Parastomal hernias -- clinical study of therapeutic strategies.

UNLABELLED: Parastomal hernias are parietal defects adjacent to the stomasite, after ileostomy and colostomy. Their incidence is variable and they are generally underestimated. METHODS: Between 2001 and 2010 at the First Surgical Clinic Iasi, we treated 861 incisional hernias, of which there were 31 parastomal hernias in 26 patients (3%), 5 of which were recurrent parastomal hernias. Parastomal hernias have been explored clinically, through imaging and intraoperatively.Because our experience and literature review have demonstrated that a mesh repair is a safe procedure in the treatment of parastomal hernia, in 2010 we initiated a prospective randomized trial on the use of prophylactic polypropylene mesh at the time of stoma formation to reduce the risk of parastomal hernia. We enrolled in the study 20 patients with mesh implanted at the primary operation and 22 patients without mesh. The inclusion criteria were: patients with low rectal cancer, stage II-III, irradiated, obese, with a history of hernias, patients who do physical work. RESULTS: Most parastomal hernias were asymptomatic; only six cases with parastomal hernias required emergency surgical treatment. We performed local tissue repair in 16 cases (4 cases with recurrent parastomal hernia, stoma relocation in one case), sublay mesh repair in 15 cases (one case with recurrent parastomal hernia; stoma relocation in 5 cases). Postoperative morbidity registered included 4 wound infections (one case after mesh repair which required surgical reintervention) and stoma necrosis in one case with strangulation parastomal hernia with severe postoperative evolution and death. After local tissue repair recurrences were seen in 6 cases, after mesh repair we registered recurrence only in one case and no relapse after the relocation of the stoma. The patients with prophylactic mesh at the time of stoma formation to reduce the risk of parastomal hernia were followed for a median of 20 months(range 12 to 28 months) by clinical examination and ultrasound exam every 3 months. We registered 6 recurrences(27,2%), all in the no mesh cohort. We have not seen any morbidity in patients from the mesh group. CONCLUSIONS: Parastomal hernia is a relatively rare disease compared to the number of incisional hernias. With increasing life expectancy stands we noted increased incidence of parastomal hernia as well. Prophylactic use of mesh during the primary operation is a safe procedure and reduces the risk of parastomal hernia.

Gallstone ileus: a rare cause of intestinal obstruction -- case report and literature review.

Gallstone ileus is an uncommon complication of cholelithiasis with a high morbidity and mortality rate. We report a rare case of small bowel gallstone obstruction in an 87-year-old female patient with cholecystoduodenal fistula. We performed an enterolithotomy, repair of fistula and cholecystectomy. During the postoperative course a wound dehiscence appeared, which required suturing and prolonged hospitalisation. We review the diagnostic and therapeutic aspects, given that the diagnosis of this condition is usually difficult and often made intraoperatively.In fact, here is no standard surgical procedure for this disease. The one-stage procedure should be reserved for stabilized patients, but in cases with associated comorbidities,only enterolithotomy can represent the best option..

Laparoscopic approach to ovarian dermoid cysts.

INTRODUCTION: Ovarian dermoid cysts (mature cystic teratomas) are a benign type of germ cell tumours and the most common ovarian neoplasms in women of fertile age. The aim of this study was to analyze the safety of the laparoscopic approach in ovarian dermoid cysts. METHODS: We performed a prospective study between 2006 and ' 2010 including 38 mature cystic teratomas treated either laparoscopically or by open access. All preoperative and postoperative data were included in an MS Access database and statistically analysed with SPSS v. 17 for Windows. RESULTS: The study group was divided into 2 subgroups according to the approach: laparoscopic (25 cases - 2 conversions) and classic (13 cases). The mean age of the patients was 40.34 years (range 19-74): 36.92 years for laparoscopic group and significantly higher 46.21 years for open approach group. Twelve cases were admitted as emergencies either because of complications (torsion or rupture of the teratoma) (11 cases) or associated with acute appendicitis (one case). The latter did not influence the decision for open or laparoscopic approach. Only 29 out of 38 cases had preoperative measurement of CA 125. CA 19-9 was performed in 27 cases and elevated levels were found in 21 cases (78%). Cysts over 10 cm presented higher values of CA 19-9. The mean cysts diameter was 11.29 cm (range 2-27 cm): 13.93 cm mean cyst diameter for open approach vs 9.75 cm for laparoscopic approach. The specimen removal required aspiration of the content for cysts bigger the 10 cm in laparoscopic approach. Mean hospital stay was 4.05 days (range 2-6 days) for the laparoscopic group, significantly lower when compared with the open approach group: 6.96 days (range 5-16 days). CONCLUSIONS: Laparoscopic management of ovarian dermoid tumours is a safe and efficient procedure. It does not increase complications rate in comparison with the open approach, offering a shorter hospital stay, a quick recovery and very important, it allows a conservative treatment, especially in premenopausal women who want to be pregnant.

[Surgical treatment of hyperparathyroidism]. / Tratamentul chirurgical al hiperparatiroidismului.

BACKGROUND: Hyperparathyroidism (HPT), the result of excessive secretion of the parathormone, is one of the most common endocrine disorders. In most forms of HPT, surgical parathyroidectomy is the best choice. AIM: This paper aims to examine patients with hyperparathyroidism operated in First Surgical Unit Iasi, in terms of indications, surgical technique and postoperative results. MATERIAL AND METHOD: We performed a retrospective study, in First Surgical Unit Iasi, during 2000-2008. Clinical, laboratory, intraoperative and histopathological data were included in a MS Access Office XP database. Statistical analysis was performed with the SPSS ver. 15.0 for Windows (Statistical Package for the Social Sciences, Chicago, Ilinois). RESULTS: There were examined 34 patients with HPT: 32 cases were primary HPT (94.12%), and two cases with secondary HPT (patients with renal failure). The men/women ratio was 6/28 and mean age was 50.09 +/- 2.23 years old. Clinical presentation was variable: the dominant symptoms were osteoarticular (67.6%) followed by neuropsychological (64.7%), digestive (17.6%) and renal (11.8%). Associated diseases were recorded at 47.06% of patients: arterial hypertension--32.4%, coronary heart disease--23.5%, heart rhythm disorders--17.6%, diabetes--11.8%, biliary lithiasis--5.9%, renal lithiasis--8.8% and thyroid hypertrophy--55.9%. In 8 cases, primary hyperparathyroidism was associated with other diseases of the endocrine glands: 4 cases with Multiple Endocrine Neoplasia (MEN) type 1; a patient with von Recklinghausen disease; a patient with associated hypothyroidism and diabetes; two cases that with papillary thyroid carcinoma. Positive diagnosis was supported by determining serum calcium, phosphorus and serum concentration of the parathormone (PTH). All patients were evaluated by ultrasound exam; the sensitivity of the investigation was 88.23%. 99Tc-sestamibi scintigraphy was performed in 32.35% of patients with a sensitivity of 72.72%. Parathyroidectomy was performed by Kocher's incision in 88.23% and minimally-invasive open approach in 11.76%. The following types of interventions have been performed: tumor resections (73.53%), subtotal parathyroidectomies (17.6%), total parathyroidectomies (8.82%). In patients with associated thyroid disease total thyroidectomies (26.5%) and subtotal thyroidectomies were done (11.8%). The postoperative morbidity rate was 2.9% (transient hypocalcemia). Histopathological examination revealed the presence of parathyroidian adenoma in 67.6% of patients (N=23), parathyroidian hyperplasia in 26.5% (N=9) and parathyroidian carcinoma in the others 5.9% (N=2). CONCLUSIONS: The diagnosis of HPT involves positive determination of calcium and PTH. The most useful imaging techniques, are 99Tc-sestamibi scintigraphy and ultrasonography, which locates in most cases, the parathyroid pathological glands. Surgical treatment is the only curative treatment of HPT, with medical treatment only role in preoperative preparation. The precise site of the parathyroidian lesion facilitates minimally-invasive approach. The postoperative follow-up is mandatory because of the increased potential for recurrence and for diagnosis of other endocrine tumors (in patients with MEN).

[Choledochal cyst in adults and cancer of the biliary tract]. / Chistul de coledoc la adult si cancerul caii biliare.

We presented 3 cases of cystic dilatation of common bile duct classified as type IC, IVB an IVA. All 3 were women, admitted for right upper quadrant pain and jaundice. Two cases proved malignant degeneration in cystic dilatation in first cas and in gallbladder in third. Only the 3rd case had a positive preoperative diagnosis achieved through echography, TPHC, ERPC. Surgical treatment consisted of cysto-jejunal derivation in the cas of the common duct malignant cyst inoperative and cholecystectomy associated with the excision of the dilatation followed by the hepato-jejunal anastomosis in the other 2 cases. Adenocarcinoma of the gallbladder was a pathological surprise. A better knowledge of the risk of cancer on cystic dilations of the common bile duct should lead to an earlier diagnosis of this disease and a preventive treatment by radical excision of the dilatation.

[The Wermer syndrome]. / Sindromul Wermer.

The difficult diagnostic and therapeutic management of patients having gastrinoma with multiple endocrine neoplasia type I (MEN I) has been discussed by reference to the literature and a personal experience of 2 patients with Wermer syndrome. The syndrome is often familial and might be inherited as an autosomal dominant trait with a high but variable degree of penetrance. Pancreatic islets, parathyroid glands and adenohypophyseal [correction of antehypophyseal] cells are the three localization main for endocrine involvement in MEN I syndrome.

[Megaduodenum due to aortomesenteric shunt]. / Megaduoden prin pensa aorto-mezenterica.

Two new cases of megaduodenum by aortomesenteric shunt in young adults are presented. The role of some risk factors, the diagnostic and therapeutical elements are discussed, the importance of a thorough investigation of each case in view of individualizing the therapeutical management being underlined.

["Biloma": its diagnosis and treatment by percutaneous echo-guided evacuation]. / "Biloma": diagnostic si tratament prin evacuare percutana ecoghidata.

The term "biloma" describes an intra-abdominal bile collection secondary to traumatic or iatrogenic injury of the biliary tree. We present a case of biloma treated by guided percutaneous needle aspiration.

[The value and limits of subtotal gastrectomy in gastric cancer]. / Valoarea si limitele gastrectomiei subtotale în cancerul gastric.

In the interval 1970-1988, in 321 of 670 patients with gastric neoplasm admitted to the 1st Surgical Clinic of Iasi a subtotal gastrectomy was performed. Most patients were males (68.9%), more commonly aged between 50 and 70 years and in advanced evolutive stages. The gastric neoplasm were sited in order of frequency in the antrum (46.9%), body of the stomach (34.6%), eso-cardio-tuberosity (11.5%), linitis (4%), gastric stump and malignant ulcer (3%). Surgery was possible in only 59% of the cases (25% curative and 34.1% palliative). The surgical technique and its difficulties are detailed. In the 321 subtotal gastric resections 20 complications, 4 deaths (1.2%) and 20% survivals over 5 years were recorded. It is concluded that radioendoscopic and microscopic investigations, with their possibility of an early diagnosis, may cause a limitation of the indications of total gastric resection in the treatment of gastric neoplasm in favour a subtotal resection, more satisfactory from the functional viewpoint.

[Cephalic duodenopancreatectomy with pyloric preservation in the treatment of pancreatic cancer]. / Duodenopancreatectomia cefalica cu pastarea pilorului în tratamentul cancerului de pancreas.

UNLABELLED: Is the application of DPCPP in the treatment of pancreatic neoplasia a good reason? We have analysed 30 patients with cephalic duodenopancreatectomy (DPC) for biliopancreatic neoplasia between 1995-1999 in Ist Surgical Clinic of Iassy (13 with pyloric preservation). The indications were:--cephalic pancreatic neoplasia (adenocarcinoma--4 cases (one with cephalic chronic pancreatitis on the intraoperative microscopical examination);--Vater ampulloma (7 cases);--inferior common biliary duct (CBD 1 case);--duodenal adenocarcinoma (1 case). In the same time was operated 265 biliopancreatic diseases (203 mechanical jaundice with 132 neoplastic jaundice). RESULTS: --Better early postoperatively status of the patients--DPCPP does not give better prognosis;--there are necessary some technical skills to depase the important phases of DPCPP.

[Problems of therapeutic management of cancer of the superior pole of the stomach]. / Probleme de conduita terapeutica în cancerul polului superior al stomacului.

This cancer is rare (17-30%) and has the worst prognosis. In the interval 1970-1987 to the I-st Surgical Clinic of Iasi were admitted and treated 648 patients with gastric cancers of which 98 (15.2%) with adenocarcinomas of the cardiac end of the stomach. In most patients the diagnosis was late: stage II and III-40 patients; stage IV-58 patients. Given the extension of the tumoral process, the exeresis was possible but in 36 cases (36.7%), as compared to 26-70% mentioned in the literature. The therapeutical management of these cases and the obtained results are presented.

[Hepatic abscesses]. / Abcesele hepatice.

The authors analyse 16 cases of hepatic abscesses recorded in a 10-year interval. The difficulties in assessing the etiology and diagnosis, as well as in indicating an effective treatment are discussed. The clinical aspects and investigation methods, among which scintigraphy, arteriography and especially echotomography are extremely useful in making the diagnosis and in localizing the collection, are reviewed. The bacteriological examination revealed the presence of various organisms in 14 patients, the examined specimen of pus being negative in the remainder of 2 cases. The treatment was surgical in most of the cases (15) consisting in an abdominal approach or posterolateral with rib resection (1 case) and drainage. In 3 cases the intervention was extended to cholelithiasis which was the underlying cause of the abscess. The ultrasound-guided transparietohepatic drainage was performed in 2 cases. No death was recorded.

[Cervicomediastinal and thoracic goiters]. / Gusile cervicomediastinale si toracice.

Between 1950 and 1979 approximately 2400 patients with thyropathies have been operated in the I-st Surgical Clinic of Jassy. Of these 100 had cervico-mediastinal goiters, of which 79 were of the plunging cervico-mediastinal type, 18 were of the mediastino-cervical type and 3 were mediastinal goiters. The surgical treatment was applied in 98 patients, cervicotomy being sufficient to relieve the symptoms in 92 of the cases. The mixed approach (cervicosternotomy, or cervico-thoracic approach) were necessary in 5 cases, and the thoracic approach was selected in one case with an independent posterior mediastinal goiter. The immediate postoperative evolution, as well as the late evolution was good in most of the cases. Postoperative mortality was of 2 percent.