Problems of diagnosis and treatment caused by ingested foreign bodies.

An ingested foreign body often passes the gastrointestinal tract without any complications. Foreign bodies, such as fish bones, chicken bones and toothpicks, have been known to cause perforation of the gastrointestinal tract. We present 4 cases: the first 2 of a 27-year-old male and a 48-years-old female respectively, with acute abdomen, diffuse purulent peritonitis, with ileum perforation, both caused by accidentally ingesting a wire, 1 case of a 64-year-old male with sigmoid perforation, caused by accidentally ingesting a toothpick and 1 case of a 52-year-old female presented with left buttock painful swelling for 1 week associated with fever,physical examination revealed an ischiorectal abscess.During incision and drainage a 3 cm chicken bone was found inside the abscess cavity. Evolution was favorable in all 4 cases.

Pancreatic true cysts--diagnosis and treatment difficulties.

Pancreatic true cysts represent a rare, heterogeneous group of pancreatic tumors; therapeutic strategy is based on patient's general status, cyst topography, and especially the estimated risk of malignancy. This paper aim is to present 7 cases of pancreatic true cysts, operated on a six years period (January 2004-January 2010) in our surgical clinic: 2 men and 5 women, aged between 24-61 years old; cyst diameter varies between 3.5-15 cm, tumor location being pancreatic head in two cases and the distal pancreas in 5 cases. Surgical treatment consisted in cyst enucleation (two cases), splenopancreatectomy (three cases), duodenopancreatectomy (one case), and subtotal splenopancreatectomy (one case). Histology was represented by serous cystadenoma (one case), mucinous cystadenoma (2 cases), intraductal papillary mucinous cystadenoma (one case), and papillary cystadenocarcinoma (3 cases).Postoperative results were good in all cases, with 3 postoperative pancreatic external fistulas, resolved conservatory; no case of post-pancreatectomy diabetes mellitus was registered. In conclusion, surgical removal of the pancreatic cystic tumors is necessary, especially due to the risk of malignancy, at least in the absence of rigorous histological proofs of benignancy. Postoperative results are favorable in terms of postoperative morbidity and mortality.

Carcinoid tumour of the appendix: problems of diagnosis and treatment.

Carcinoids (neuroendocrine tumours) are considered the most common primary appendiceal neoplasm. Primary appendiceal tumours are uncommon. Routine histopathological examination of appendicectomy specimens is justified given the not infrequent incidental finding of appendiceal tumours. In cases of appendicitis in the elderly, the index of suspicion for epithelial tumours of the appendix should be raised. Moreover, once the diagnosis of an adenomatous lesion is made, colonoscopic examination of the entire large bowel is mandatory given the frequency of synchronous colorectal neoplasia in our population. In our study, we review 3 cases of carcinoid tumor of the appendix and describe their presentation, treatment and outcome. They are often diagnosed incidentally after histopathological examination of the vermiform appendix submitted in the course of the management of another clinical diagnosis. Appendectomy is appropriate for lesions < 1 cm but for lesions over 2 cm in diameter there is a significant increase in metastatic spread and thus right hemicolectomy is required in such cases. Appendiceal carcinoid tumours are found in 0,3 - 0,9 per cent of patients undergoing appendicectomy. Controversy exists over the management following appendicectomy, especially with regard to the role of right hemicolectomy in patients with tumours smaller than 2 cm in diameter.

Horseshoe appendix: a extremely rare anomaly.

Appendiceal anomalies are extremely rare malformations. We presented the case of a patient 43-year-old who had undergone emergency surgery for bowel occlusion. Incidentally we have found an "horseshoe-shaped" appendix which removed. After review of the literature we have introduced this appendiceal variant in a complete classification of appendiceal anomalies.

Primary varices pathogenesis. The appealing unitary model.

Primary varices pathogenesis is still unclear about the trigger event and the disease progression. Throughout time, a lot of hypotheses were created, each with a certain degree of veracity, to explain the aforementioned dilemmas. Present day investigation technologies allowed the undeniable progress in deciphering venous mechanics and biochemistry. Objectifying venous hemodynamic and valvular-parietal changes, their dynamic progression as well, lead to important clarifications in primary varicose disease physiopathogenesis. The importance of establishing a complete, unitary pathogenic model implies the practical possibility of immediately applying the right therapy addressing the pathogenic mechanism of this disease (i.e. correcting the "pressure escape" gateway) correlated with the progression stage (reflux degree) and the type of primary varices (gravitational, non-gravitational, or "suspended" varices). Initially, our study produces a critical evaluation of the classic pathogenic hypotheses and, later on, based on our long time experience in this field, it presents a complete and unitary, evolutive and pathogenic model in primary varices. The proposed model details a pathogenesis and a progression far more nuanced in primary varices, based on solid evidence, having obvious therapeutic implications and predictable results.

[Postoperative enteral feeding in digestive anastomosis with proximal oesophageal partner]. / Nutritia enterala postoperatorie în anastomozele digestive ce au ca partener proximal esofagul.

This paper aim is to discuss the advantages of enteral postoperative feeding on patients submitted to surgery finalized through an eso-digestive anastomosis; in these cases enteral feeding is often delayed 5-8 days after the surgery, and in case of an anastomotic dehiscence may be even impossible. Also, the paper promotes duodenostomy as an important enteral feeding way, and discusses the indications and contraindications of different enteral nutrition pathways in such cases. There were studied 230 cases, 149 cases submitted to cancer surgery and 81 cases with benign condition surgery followed by an eso-digestive anastomosis, in which the following enteral nutrition pathways was practiced: nasogastric or naso-esojejunal feeding tube (55 cases); Witzel jejunostomy (28 cases); gastrostomy (79 cases); duodenostomy (68 cases). Postoperative morbidity induced exclusively by the enteral nutrition pathway was encountered in 36% of patients. On patients with an eso-gastric cervical anastomosis or esogastric thoracic anastomosis we used jejunostomy as enteral feeding path and a gastric tube passed by pyloric canal for gastric decompression. In cases of esophageal reconstruction for benign esophageal strictures gastrostomy remains the best feeding method. Duodenostomy was practiced as a feeding pathway in cases of total gastrectomy with esojejunal anastomosis, with closure of the duodenal stump.

[Soft tissue sarcoma--problems of diagnosis and treatment]. / Sarcoamele de parti moi--probleme de diagnostic si tratament.

Soft tissue sarcomas are a rare group of cancers compromising 1% of all malignancies and there has been a slight increase in incidence. We present 3 cases of soft tissue sarcomas (the tumors were located to the right axilary region, perianal and dorsale face of the left leg) hospitalized in 2nd Surgical Clinic of Emergency Hospital of Craiova and we discuss the difficulties of diagnosis and treatment. The classification and characterization of soft-tissue sarcomas have evolved as the information supplied by histologic analysis has been supplemented with that provided by immunohistochemical analysis. Surgical resection involving wide margins, with or without radiotherapy, offers the best chance of cure in the absence of metastatic disease. There is little evidence that local recurrence increases the likelihood of metastatic spread, although debate on this point continues. Except for rhabdomyosarcomas and Ewing's sarcomas, the use of adjuvant chemotherapy generally does little to influence the natural history of the disease. In conclusion surgical treatment is mainstay of treatment for soft-tissue sarcomas and is usefull the prompt diagnosis for decrease the risk of local recurrence and metastatic disease.

The valvular segment of the lower limbs venous system: anatomical, physiological and physiopathological aspects.

The valvular segment is a distinct venous structure, which, from a morphological point of view, is comprised of the following components: the valvular insertion, the valvular gorge entrance orifice, the valvular defile, the valvular gorge exit orifice, the valvular sinus. Endoscopic and echo Doppler examinations are used to identify the normal and the pathological morphology of the valvular segment, and the hemodynamic phenomena occurring at this level. Cusps' integrity and size as well as valvular dynamics are key elements directly involved in shaping the valvular segment in general, and the valvular sinus in particular. The valvular sinus shows an obvious hemodynamic determinism. Valvular segment pathology is the outcome either of a progressively long evolving process initialized by gravitational venous pressure overcharges, or of a rapidly evolving process such as the hemodynamic shock following intense physical efforts. Valvular defunctionalisation implies a different mechanism and a different type of cusp lesion.

Axillary and perianal leiomyosarcoma: report of two cases.

Soft tissue leiomyosarcoma is a relatively rare malignant tumor. It may be difficult to be distinguished from gastrointestinal stromal tumors and Schwann cell neoplasms. To make a correct identification of soft tissue leiomyosarcoma, immunostaining with several smooth muscle differentiation markers (actin, calponin and desmin), and negative staining results with S100 (to rule out Schwann cell neoplasm), c-kit and CD34 (to rule out gastrointestinal stromal tumors) is needed. Prompt diagnosis and referral are desirable, since the size of the tumor at presentation is a continuous variable for the risk of local recurrence and metastatic disease. Chemosensitivity varies according to the tumor subtype, and the tumor grade, the patient's age, performance status, and the timing of metastatic disease further influence the likelihood of a response and survival. Chemotherapy is palliative for most patients with unresectable or metastatic disease. Ifosfamide and doxorubicin are routinely used in this setting; doxorubicin as a single agent is considered the drug of choice.

[Esophago-digestive anastomosis dehiscence]. / Dehiscenta anastomozelor esofagodigestive.

This paper aim is to discuss the main etiopathogenic aspects responsible for eso-digestive anastomotic leakage, as well as prophylactic and therapeutic measures of this postoperative complication. There were studied 173 consecutive eso-digestive anastomosis: 103 anastomosis performed for malignancy and 70 anastomosis for benign conditions. Surgical operations followed by an eso-digestive anastomosis were: esophageal reconstruction for benign esophageal caustic strictures (n=67); total gastrectomy (n=55); total esophagectomy (n=13); total esophagectomy plus total gastrectomy (one case); eso-gastrectomies (n=34); upper gastric pole resection (n=2); distal esophageal resection (n=1). Eso-digestive anastomosis topography were cervical (n=81), intrathoracic (n=37) and abdominal (n=57). There were 30 eso-gastrostomies, 81 eso-jejunostomies, and 62 eso-colostomies. There were recorded 24 eso-digestive anastomotic dehiscences (13.8%): 14 in the cervical region (17.2% out of 81 cervical anastomosis); 5 intrathoracic leakages (14.2% out of 35 anastomosis); 5 intraabdominal anastomotic dehiscences (8.7% out of 57 intraabdominal anastomosis). Four patients died as an anastomotic leakage consequence: two patients died after cervical eso-gastrostomy dehiscences, one patient died after an intrathoracic eso-jejunostomy leakage, and one patient died after intraabdominal eso-gastrostomy leakage. In conclusion, we analyze postoperative results, emphasizing the role of discovering and removal of predisposing factors which may lead to an eso-digestive anastomotic leakage.

Ileal iterative spontaneous perforation from foreign body granuloma: problems of histopathologic diagnosis.

Spontaneous ileal perforation is a very rare cause of peritonitis. It occurs, in most of the cases, as a complication of Crohn's disease or intestinal tuberculosis. We present the case of a 23-year-old female patient with multiple surgical interventions during the last year, for iterative ileal spontaneous perforation with generalized peritonitis of which cause was initially assigned to intestinal tuberculosis. Actual episode of generalized peritonitis was determined once again by an ileal perforation of 5 mm at 70 cm from the ileo-cecal valve situated on a suture scar. Distally, a bowel stricture and a non-complicated Meckel's diverticulum were also noted. We performed an enterectomy including all three aforementioned lesions with end-to-end anastomosis. The histopathologic report revealed granulomatous giant-cellular inflammation in the margins of the perforation. The tuberculous etiology was questioned because of the negativity of the PCR-test and multiple recidives of perforation under specific anti-tuberculous medical therapy. The discovery of some rests of non-resorbable suturing material in a granuloma on an ancient enterorraphy scar in the resected specimen, finally established the cause. The granulomatous giant-cellular inflammation of foreign body is a rare cause of ileal perforation. The histopathologic differential diagnosis is difficult needing correlation with clinical data. Usage of resorbable suture material avoids that risk.

Subungual exostosis of the big toe.

The subungual exostosis is a benign bone tumor on the distal phalanx of a digit, beneath or adjacent to the nail, often bringing in discussion many differential diagnosis. We present a 14-year-old boy with a cutaneous nodular lesion, painful to the easy touch on the latero-internal half of the nail of right big toe with extension in the cutaneous part of this. He suffered many treatments, especially cauterization, but with recurrence. In the present, the radiological findings of the affected finger and the histopathological ones from the fragment excised confirmed the diagnosis of subungual exostosis. The local excision of the entire region with the removal of the cartilaginous cap has been followed by a silent period without recurrences of almost two years when he as revised.

Tuberous sclerosis complex: report of two intrafamilial cases, both in mother and daughter.

Tuberous sclerosis complex (TSC) is a multisystem syndrome characterized by neurological symptoms and tumors in multiple organs including kidney, brain, skin, eyes, heart and lung. Kidney and brain are the two most frequently affected organs in TSC. TSC is an autosomal disorder with extensive clinical variability. We described TSC in a family at a mother and her daughter. We emphasized the importance of Computed Tomography in the discovery of some asymptomatic organic involvement as bilateral renal angiolipoma in the mother.

Horner's Syndrome: An Uncommon Complication of Thyroidectomy and Selective Lateral Neck Dissection.

BACKGROUND: Horner's Syndrome is defined by myosis, enophthalmos, lack of sweating and eyelid ptosis, as well as vascular dilatation of one half of the face, caused by damage of the ipsilateral cervical sympathetic chain. It is known that Horner's syndrome is an unusual complication of thyroidectomy and selective lateral neck dissection. Its exact pathophysiology is not totally explained and its treatment remains conservative. CASE PRESENTATION: A 27-year-old man developed one-sided partial eyelid ptosis, enophthalmos and myosis two hours after a total thyroid gland excision and a selective lateral neck dissection for papillary carcinoma. A clinical diagnosis of Horner's syndrome was formed. He was treated conservatively and presented with an incomplete recovery at a 2-month follow up. CONCLUSIONS: The present case report underlines the adjacent anatomical correlation between the thyroid gland, the celluloadipose tissue and the cervical sympathetic trunk throughout thyroidectomy and selective lateral neck dissection. Every surgeon should be familiar with the potential complications in order to preoperatively counsel patients, as well as avoid them during the surgical procedure.

Metastasized squamous cell carcinoma developed on lupus vulgaris.

Lupus vulgaris (LV) is the most frequent cutaneous tuberculosis, representing more than 55% of the tuberculoses with this location. Malignization can occur after a long latency (10-30 years), in 1-2% of the cases, and it is mainly in squamous cell carcinoma. The histological exam is highly important in the observation of neoplasic transformations. The authors present a 59-years-old female patient, from the rural environment, working as a farmer, with lupus vulgaris developing since her first childhood years. It started at the age of 2 years, at the right ear lobule, after the empiric perforation for earrings. The evolution was progressive, eccentric, interesting the pinna and the right cheek in the meanwhile. At the first examination, in 2002, a diffuse mass of red-yellowish infiltration was found at the level of the right ear and the right cheek. In the following two years, an ulcero-vegetating tumor developed at the level of the right ear lobule, accompanied by the presence of a right retromandibular adenopathy, of about 1 cm, which was proved by the histopathologic exam to be a squamous cell carcinoma developed from a lupus vulgaris. After scraping out the right retromandibular ganglion, detected by palpation, a histological exam showed ganglion metastasis.

The venous system of the lower limbs.

The venous system anatomy of the lower limbs and especially its functionality still presents half-lighted areas, fact easily qualified as incredible for the third millennium. Our dissections on fresh amputation segments, methylene blue injected in superficial veins or in deeper veins pointed out that venous circulation is much more complex than it seemed, that there are subdermal collectors connected to the saphene trunks which permit bidirectional transfer of blood mass to saphene venous roots or to derm. The dermal plexus has also a complex connection with the deep venous system by Delater perforators, by perforators, which drain saphene systems after having previously received dermal affluents, and by Delater equivalences (submillimetric perforators) that provide blood mass transfer from deep to surface under the conditions of a moderate and temporary venous hypertension. High- and long-term venous hypertension determines the valvular device deterioration of classical perforators making possible a pathological bi-directional flow.

Continuous local analgesia is effective in postoperative pain treatment after medium and large incisional hernia repair.

INTRODUCTION: Incisional hernias are a frequent complication of laparotomy. Open surgery is still an option for the treatment of incisional hernias with medium and large wall defects. Major opioids are routinely used in the treatment of postoperative pain, with several side effects. Continuous local analgesia can be effective in postoperative pain management after various surgical interventions. However, very few reports exist on its application in incisional hernias. PURPOSE: We assessed the effectiveness of ropivacaine in reducing the need for systemic analgesics in postoperative pain management related to these interventions. METHODS: We conducted an open-label, prospective, randomized design study. One hundred patients with medium and large incisional hernias were treated by open surgery. Thirty patients with abdominal defects > 8 cm received continuous postoperative local analgesia with ropivacaine 5 mg/ml. Thirty four and 36 patients (abdominal defects of more, and respectively less than 8 cm) received conventional analgesia. RESULTS: Continuous local anesthesia during the first 72 h after surgery reduced the number of patients needing analgesia with pethidine (17 vs 47% and 53%, p = 0.006), as well as the cumulative doses of pethidine (p < 0.05), tramadol (p < 0.001), and metamizole (p < 0.001) needed to control postoperative pain. Catheter installation for local anesthesia did not increase surgery time (p = 0.16) or the rate of local complications. CONCLUSION: Continuous local analgesia reduces the need for systemic opioids and can be successfully used in the postoperative pain management after medium and large incisional hernias treated by open surgery.

Upper Gastrointestinal Bleeding - Initial Manifestation of Pancreatic Head Carcinoma.

Pancreatic head carcinomas are a rare cause of upper digestive bleeding and the diagnosis and the treatment of these pose particular problems. We selected 6 cases from a number of 283 patients who were hospitalized for surgery between January 2014 and December 2016 with signs of upper digestive bleeding with no varicose origin who were subsequently diagnosed with pancreatic head carcinomas. The diagnosis was established by endoscopic and surgical methods. The evolution of these patients was influenced by whether there was active digestive bleeding or history of digestive bleeding and the possibility of tumor resection. Four patients needed emergency surgery due to continuous bleeding or rebleeding. The resectability of the cephalo-pancreatic tumor was determined and then subsequently performed in two patients who had a favorable postoperative outcome, while in two patients the tumor resection was impossible. The other two patients with upper digestive haemorrhage responded favorable to drug therapy, and digestive endoscopy and CT explorations were negative. After a 5-month interval they presented with clinical signs of a pancreatic neoplasm with invasion into the common bile duct, unwanted weight loss, abdominal pain, and icterus of the sclera and skin. The surgical intervention resulted in the confirmation of locally advanced pancreatic head carcinomas and the performing of bilio-digestive derivations. Pancreatic head carcinomas may be associated with upper digestive tract haemorrhage due to duodenal or bile duct invasion. The clinical picture of these patients can vary from occult haemorrhage to severe upper digestive tract haemorrhage accompanied by hypovolemic shock.

Squamous Esophageal Carcinoma Synchronous to Pericolic Malignant Conjunctive Tumor.

Esophageal carcinoma represents a great diagnostic and therapeutic challenge due to the anatomical situation and physiopathology of the disease. The medical challenge can be even greater since esophageal carcinoma can evolve concomitant to another malignant tumor with different localization. This paper's aim is to present a case of squamous esophageal cancer associated to another primitive malignant tumor-malignant pericolic conjunctive tumor, this kind of association being singular in medical literature from our knowledge. Upon emergency presentation the patient was sketching a sub-occlusive syndrome with mild anemia and inflammatory syndrome, somehow suggesting a possible right colon cancer. However, discreet upper digestive pole symptomatology that, on first sight, seemed secondary, made the consultant to perform a superior digestive endoscopy that raised a strong suspicion of early stage esophageal carcinoma. Further exploration was not completed because occlusive complication occurred and the patient needed emergency surgery. On laparotomy a stenotic right colic angle tumor was discovered that later proved to be extra-mucosal, with conjunctive origin. Our paper focuses on highlighting the crucial importance of the imagistic explorations in the primary diagnosis of esophageal carcinoma, in the correct staging (lymphatic extension, loco-regional or distant metastases) and also for malignant tumors with another localization that can radically modify the therapeutic strategy.

Update on Endoscopy-Based Imaging Techniques in the Diagnosis of Esophageal Cancer.

The early diagnosis of esophageal cancer is necessary for improving the surviving of patients with this disease. To ensure an accurate staging, there are necessary imaging tests to establish the local and regional extension, as well as excluding the metastases. Computed tomography (CT), endoscopic ultrasonography (EUS), and positron emission computed tomography (PET-CT) constitute standard methods for esophageal cancer staging. These techniques are complementary; using only one of these tests is not suitable for correct staging. The role of EUS has improved the doctors' ability to evaluate and select the patients to undergo surgery, radiotherapy, or chemotherapy.