Innovative Surgical Approaches That Improve Individual Outcomes in Advanced Breast Cancer

Breast cancer is the most common cause of cancer death in women and the second cause in the general population. The incidence has increased over time. Women in developing countries often present at an advanced stage where initial surgery is not feasible. Short disease-free intervals, the number of metastatic organs and liver metastasis were consistently associated with poor overall survival. Surgery is an integral part of the therapeutic plan for locally advanced breast cancer. The integration of surgical care into the management of patients with advanced cancer has changed substantially with the use of neoadjuvant chemotherapy. Also, more recently, neoadjuvant endocrine therapy and targeted therapies offer new opportunities to downsize the tumor burden and transform the role of surgery for this population from palliation to largely curative intent. Innovative surgical approach to the primary tumor in metastatic disease may provide survival benefits and local control in some patients. Similar to systemic therapy, surgical therapy for secondary dissemination should be considered in certain cases for improved individual outcomes. Advances in reconstructive techniques have improved the quality of life of these patients.

Surgical Management of Perianal Giant Condyloma Acuminatum of Buschke and Löwenstein: Case Presentation

INTRODUCTION

The Buschke-Löwenstein tumor (BLT) is an uncommon sexually transmitted ailment attributed to the human papillomavirus (HPV)-usually the 6 or 11 type (90%)-with male predominance and an overall infection rate of 0.1%. BLT or giant condyloma acuminatum is recognized as a tumor with localized aggressiveness, displaying distinctive features: the potential for destructive growth, benign histology, a rate of 56% malignant transformation, and a high rate of recurrence after surgical excision. There are several treatment choices which have been tried, including laser, cryotherapy, radiotherapy, electrocoagulation, immunotherapy, imiquimode, sincatechins, intralesional injection of 5-fluoruracil (5-FU), isolated perfusion, and local or systemic chemotherapy. In the case of an extensive tumor, preoperative chemotherapy or radiotherapy is used for tumor shrinkage, making the debulking procedure safer. HPV vaccines significantly decrease the incidence of genital warts, also decreasing the risk of BLT; HPV-6 and HPV-11 are included in these vaccines.

MATERIALS AND METHODS

We present a 53-year-old heterosexual man, hospitalized in our department in June 2021 with a typical cauliflower-like tumor mass involving the perianal region, which progressively increased in size for almost 7 years. The perianal mass was completely removed, ensuring negative surgical margins. The large perianal skin defect which occurred was reconstructed with fascio-cutaneous V-Y advancement flap. There was no need for protective stoma. The literature review extended from January 1980 and December 2022, utilizing Pubmed and Google Scholar as search platforms.

RESULTS

Due to the disease's proximity to the anal verge and the limited number of reported cases, arriving at a definitive and satisfactory treatment strategy becomes challenging. The optimal approach entails thorough surgical removal of the lesion, ensuring well-defined surgical margins and performing a wide excision to minimize the likelihood of recurrence. In order to repair the large wound defects, various rotation or advancement flaps can be used, resulting in reduced recovery time and a diminished likelihood of anal stricture or other complications. Our objective is to emphasize the significance of surgical excision in addressing BLT through the presentation of a case involving a substantial perianal condyloma acuminatum, managed successfully with complete surgical removal and the utilization of a V-Y advancement flap technique. In the present case, after 5 months post operation, the patient came back with a buttock abscess, which was incised and drained. After another 5 months, the patient returned for difficult defecation, with an anal stenosis being diagnosed. An anal dilatation and sphincterotomy were carried out, with good postoperative results.

CONCLUSIONS

The surgical management of Buschke-Löwenstein tumors needs a multidisciplinary team with specialized expertise. The reconstruction techniques involved can be challenging and may introduce additional complications. We consider aggressive surgery, which incorporates reconstructive procedures, as the standard treatment for Buschke-Löwenstein tumors. This approach aims to achieve optimal surgical outcomes and prevent any recurrence.

Epidermolysis Bullosa-A Kindler Syndrome Case Report and Short Literature Review

INTRODUCTION

Epidermolysis bullosa (EB) represents a group of rare disorders, genetically determined, characterized by skin fragility, blister formation and erosions due to minimal trauma. Depending on the ultrastructural level of skin cleavage, above or below the basement membrane, epidermolysis bullosa can be classified into four major types: simplex, junctional, dystrophic and Kindler Syndrome. In the junctional form of EB, the cleavage level is at the dermo-epidermal junction and the targeted proteins are laminin, type XVII collagen and integrins. The dystrophic form of EB is characterized by cleavage in the dermal layer, collagen VII being the targeted protein. In Kindler EB, multiple levels of cleavage have been described. The mutated gene is FERMT1. Another classification of this disease refers to phenotypic aspects such as extracutaneous lesions, severity, and distribution. The management of epidermolysis bullosa includes supportive wound treatments as well as nutritional support.

CASE REPORT

We present a case of epidermolysis bullosa presented at birth, in a newborn with no family history of bullous skin conditions. The clinical presentation revealed extensive denuded areas and significant skin fragility as well as mucous and nail involvement. Prenatal diagnosis is very hard to achieve due to increased genetic heterogeneity of the disease. The short-term results were good. The importance of prenatal testing and possibilities of diagnosis are reviewed in this article.

CONCLUSIONS

EB is a devastating disease. The presented case had a favorable evolution, with good short-term results. Significant morbidity can result from secondary infections of blisters and complications of the extracutaneous manifestations.

Challenges and Solutions in Choosing the Surgical Treatment in Patients with Complicated Colon Cancer Operated in an Emergency - A Retrospective Study

Introduction: Choosing the optimal treatment for patients with complicated colon cancer operated in an emergency remains a challenge. The study aims to identify the factors that influence the therapeutic decision in these patients. Patients and Methods: We included in this retrospective study 449 patients operated in emergency for complicated colon cancer, in the Clinical Emergency County Hospital "St. Ap. Andrei" Galati between 2008-2017. The patients data were collected from the observation sheets, the surgical, imaging and laboratory protocols. Results: The operations performed were: resections with a stoma in 37.63% of cases, resections with anastomosis in 36.97%, stomas in 16.26% and internal derivations in 9.13% of patients. Elderly age was correlated with stomas with or without tumour resection (p 0.05). Preoperative diagnosis of IDH was associated with resections with anastomosis, those with occlusion were associated with internal derivations and those with digestive perforations with resections with a stoma (p 0.05). The stomas were associated with the presence of intraoperatively detected complications (p 0.05). Conclusions: Complicated colon tumours operated on in an emergency require surgical treatment tailored to each patient. It is important to choose the type of treatment taking into account the patient's condition at admission, clinical-paraclinical data, tumour location, tumour complication and the presence of other complications detected intraoperatively.

LAR vs VLAR in Low Rectal Cancer - Postoperative Results - A Single-Center Experience

Background: The management of rectal cancer recognizes surgical resection as the most important step towards a permanent cure. Respecting the oncological principles, functional preservation represents a priority in achieving an acceptable quality of life for the patient. This study aimed to compare the results after low anterior resection (LAR) versus very low anterior resection (VLAR), in terms of postoperative outcome. Methods: We conducted a retrospective, observational study on a group of 147 patients with LAR or VLAR done for low rectal cancer in the 1st Department of General Surgery of the Emergency County Hospital of Targu Mures, between January 2015 and December 2019. We considered as low rectal cancer tumors located between 5-10 cm from the anal verge and very low those situated less than 5 cm from it. Patients were divided in two groups according to the type of operation. The postoperative evolution was followed. Results: The two groups, LAR with 81 and VLAR with 66 cases, had homogenous distribution regarding patients demographic and biological parameters and tumor pathological features. A significantly (p=0.0223) longer surgical intervention time was reported in VLAR than in LAR procedures. We found no statistically significant differences between LAR and VLAR in terms of associated postoperative morbidity or mortality, neither in hospitalization time. Conclusions: There was no statistical difference in terms of early postoperative outcomes among LAR and VLAR. The most important factor in achieving good oncologic and functional results in low rectal cancer is choosing the adequate, tailored to the case surgical management.

Antioxidant Profile of Buckwheat Honey from the Republic of Moldova

The honey is a natural substance, whose therapeutic qualities have been developed in parallel with human evolution. Its antioxidant and antiinflammatory properties are due to the polyphenolic compounds. The purpose of this study is to identify and quantify the phenolic compounds and the FTIR spectrum from buckwheat honey from the Balti region, Republic of Moldova. The radical scavenging activity of honey was 83% in the DPPH� reaction system. Phenolic compounds from honey were identified by HPLC-MS method, the significant concentrations being lignans, catechins, isorhamnetin, rutin, apigenin and luteolin. FTIR analysis revealed both the carbohydrate profile in buckwheat honey and the presence of active compounds.

Reactive Arthritis The Reiter-Fiessinger-Leroy Syndrome

The role of creating the expression of reactive arthritis rests with AHO in 1973, which defines reactive arthritis as an acute, unsupportive, sterile inflammatory arthropathy, arising from infections located at a distance in people with a certain genetic predisposition; the disease is systemic and, despite its name, is not limited to the joints. Reactive arthritis (RA), included in Reiter syndrome (with the classic triad of urethritis, conjunctivitis and arthritis), is a non-suppurative inflammatory joint pathology, with a minimal autoimmune component, which it is installed following intestinal or urogenital infections, mainly in people with genetic predisposition. Reactive arthritis is a form of arthritis that affects the joints, urethra, eyes and membranes and sometimes the skin and mucous membranes. This condition is also called Reiter`s syndrome, although this name only indicates a subtype. Reactive arthritis is a seronegative spondyloarthropathy, which brings together a group of disorders that cause inflammation in the body, especially in the spine - such as ankylosing spondylitis, and in the legs. The study covers a number of 20 patients (11 men, 9 women) admitted to the Rheumatology Service of the Clinical Recovery Hospital, between 2010 and 2011, aged over 20, who were diagnosed with reactive arthritis. The existence of a structural similarity between the etiological agent and the HLA-B27 molecule determines either the recognition of the disease-causing germ as a self, so that no immune response will be initiated against it and the antigen will be able to trigger the disease, or the recognition of the germ as nonself, with the triggering of an immune response aimed at both itself and against the HLA-B27 molecule carrying cells of similar structure. Reactive arthritis (RA), included in the Reiter syndrome (with the classic triad of urethritis, conjunctivitis and arthritis), is a non-suppurative inflammatory joint pathology, with a minimal autoimmune component, which is installed as a result of intestinal or urogenital infections, mainly in people with genetic predisposition.

Primitive Gastric Lymphoma - a Series of 3 Cases

The Primitive Gastric Lymphoma represents the extra-ganglionic non-Hodgkin lymphoma most frequently and comprises a large spectrum, ranging from the mucosa-associated lymphoid tissue (MALT) lymphoma to aggressive diffuse large B-cell lymphoma. The Primitive Gastric Lymphoma is a rare tumor, with an occurrence ranging from 4% to 20% of non-Hodgkin lymphomas and approximatively 5% of primary gastric neoplasms. The chronic gastritis secondary to the infection with Helicobacter pylori was considered a major predisposing factor for MALT lymphoma. The clinical evolution and the prognosis of this disease depend on the subtype and histopathological stage at the moment of the diagnosis. Due to its rarity, many aspects of this neoplasm remain still controversial.

THE MARK OF THE DURATION OF SURGERY ON THE POSTOPERATIVE COMPLICATIONS IN PATIENTS WITH COMPLICATED COLON CANCER

Postoperative complications are common in patients with complicated colon cancers operated in Emergency. Most complications are those of the sound (suppurations, hematoma, dehiscence), postoperative ileus, anastomotic fistula. The purpose of this study is to evaluate the influence of the duration of the surgery on the postoperative complications in patients with complicated colon tumors, operated in emergency. We made a retrospective study on 451 patients treated for complicated colon cancers in the surgery clinics I and II of the Clinical Emergency County Hospital Galați between 2008 and 2017. In this study, we found all the 3 types of complications of colon tumors, but the most common was the intestinal obstruction. The operations varied from colostomies to subtotal and total colectomies. Most complications occured on the postoperatory days 4-8. The statistical analysis that we made revealed important statistical significance in the correlation of the postoperative complications and the duration of the surgical intervention (p value less than 0,001).The emergency colon cancer surgery has a high rate of postoperative complications, of which the most common are cardio-respiratory, parietal and fistulous. Their occurrence is directly influenced by the duration of the surgery.  

Microbiological Evaluation of Surgical Site Infections in the Clinic of Oral and Maxillofacial Surgery of the Sf.Spiridon Clinical Hospital in Iasi, Romania

The study aims to evaluatethe bacteriological profile of the surgical site infections at the Clinic of Oral and Maxillofacial Surgery of the Sf.Spiridon Clinical Hospital in Iasi, Romania between 2011 and 2018. Microbiological data were obtained from the Microbiology Laboratory of the Sf.Spiridon Emergency Clinical Hospital Iasi. 125 surgical site infections, accounting for 54,1% of health care associated infections were reported in 106 patients, representing 66,6% of the patients with HAI. The most commonly identified pathogens were Klebsiella Pneumoniae, Staphylococcus aureus, Acinetobacter baumanii and Pseudomonas aeruginosa.A high level of antibiotic resistance was reported. Prevention of SSI and antibiotic resistance control are complex and require coordinated measures in view of an integrated, multidisciplinary approach.

CBCT Evaluation of the Mandibular Bone Quality in Relation to Skeletal Status After Treatment with Strontium Renelate in Diabetic Patients

The aim of this study was to evaluate the diagnostic efficacy of the cone beam computed tomography (CBCT) - based mandibular indices and the CBCT mandibular bone density values and to determine whether they correlate with bone mineral density (BMD) of the lumbar spine (L1 - L4) and proximal left femur in patients with osteoporosis and diabetes mellitus, which were taken a treatment with strontium ranelate over a period of 6 months. The study included 20 osteoporosis patients and 40 diabetic patients (16 patients � type 1 diabetes mellitus and 24 patients � type 2 diabetes mellitus). In CBCT images, the radiomorphometric indices were measured in the right and left mandibles. The relationship between the CBCT measurements of the mandible and skeletal BMD was assessed. The present study showed that mandibular bone quality is closely correlated with the skeletal status of the patients with osteoporosis and diabetes mellitus which were in treatment with strontium ranelate for bone improving.

Comparative Evaluation of Casein Phosphopeptide - Amorphous Calcium Phosphate and Fluoride in Managing Early Caries Lesions

The aim of the present study was to assess the remineralizing potential of 10% casein phosphopeptide-amorphous calcium phosphate complex (CPP-ACP) -Recaldent used alone or with fluoride (CPP-ACFP) as compared to fluoride mouthrinse for the non-invasive treatment of occlusal non-cavitary caries lesions in vivo.A total of eighty subjects were randomly assigned to four groups, i.e. group 1 - 10% CPP-ACP, group 2- 10% CPP-ACP + 0.2% NaF, group 3- 0.05% NaF mouthrinse and group 4 �control. The lesions were assessed using visual examination and DIAGNOdent measurements. After 12 weeks of using the corresponding product, the results showed that the highest decrease in fluorescence was produced by CPP-ACFP (from 16.28�1.40 to 6.53�0.59, p=0.002), followed by CPP-ACP (from 15.70�1.82 to 8.18�0.70, p=0.004) and fluoride mouthrinse (from 14.32�1.72 to 7.88�0.68, p=0.005), significantly higher than in the control group (p[0.05). No significant differences were found between the three treatment groups.

Comparative Effectiveness of Vancomycin and Metronidazole for the Initial Episode of Nonsevere Clostridium Difficle Infection

The infection with Clostridium difficile (CDI), which appeared at epidemic level, after acquiring the germ of some fluoroquinolone resistance genes, initially considered nosocomial infection and adverse effect post-antibiotic therapy, is affecting more and more people without risk factors and extending into the community. This paper proposes an analysis of the two main antibiotics used in therapy: metronidazole and vancomycin, the evidence of efficacy in the literature and the chemical stability of antibiotics in simulated gastrointestinal fluid. Based on UV-Vis absorption spectra, it can be considered that there are no major changes in the chemical structure of the investigated drugs in the presence of gastro-duodenal conditions. Clinical impact of comparative treatment with metronidazole and vancomycin has also been studied, in a group of 720 CDI patients hospitalized during the period 1.01.2017-31.12.2018 in the Clinical Hospital St. Parascheva of Infectious Diseases Galati. From this group, two subgroups were selected, one of 284 patients receiving oral vancomycin treatment and one group of 62 patients receiving oral metronidazole for an initial nonsevere episode of CDI. The number of days from the beginning of the treatment until the normalization of the stool, the length of hospitalization, the number of days of antibiotic treatment and the percentage of relapses were comparable in the two groups, the percentage of deaths in the first 30 days from the episode of CDI was higher in the vancomycin-treated group, probably due mainly to the severe comorbidities of these patients. The conclusion of the study is that the treatments with metronidazole and vancomycin, of the initial episode, nonsevere of CDI are comparable as a therapeutic response, provided that the patients treated with metronidazole do not associate hepatic, renal or neurological impairment due to the risk of adverse reactions.

The Therapeutic Relevance of Vitamin E

Maintaining cellular homeostasis in the context of its normal metabolic function is achieved by establishing the balance between its own antioxidant capacity and the level of harmful compounds resulting from the mitochondrial activity and the immune system. One of the antioxidants involved in this process is vitamin E with its most active form - alpha-tocopherol, which exerts its functions through vitamin C. The main functions of this antioxidant are: regulation of platelet aggregation, cellular signaling, antioxidation. The therapeutic relevance of vitamin E has increased due to the incrimination of oxidative stress as a link in the pathophysiology of many chronic diseases. Respectively, the role most targeted is that of antioxidant.

[Post traumatic entero-mesenteric venous infarct]

The paper presents a case of entero-mesenteric venous infarct, occurred in a man of 34 years, discovered intraoperator, when to intervene surgically in emergency surgery for acute abdomen of peritonitic type. The etiology of this venous infarct was posttraumatic, the patient underwent an abdominal aggression with seven days prior to onset of symptoms. In literature, the posttraumatic etiology is found in a small number compared to the large number of abdominal contusion, intimal lesional factor beeing associated with blood thickness. Paraclinical investigations were not significant in terms of preoperator diagnosis, surgical intervention (backward and forward thrombectomy of superior mesenteric vein with Fogarty probe and venosuture) having a favorable evolution. This intervention is practiced as an exception on the basis of the idea that venous thrombosis spreads to mezenteric vein and its collaterals followed by extensive arterial thrombosis and total compromise of intestinal viability.

[Malignant peritoneal mesothelioma]

This work presents the case of a hemorrhagic, necrotized peritoneal malignant mesothelioma in a 46-year old man, discovered during the emergency surgery, performed for an acute surgical abdomen/hemoperitoneum. Mesotheliomas are rare neoplasms of the pleura, peritoneum or pericardium, which are frequently associated with exposure to asbestos. The paraclinical investigations (echography) were not able to specify the diagnosis before the operation. The surgical intervention--tumorectomy, electrocoagulation, hemostasis with Gelaspon sponges-- had favourable results.

[The Krukenberg tumor caused by an adenocarcinoma of the gallbladder]

This work presents the case of a 62 year-old woman's Krukenberg tumor caused by an adenocarcinoma of the gallbladder. This was the presumptive diagnosis that was confirmed during the operation. The characteristic feature of this case consists of the rarity of the Krukenberg tumors caused by a cancer of the gallbladder, the paraneoplastic pleurisy and the presence of the cells with "a ring with a seal" in the pleural liquid and in the ascites liquid. The paraclinical investigations (echography, computerised tomography) were not able to specify the diagnosis before the operation. The surgical intervention (cholecystectomy and total hysterectomy with bilateral adnexectomy) has had favourable consequences. Nevertheless, the woman died 5 months after the operation.

[Abdominal aorta section caused by abdominal stab wound: discussion of two cases]

Abdominal vascular lesions are generally caused by accidents (most frequently car accidents, but also falling from an altitude, etc.) or by aggression with knives and fire arms. Abdominal vascular wounds, especially those involving the aorta, cause high mortality. Many patients die on the way to the hospital due to massive blood losses, their lesions being determined only through necropsy. Mortality is increased when abdominal vascular lesions are associated with abdominal or thoracic visceral lesions. We present two cases of partial sections of the abdominal aorta caused by stab wounds: a 16-year-old male aggressed by a school-mate and a 45-year-old male who aggressed himself. We discuss the necessity of immediate surgery on patients with abdominal stab wounds in order to determine the localization and gravity of the lesions.

Biochemical and Surgical Aspects of Cystic Pancreatic Tumours

The cystic pancreatic neoplasias are very rare (only 1-2 % of the exocrine pancreatic tumours) and, because of their clinical and biological characteristics, they can be treated by surgery in a effective way, as simple excision, with a good prognosis. Despite the histological analogies, the 5 types of cystadenomas vary by their dimensions, localization and biology; the serous solid adenoma is the most rare of the 5 types. The paper presents aspects from 4 young patients admitted for severe superior abdominal pain. The MRI examination revealed hypervascular mass, well delimited, situated between the pancreatic tail and the spleen. In each case have been practiced the excision of the tumour by spleen distal pancreatectomy. The histological and imunohistochemical examinations established the diagnosis: solid serous pancreatic adenoma. Taking into account that the malignity is hard to be suspected even intraoperatory, the surgical excision is the most effective treatment. The surgical excision makes the healing possible, but an imagistic and biochemical follow-up is necessary, especially in those cases where the splenectomy has also been practiced. Within the study group the serum glucose level was high and it decreased rapidly after surgery. More cohort studies are needed to make a possible correlation between serum glucose level and nonmucinous pancreatic cysts.

[Evolutive peculiarities of streptococcal infections in the year 1980, in the city of Bucharest]

In further investigations on the evolutive trends of the epidemiologic streptococcal process, an extensive epidemiological survey was carried out in prescholar and school communities in the town of Bucharest with a view to applying efficient antiepidemic measures able to limit primary streptococcal infections and prevent late, redoubtable complications. In 1980, in Bucharest, morbidity from scarlet fever was at its lowest level (92.7 per 100,000) during the last 31 years; it was in general benign, affecting especially in the month of March the 5-9 years age group (623.9 per 100,000) and the 1-4 years age group (529.4 per 100,000). The trailing evolution of a scarlet fever focus in a prescholar community suggested the hypothesis of the potentiation of the induction of streptococcal toxigenesis under the influence of intercurrent vital infections, especially measles. There were no deaths from scarlet fever. Laboratory investigations for the active detection and treatment of anginas, of carriers at risk, totalled 52101 tests; of these 4478 (8.59%) were positive for group "A" streptococci. In the prescholar communities surveyed no poststreptococcal complications were reported (acute articular rheumatism and glomerulonephritis). In 1980, there were 63 cases of acute articular rheumatism (code 250) in the 0-18 year-old group. The results suggest the need of continued epidemiological survey of streptococcal infections in children with a view to improving the health status of the population.