells in colorectal cancer using flow cytometry.

OBJECTIVE: We aimed to evaluate the prognostic value of circulating tumor cells (CTCs) and the impact of intraoperative tumor manipulation on CTCs in colorectal cancer (CRC) patients. METHODS: We performed a prospective study on 40 patients with CRC stages I to IV who received curative surgery using the no-touch technique. Flow cytometry was used to identify CTCs in peripheral blood samples (4 mL/sample) collected at two surgical moments: skin incision (T1) and after surgical resection (T2). A threshold of ≥4 CTCs/4 mL blood was established for considering patients CTC positive. RESULTS: In the univariate analysis, CTC evaluation at T2 was correlated with female sex, vascular invasion, tumor localization in the colon and metastatic lymph nodes. In the multivariate analysis, only female sex and colon cancer maintained statistical significance. At a medium follow-up of 15 months (1-25 months), the mortality rate was 10% (n = 4), with no significant differences between the overall survival of T1 or T2 CTC-positive and CTC-negative patients. CONCLUSIONS: Flow cytometry is a feasible CTC identification technique in CRC, and although surgical manipulation has no influence on CTC numbers, CTCs may serve as a prognostic and predictive factor.

Multiple versus unifocal breast cancer: clinicopathological and immunohistochemical differences.

Multiple breast cancer (MBC) is a controversial topic due to the lack of a consensus regarding its definition, classification issues and imprecise management recommendations in current reference guidelines. In four years, 756 patients with breast cancer (BC) were surgically treated in our Unit, 91 (12.03%) of them being pathologically diagnosed as MBCs. We present the results of our retrospective case-control study that performed a comparison between the clinicopathological characteristics and immunohistochemical (IHC) profiles of our MBC group versus a control group, represented by a sample of 184 cases randomly chosen from those with unifocal breast cancer (UBC). Starting from the premise of increased biological aggressivity of MBC, showed by several reports, we proposed to research the possible differences between these groups and to highlight their potential predictive and/or prognostic value. We found that MBC patients have a poorer prognosis than UBC ones - younger age at diagnosis [more cases less than 50 years old (p=0.03)], a lower frequency of T1 and a higher rate of T3 tumors [when using aggregate tumor size measuring method (p<0.001)], fewer node-negative (N0) cases (p=0.046) and a higher frequency of mucinous breast carcinoma (p=0.026). It worth mentioning that we obtained lower rates of poorly differentiated (G3) tumors (p=0.022) in the MBC group, this result being opposite to those found by other researchers. Our study also revealed a higher rate of human epidermal growth factor receptor 2 (HER2∕neu)-type cases in MBC group (p=0.022), these patients having the chance to benefit from treatment with monoclonal antibodies, with a better outcome than patients with triple-negative type. We registered significantly lower progesterone receptor (PR) positivity rates in patients with MBC, thus having a negative predictive value by showing a worse response to hormone-based therapies. Besides, we found heterogeneity of IHC features among tumor foci in MBC that may influence the therapeutic decisions. Our results sustain that MBC is biologically a more aggressive type of mammary neoplasia requiring a more particular therapeutic approach.

Pelvic exenteration, a surgical treatment option for locally advanced, primary and recurrent neoplasia.

Pelvic exenteration (PE) is an extensive surgical procedure for locally advanced primary neoplasia (LAPN) or recurrent neoplasia (RN) that consists in the en bloc removal of the pelvic organs (rectum, internal genital organs and bladder) associated with pelvic lymph nodes. PE is classified into anterior, posterior and total, supra or infralevatorian approaches. Our aim was to evaluate the surgical procedure and the resection margins in correlation with postoperative complications and morbidity rates after PE in patients treated in a single surgical unit. The study group comprised patients diagnosed with different malignancies, surgically treated by using PE procedure, during 2012-2018. The cohort included 121 cases with LAPN (n=98, 80.99%) and RN (n=23, 19%), mostly female (n=114, 94.21%), with a mean age of 61.16 (33-85) years. LAPN had predominantly digestive (n=48, 49.98%) and gynecological (n=28, 28.57%) origins, while the majority of RN cases were cervical cancers (n=9, 39.13%). The univariate analysis showed that the gynecological origin of the tumor (p=0.02), urinary stoma (p=0.02) and posterior PE (PPE) (p=0.004) were significant prognostic factors for postoperative complications. After performing the multivariate analysis, only the gynecological origin (p=0.02) of the tumor and PPE (p=0.03) remained determining factors for postoperative complications. PE is a disabling surgical procedure associated with high postoperative mortality and morbidity, although it is often the only solution for advanced cases. The judicious selection of patients who can benefit from such extensive surgery is compulsory. Our study suggests that the gynecological origin of the tumor and PPE are key factors in postoperative complications.

Bilateral Synchronous Male Breast Cancer of Rare Histologic Type. Case Report.

The particularity of the presented case is bilateral synchronous male breast cancer of uncommon histologic type ­ invasive cribriform carcinoma. In the practice of our surgical unit it is the first and only case of synchronous bilateral male breast cancer. The patient was followed up regularly for the last 4 years after a modified radical bilateral mastectomy with axillary lymph node clearance followed by adjuvant chemotherapy and endocrine therapy and he showed no signs of local recurrence or metastatic disease.