Albuminuria--marker of progressive renal disease

The presence of albuminuria has long been recognized as an adverse prognostic feature in patients with renal disease: the patients with appreciable albuminuria are much more likely to develop tubulointerstitial scarring and fibrosis and progress to end-stage renal failure. For many years, it was thought that excess albuminuria was simply a marker of a more severe renal disease, which was more likely to progress as a result of this severity rather than as a result of the albuminuria itself. This conviction was strengthened by the general assumption that albumin was a benign or inert molecule serving primarily to exert oncotic pressure and act as a carrier within the circulation. More recently, this view has been challenged with the accumulation of evidence suggesting that albumin is able to influence the function of cells with which it makes contact in the manner of a signalling molecule.

Lethal evolution of a newborn with consistent features of hydrolethalus syndrome--Romanian patient

Hydrolethalus syndrome is a severe lethal disorder most commonly found in Finland. We present a lethal case of complex congenital malformation in a Romanian family who showed multiple signs described in hydrolethalus syndrome. Our case presented the specific characteristics: macrocephaly, midline cleft-lip, cleft palate, polydactyly of both hands and feet but without occipitoschisis, considered as the pathognomonic sign of the syndrome. Sequencing analysis of HYLS1 did not identify the point mutation present in the Finnish cases or other mutations in this gene.

Electrosurgical loop excision/conisation for cervical intraepithelial neoplasia in an algorithm that excludes punch biopsy--a study of 210 cases

This study aims to evaluate the use of LLETZ/conisation in an algorithm that excludes the colposcopically guided biopsy.

MATERIAL AND METHODS

The study was carried out on 210 patients with LLETZ/conisation, performed in our service in 2 years. They were selected by pap smear, colposcopy, HPV genotyping, without punch biopsy.

RESULTS

The pathological results on the excision specimen showed: benign lesion 10%, CIN 1/condyloma 58%, CIN 2 18%, CIN 3/CIS 11%, microinvasion 2% and invasion 1%. The Pap test showed: HGSIL 27%, LGSIL 56%, ASCUS 13%, and normal/benign in 4%. The therapeutic efficiency of the excisional treatment showed that there was a 9.5% excessive treatment, 14.8 residual lesions, 3 cases of hemorrhage, 2 cervical stenosis, and 7 cases with specimen alteration that made the pathological diagnostic difficult or impossible. In conclusion, the LLETZ/conisation are ambulatory procedures with an acceptable rate of over-treatment and residual lesions, and reduced rate of complication.

Past experience of SUUB's Pathology Department in classic based cervico-vaginal cytology

The importance of screening to detect early lesions that may soon turn into cervical carcinoma is well known. The Romanian contribution to the diagnosis of these lesions dates back over a century ago and is due to A. Babes (1926 and later in the standardization of the Papanikolaou 1928). The experience of the Cytology Compartment of the University Emergency Hospital in Bucharest increased permanently regarding smears made conventionally and those in liquid medium. We believe that this experience should be statistically analyzed and compared with the histological results, especially for the cases of high-grade intraepithelial neoplastic lesions. The article scholastically presents the activity of SUUB's Cytology Compartment, our cases arising mostly from Departments of Gynecology and from medical or surgical emergency cases that were considered at risk by SUUB's clinicians. Our study is based on conventional based Pap test cervico-vaginal cytology activity reports of SUUB's Pathology Department from the past 23 months - 9730 cases -, using Bethesda 2001 system, including descriptive statistics parameters by age, year period, and diagnostic categories. The authors make a detailed description of the pool, enumerating its epidemiological attributes for a future comparative analysis CBP versus LBP - the current technical procedure in SUUB's Cytology Compartment.

[Pancreaticoduodenectomy with or without pylorus preservation: a retrospective analysis of 137 patients]

OBJECTIVE

We performed a retrospective study to assess the postoperative results, long-term survival and quality of life after pylorus preserving pancreaticoduodenectomy (PPPD) versus standard Whipple pancreaticoduodenectomy (WPD).

METHODS

A retrospective study was performed in a nonselected series of 137 patients who were operated in the Surgical Clinics of "St. Spiridon" University Hospital Iaşi, Romania, from January 1st, 1995 till December 31, 2005. Demographics, preoperative and intraoperative data, as well as postoperative morbidity, mortality and follow-up were analyzed. Quality of life, after to at least six months after discharge, was also studied.

RESULTS

There were no significant differences noted in demographics data. Jaundice was more frequent in the PPPD group as for WPD patients (p=0.047). For the most patients the digestive reconstruction after resection were performed as in Child technique: the first anastomosis was pancreaticojejunostomy (end-to-end or end-to-side), the second anastomosis was hepaticojejunostomy (end-to-side) and the last anastomosis was gastrojejunostomy end-to-side (duodenojejunostomy in PPPD group). For 31 cases a pancreatico-gastrostomy were performed. We also noted 14 cases with pancreatico-gastrostomy and duodenojejunostomy end-to-end, and a Roux jejunal loop for 3 patients with previous gastrectomy and gastrojejunostomy (Reichel-Polya). The operating time was shorter in the PPPD group as in WPD (p < 10-3), but the mean blood loss was the same. Postoperative morbidity rate was 46.8% in PPPD group vs 39.2% in WPD (p > 0.05), but the reintervention rate was significant higher in PPPD group (30.6% vs 15%; p = 0.027). We also noted no significant differences of Delayed Gastric Emptying, postoperative mortality rate (14.5% in PPPD group vs 10.1% in WPD group) and mean survival time (42.42 months (24.94 - 59.89; 95% CI) in PPPD group vs 46.78 months (28.07 - 61.50; 95% CI) in WPD group; log rank test p = 0.643). Pathological exam diagnosed a malignancy in 109 cases (54 cases with pancreatic cancer); we noted chronic pancreatitis in 22 cases. Quality of life was also the same in the two groups.

CONCLUSIONS

PPPD and WPD were associated with comparable results, but, there is a tendency of increase rate of postoperative morbidity and mortality for PPPD patients. We also noted that postoperative quality of life is the same for both procedures.

[Pancreaticoduodenectomy for pancreatic head cancer, 54 cases]

Pancreatic cancer has an increase rate in western countries. From the first pancreaticoduodenectomy (PD) performed by Kausch in 1909, the value of the resection in the treatment of pancreatic head cancer was disputed.

AIM

To assess the PD with or without pylorus preservation as surgical treatment for pancreatic cancer.

METHODS

Retrospective review of the clinical records of patients undergoing PD for pancreatic cancer.

RESULTS

From January 1995 till December 2005, in the First and Third Surgical Units, "St. Spiridon" University Hospital Iaşi, Romania, were performed 137 PD. From these, 54 cases were histologic diagnosed with pancreatic cancer; 23 cases underwent pylorus preserving pancreatico-duodenectomy (PPPD) and 31 patients, classical Whipple procedure (PDW). Mean age was 59.07 +/- 1.42 years old (26-75 years old), and male to female ratio was 29 to 25. Jaundice was presented in 51 cases (94.4%), abdominal pain at 39 patients (72.2%) and Curvoisier-Terrier sign at 37 cases (68.7%). Fever was observe only in 4 cases (7.4%). Other biological and imaging parameters (e.g. main diameter of the biliary duct, tumor and wirsung ) were also discussed, but no significant difference was found between PPPD and PDW. Pancreatico-jejunostomy was performed in 41 cases (28 during the PDW and 13 in PPPD) and 13 pancreatico-gastrostomy (3 during PDW and 10 during PPPD). Mean operating time and mean blood loss in the PDW group were 358.22 +/- 10.53 minutes and 587.74 +/- 60.87 mL. After PPPD, these figures were 326.08 +/- 15.04 minutes and 571.74 +/- 90.50 mL, but no significant difference was noted. Delayed Gastric Emptying (DGE) was presented at 15 patients: 8 in PPPD group and 7 in PDW group (p=0.322). Postoperative morbidity rate (excluding DGE) was 33.33% (8 cases in PDW group and 10 in PPPD group). Pancreatic leak has a rate of 5.55% (3 cases--one in PPPD group vs two in PDW group), biliary leak has a rate of 12.96% (4 in PPPD group vs 3 in PDW group)and duodeno-jejunal anastomotic fistula appeared in one cases (PPPD). Acute postoperative pancreatitis is presented in one case (PPPD group) and postoperative hemorrhage appeared in 4 cases (2 in PPPD and 2 after PDW). Hospital stay was 19.91 +/- 2.28 days in PPPD group vs 18.87 +/- 2.24 days in PDW group (p = 0.751). Postoperative mortality rate was 5.5% (one case after PPD and 3 cases after PDW). Histological exam diagnosed ductal pancreatic adenocarcinoma in 51 cases (94.44%). Mean long-term survival rate was 20.98 months (10.52-31.45 months; 95 CI) and no difference was revealed between PPPD and PDW (log rank test - p = 0.796).

CONCLUSION

PD should be performed for any pancreatic tumor even without preoperative histologic confirmation. The results after PPPD (postoperative morbidity and mortality, long-term survival) are similar to that following conventional Whipple procedure, if the principles of viable and tumor free margins are observed.

[Tumors of the ampulla of Vater--local or radical resection?]

Duodenal ampulla is a complex anatomical and histological site and a tumor may arise from one of three types of epithelium: duodenal mucosa, pancreatic duct and distal common bile duct. Neoplasia from each of these locations may exhibit different growth models and though it is difficult to establish their origin before operation, surgical treatment for all resectable tumors is essentially alike. The outcome of these tumors is vitally influenced by the type of epithelium from which they derive. Benign adenomas appear to be a frequent precursor of carcinoma of the ampulla of Vater, therefore, a local resection can lead to an under treated early cancer which would have benefited from a radical excision, with a much better long term result. We consider acceptable to perform an ampullectomy whenever is possible to safely state the benignity of the tumor or when a major procedure is hazardous.

[Surgical treatment of esophageal strictures secondary to gastroesophageal reflux disease]

The end point in gastro-oesophageal reflux disease (GERD) evolution is oesophageal stenosis. The aim of this study is merely to establish the absolute requisite of treating simultaneously the oesophageal stenosis and the causal disorder, GERD. This article analyses the diversity of surgical treatment in relationship with the location and length of the oesophageal stenosis using a group of 35 patients with GERD over a period of 25 years. Treatment of this condition has enriched and diversified in the last decades with more conservative and complex techniques, having the task to preserve, whenever possible, the oesophagus. The ability to decide the optimal moment for the surgical treatment, to elect the most suitable procedure, to treat simultaneously the stenosis and to prevent further reflux guarantee a successful, free of recurrence outcome.

[Surgical resection in esophageal-gastric junction adenocarcinoma]

Between January 1999 and November 2005 there have been a number of 44 cases of cancers of the esophageal-gastric junction. Only 24 of them have been surgically removed. The carcinoma of the esophageal-gastric junction was defined on topographical and histological grounds, complemented by radiological, endoscopical and tomographical aspects. The authors analyzed the location of the tumor, compared the imaging with the intra-surgical findings and chose the surgical strategy. The authors widely used the classification proposed by Siewert and Stein, which should be the reference for such tumors. The distal esophagectomy for type I and II tumors should reach much closer, at a reasonable, oncologically sufficient, distance from the upper limit of the tumor; the transhiatal approach is as good as a trans-thoracic one for an accurate mediastinal lymphadenectomy; an esophago-jejunal anastomosis should not be carried out at any costs, reducing the height of the esophageal resection (a risk of positive resection margins), for the length of the jejunal segment to fit the gap.

[Tailored surgical treatment for post-caustics stenosis of the upper digestive tract with complicated lesions. Clinical experience at our department in the last ten years]

The ingestion of caustic substances generates severe lesions of superior digestive tract, leading to stenosis in 50% of patients, of which almost 50% will require surgical treatment. A number of 29 patients with caustic lesions were treated in the IIIrd Surgical Unit from 1993 to 2004. The most frequent corrosive agent was a strong alkaline solution. The location of the post caustics strictures was esophageal in 18 cases, esophagogastric in 7 cases and laryngo-pharyngo-esophageal in 4 cases. Surgical procedures consisted of 8 esophagoplasties with ascending colon and ileum, 12 with left colon, 3 with transverse colon and splenic flexure, and in 5 cases transhiatal resection with cervical esophago-gastric anastomosis. 5 patients required gastric resections of variable extent, in addition to the esophageal reconstruction: antrectomy with trunk vagotomy--1 case, subtotal gastrectomy--3 cases and total gastrectomy--1 case. In the group with pharyngeal lesions, esophageal reconstruction followed pharyngoplasty with cutaneous tube performed in the ENT department. Hospital mortality rate was 3,4 % (1 case). Postoperative morbidity of 20,6 % consisted of cervical anastomosis leakages in 2 cases and pleural effusions in 4 cases. Surgical treatment of the post caustics strictures of the upper digestive tract must be adapted to the location and severity of the lesions, requiring adequate operative experience and special pre- and postoperative care.

[Transhiatal esophagectomy for treatment of benign and malignant esophageal diseases]

In 1978 the technique of transhiatal esophagectomy without thoracotomy was rediscovered and now it is widely used in certain, selected, cases. Between 1987 and 2003 we have performed transhiatal esophagectomy in 35 patients with intrathoracic esophageal disease: 13 (37.14%) for benign lesions of the esophagus and 22 (62.85%) for malignant lesions (22.72% upper, 9% middle and 68.18% lower third of the thoracic esophagus). The reconstruction was performed at the same operation in all but two patients. The esophageal substitute was stomach in all but one patient when left colon was used. Hospital mortality was 14.28% with one death due to uncontrollable intraoperative hemorrhage. Major complications included anastomotic leak, recurrent laryngeal nerve paralysis, atelectasis/pneumonia. The advantages of this approach over standard transthoracic esophagectomy are avoidance of a combined thoracoabdominal operation in a debilitated patient and fewer postoperative pulmonary complications and also avoidance of an intrathoracic esophagogastric anastomotic leak with high mortality due to mediastinitis.

[Intraoperative and early postoperative intraperitoneal chemotherapy--adjuvant treatment for locally advanced digestive system cancer]

Surgical treatment for locally advanced digestive cancers (invasion beyond the serosa, adjacent structures penetration and perforated tumors) is followed by a high rate of peritoneal recurrence and distant metastasis. Simultaneous intraperitoneal chemotherapy with surgical resection, which is continued over the early postoperative period act on the tumor cells which can be mobilized during the surgical dissection. This adjuvant treatment could lead to better control of local recurrence. Moreover, high levels of the agents are reached in the portal circulation which could be profitable for preventing hepatic metastasis. The main drawback of the method is represented by the impaired immunologic activity of the peritoneum, which can cause, at least theoretically, detrimental complications.

OBJECTIVE

The efficiency of the intraoperative and early postoperative intraperitoneal chemotherapy is the subject of a prospective randomized study, started 8 months ago in our department.

METHOD

Patients with locally advanced (penetration of the tumor beyond serosal layer, without liver metastasis) are randomized for adjuvant intraperitoneal chemotherapy or standard treatment. Intraoperative chemotherapy is commenced after surgical resection but before accomplishing any anastomosis. We use 50 mg of cisplatinum for washing the peritoneal cavity and continue to instill 20 mg/m2 of cisplatinum intraperitoneally in the first four days after surgery. (8 patients were selected to be treated according to this protocol).

CONCLUSION

Immediate postoperative outcome does not seem to be influenced by this treatment. The disease free interval and the overall survival rates can not be assessed at this moment of the study.

[Synchronous colonic cancers]

The aim of this study is to present the difficulty of an accurate preoperative diagnostic for synchronous colonic cancers and to sustain the necessity of total colectomy. A retrospective study was carried out on 16 patients hospitalized in the IIIrd Surgical Unit, St. Spiridon Hospital, U.M.Ph. "Gr.T.Popa" Iasi between 1990-1999. The surgical procedures were: extensive colectomy with ileo-sigmoid anastomosis, segmentary colectomy, total colectomy with ileo-rectal anastomosis.

RESULTS

Perioperative mortality: zero; uneventfully recovery for all patients. A metachronous lesion 3 years after the first operation was detected in one patient; postoperatively, one patient developed occlussion 3 months after, requiring re-operation.

CONCLUSIONS

1. synchronous colonic cancers are closely related with a genetic instability of the colonic mucosa; 2. total colectomy is a safe manner to prevent metachronous lesions.

Familial adenomatous polyposis--which operation?

Familial adenomatous polyposis (FAP) syndromes are well recognized entities that benefit from surgical treatment which should not be delayed. Screening of first degree relatives is important. The aim of removing the colorectal mucosa with significant potential of malignant transformation can be achieved by means of three distinct procedures: pan-proctocolectomy and ileostomy, subtotal colectomy with ileorectal anastomosis, restorative proctocolectomy with ileoanal anastomosis. In a series of eight patients with FAP we performed mostly subtotal colectomy with ileorectal anastomosis. Of five patients who underwent a form of subtotal colonic resection, one was lost from follow up and two developed carcinoma in the remaining rectal mucosa, which necessitated completion of the resection with proctectomy and permanent ileostomy. Nevertheless, in the increasing number of patients amenable to regular outpatient supervision, there are strong points for recommending sphincter-saving operations.

Polipoza adenomatoasă familială--care operaţie? [Familial adenomatous polyposis--which operation?]

Familial adenomatous polyposis (FAP) syndromes are well recognized entities that benefit from surgical treatment which should not be delayed. Screening of first degree relatives is important. The aim of removing the colorectal mucosa with significant potential of malignant transformation can be achieved by means of three distinct procedures: panproctocolectomy and ileostomy, subtotal colectomy with ileorectal anastomosis, restorative proctocolectomy with ileoanal anastomosis. In a series of eight patients with FAP we performed mostly subtotal colectomy with ileorectal anastomosis. Of five patients who underwent a form of subtotal colonic resection, one was lost from follow up and two developed carcinoma in the remaining rectal mucosa, which necessitated completion of the resection with proctectomy and permanent ileostomy. Nevertheless, in the increasing number of patients amenable to regular outpatient supervision, there are strong points for recommending sphincter-saving operations.

Clinical and epidemiological correlations between the infection with HPV 16 and HPV 18 and female cervical lesions

A number of 66 specimens from female cervical lesions were examined for infection with human papillomavirus (HPV) types 6, 11, 16, and 18 by nucleic acid hybridization in dot-blot techniques and 35 sera were tested by the immunodot-blot technique, in order to detect the presence of anti E4 and E7 HPV protein antibodies. The findings were compared with the histologic diagnosis. Fifty-six per cent of specimens contained HPV DNA sequences. In 47% of specimens from cervical carcinoma, HPV 11 was detected in 4 cases, HPV 16 in 21 cases, and HPV 18 in 7 cases. Serum antibodies against HPV 16 E4 and HPV 16 E7 occurred in all the cases of uterine carcinoma, in 4 of 10 cases of CIN I-II, and in 3 of 5 sera obtained from apparently healthy women. The analysis of risk factors disclosed the early onset of sexual activity, a relatively high number of births and abortions before the age of 22 years, the use of oral oestroprogestative contraceptive agents, the presence in anamnesis of genital infections with bacterial flora--Candida albicans, Trichomonas vaginalis, Chlamydia trachomatis, Mycoplasma, etc. Our results showed that HPV typing by nucleic acid hybridization was useful for differentiating low- from high-risk cervical lesions and also tried to elucidate the risk factors associated with HPV infections and progression to malignancy.

Gastric malignant schwannoma

One case of gastric malignant schwannoma is presented, the clinical diagnosis, the morphological particularities and the prognostication of this tumour are discussed. Personal observation. In December 1986, the patient H. R., of female sex, aged 27, was hospitalised in "The Second Medical Clinic" of "St. Spiridon Hospital" for epigastric pains accompanied by melena. After analysing the evolution of the disease, it resulted that the patient had been suffering from epigastric pains, which gave unfavourable prognosis after a symptomatic treatment for 10 years.

Presence of papillomavirus infections in genital lesions of women in Romania

This study is aimed at establishing the presence of HPV infection in Romania, in women with various benign or malignant anogenital lesions. A number of 76 tissue samples were investigated by nucleic acid hybridization in the dot-blot techniques for identifying the HPVs presence and their serotypes and 35 sera were tested by the immunodot-blot technique in order to detect the presence of antiHPV16 E6 and E7 proteins antibodies. The results obtained suggest the incidence of HPV16 infection is high not only in persons with different tumours or other anogenital lesions (approximately 585), but also in apparently healthy women (3 of 4 cases).

Experimental and clinical correlation in acute pancreatitis pathogenesis

Pathological aspects in 100 cases of operated A.P. different in severity are not strictly related to aetiological conditions. Clinical observations have suggested some components of pathogenesis: obstruction of bilio-pancreatic inflow in duodenum at the beginning of the attack, bilio-pancreatic reflux on cholangiograms, strong secretory digestive stimulation before attack. Some experimental animals models (dogs) which can mimic pathogenic mechanism (obstruction of pancreatic flow, common bilio-pancreatic duct, closed duodenal loop, acute cholecystitis) have revealed characteristic pathological changes depending on the initiating process. Our conclusion that severity of pathological changes in A.P. are determined by the initiating mechanisms which may differ in some aetiological condition or may be common for different ones.

Identification of antibodies against human papillomavirus type 16 E4 and E7 proteins in sera of patients with cervical neoplasias

Sera from 35 women (patients with various clinical diagnosis: cervical dysplasia, benign and malignant tumors of the uterine cervix) were tested by immunodot blot for the presence of antibodies to E4 and E7 HPV16 proteins. A number of 26 sera displayed positivities for at least one antibody type. The mean absorbance for anti-E antibody in positive cases was higher in cancer patients (15 from 16 sera) as compared with other diagnoses (2 from 5 in dysplasia or one from 4 in uterine fibroma). Interestingly, most sera were reactive for both proteins. The high prevalence rates and high absorbance values for HPV16 E7 antibodies in association with malignant transformation suggest that the detection of these antibodies may be a useful diagnostic aid for cervical cancer--associated HPV16.

Nucleic acid dot blot hybridization with fragmented digoxygenin labelled probes in human papillomavirus DNA screening

Twenty human genital tissue samples from patients with different premalignant and malignant lesions were investigated by nucleic acid hybridization, using the dot blot technique. Molecular probes of various length--whole or fragmented papillomavirus genome--were digoxygenin-labelled. Human papillomavirus 16 DNA was identified in fifteen cases, well correlated with the clinical diagnosis. Fragments of papillomavirus genome proved to be efficient probes in nucleic acid hybridization as compared with the whole genome used for the same purpose.

[Detection of polynucleotide fragments using hybridization with probes labelled with digoxigenin]

A new nonradioactive system for labeling molecular probes, using digoxygenine, was studied. Detection of ADN-ADN type hybrids formed on a nylon membrane was realised photochemically or by ELISA, dot-blot or Southern-blot. The high sensitivity and specificity of this new system allow to use it for detection of amounts of ADN as small as 5 ng.