The influence of anastomotic techniques on postoperative anastomotic complications: Results of the Oesophago-Gastric Anastomosis Audit

BACKGROUND

The optimal anastomotic techniques in esophagectomy to minimize rates of anastomotic leakage and conduit necrosis are not known. The aim of this study was to assess whether the anastomotic technique was associated with anastomotic failure after esophagectomy in the international Oesophago-Gastric Anastomosis Audit cohort.

METHODS

This prospective observational multicenter cohort study included patients undergoing esophagectomy for esophageal cancer over 9 months during 2018. The primary exposure was the anastomotic technique, classified as handsewn, linear stapled, or circular stapled. The primary outcome was anastomotic failure, namely a composite of anastomotic leakage and conduit necrosis, as defined by the Esophageal Complications Consensus Group. Multivariable logistic regression modeling was used to identify the association between anastomotic techniques and anastomotic failure, after adjustment for confounders.

RESULTS

Of the 2238 esophagectomies, the anastomosis was handsewn in 27.1%, linear stapled in 21.0%, and circular stapled in 51.9%. Anastomotic techniques differed significantly by the anastomosis sites (P < .001), with the majority of neck anastomoses being handsewn (69.9%), whereas most chest anastomoses were stapled (66.3% circular stapled and 19.3% linear stapled). Rates of anastomotic failure differed significantly among the anastomotic techniques (P < .001), from 19.3% in handsewn anastomoses, to 14.0% in linear stapled anastomoses, and 12.1% in circular stapled anastomoses. This effect remained significant after adjustment for confounding factors on multivariable analysis, with an odds ratio of 0.63 (95% CI, 0.46-0.86; P = .004) for circular stapled versus handsewn anastomosis. However, subgroup analysis by anastomosis site suggested that this effect was predominantly present in neck anastomoses, with anastomotic failure rates of 23.2% versus 14.6% versus 5.9% for handsewn versus linear stapled anastomoses versus circular stapled neck anastomoses, compared with 13.7% versus 13.8% versus 12.2% for chest anastomoses.

CONCLUSIONS

Handsewn anastomoses appear to be independently associated with higher rates of anastomotic failure compared with stapled anastomoses. However, this effect seems to be largely confined to neck anastomoses, with minimal differences between techniques observed for chest anastomoses. Further research into standardization of anastomotic approach and techniques may further improve outcomes.

Textbook outcome following oesophagectomy for cancer: international cohort study

Background

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

Methods

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

Results

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter ‘no major postoperative complication’ had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P &lt; 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P &lt; 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

Conclusion

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Textbook outcome following oesophagectomy for cancer: international cohort study

BACKGROUND

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

METHODS

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

RESULTS

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter 'no major postoperative complication' had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P < 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P < 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

CONCLUSION

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Postoperative outcomes in oesophagectomy with trainee involvement

BACKGROUND

The complexity of oesophageal surgery and the significant risk of morbidity necessitates that oesophagectomy is predominantly performed by a consultant surgeon, or a senior trainee under their supervision. The aim of this study was to determine the impact of trainee involvement in oesophagectomy on postoperative outcomes in an international multicentre setting.

METHODS

Data from the multicentre Oesophago-Gastric Anastomosis Study Group (OGAA) cohort study were analysed, which comprised prospectively collected data from patients undergoing oesophagectomy for oesophageal cancer between April 2018 and December 2018. Procedures were grouped by the level of trainee involvement, and univariable and multivariable analyses were performed to compare patient outcomes across groups.

RESULTS

Of 2232 oesophagectomies from 137 centres in 41 countries, trainees were involved in 29.1 per cent of them (n = 650), performing only the abdominal phase in 230, only the chest and/or neck phases in 130, and all phases in 315 procedures. For procedures with a chest anastomosis, those with trainee involvement had similar 90-day mortality, complication and reoperation rates to consultant-performed oesophagectomies (P = 0.451, P = 0.318, and P = 0.382, respectively), while anastomotic leak rates were significantly lower in the trainee groups (P = 0.030). Procedures with a neck anastomosis had equivalent complication, anastomotic leak, and reoperation rates (P = 0.150, P = 0.430, and P = 0.632, respectively) in trainee-involved versus consultant-performed oesophagectomies, with significantly lower 90-day mortality in the trainee groups (P = 0.005).

CONCLUSION

Trainee involvement was not found to be associated with significantly inferior postoperative outcomes for selected patients undergoing oesophagectomy. The results support continued supervised trainee involvement in oesophageal cancer surgery.

Mortality from esophagectomy for esophageal cancer across low, middle, and high-income countries: An international cohort study

BACKGROUND

No evidence currently exists characterising global outcomes following major cancer surgery, including esophageal cancer. Therefore, this study aimed to characterise impact of high income countries (HIC) versus low and middle income countries (LMIC) on the outcomes following esophagectomy for esophageal cancer.

METHOD

This international multi-center prospective study across 137 hospitals in 41 countries included patients who underwent an esophagectomy for esophageal cancer, with 90-day follow-up. The main explanatory variable was country income, defined according to the World Bank Data classification. The primary outcome was 90-day postoperative mortality, and secondary outcomes were composite leaks (anastomotic leak or conduit necrosis) and major complications (Clavien-Dindo Grade III - V). Multivariable generalized estimating equation models were used to produce adjusted odds ratios (ORs) and 95% confidence intervals (CI95%).

RESULTS

Between April 2018 to December 2018, 2247 patients were included. Patients from HIC were more significantly older, with higher ASA grade, and more advanced tumors. Patients from LMIC had almost three-fold increase in 90-day mortality, compared to HIC (9.4% vs 3.7%, p < 0.001). On adjusted analysis, LMIC were independently associated with higher 90-day mortality (OR: 2.31, CI95%: 1.17-4.55, p = 0.015). However, LMIC were not independently associated with higher rates of anastomotic leaks (OR: 1.06, CI95%: 0.57-1.99, p = 0.9) or major complications (OR: 0.85, CI95%: 0.54-1.32, p = 0.5), compared to HIC.

CONCLUSION

Resections in LMIC were independently associated with higher 90-day postoperative mortality, likely reflecting a failure to rescue of these patients following esophagectomy, despite similar composite anastomotic leaks and major complication rates to HIC. These findings warrant further research, to identify potential issues and solutions to improve global outcomes following esophagectomy for cancer.

Comparison of short-term outcomes from the International Oesophago-Gastric Anastomosis Audit (OGAA), the Esophagectomy Complications Consensus Group (ECCG), and the Dutch Upper Gastrointestinal Cancer Audit (DUCA)

BACKGROUND

The Esophagectomy Complications Consensus Group (ECCG) and the Dutch Upper Gastrointestinal Cancer Audit (DUCA) have set standards in reporting outcomes after oesophagectomy. Reporting outcomes from selected high-volume centres or centralized national cancer programmes may not, however, be reflective of the true global prevalence of complications. This study aimed to compare complication rates after oesophagectomy from these existing sources with those of an unselected international cohort from the Oesophago-Gastric Anastomosis Audit (OGAA).

METHODS

The OGAA was a prospective multicentre cohort study coordinated by the West Midlands Research Collaborative, and included patients undergoing oesophagectomy for oesophageal cancer between April and December 2018, with 90 days of follow-up.

RESULTS

The OGAA study included 2247 oesophagectomies across 137 hospitals in 41 countries. Comparisons with the ECCG and DUCA found differences in baseline demographics between the three cohorts, including age, ASA grade, and rates of chronic pulmonary disease. The OGAA had the lowest rates of neoadjuvant treatment (OGAA 75.1 per cent, ECCG 78.9 per cent, DUCA 93.5 per cent; P < 0.001). DUCA exhibited the highest rates of minimally invasive surgery (OGAA 57.2 per cent, ECCG 47.9 per cent, DUCA 85.8 per cent; P < 0.001). Overall complication rates were similar in the three cohorts (OGAA 63.6 per cent, ECCG 59.0 per cent, DUCA 62.2 per cent), with no statistically significant difference in Clavien-Dindo grades (P = 0.752). However, a significant difference in 30-day mortality was observed, with DUCA reporting the lowest rate (OGAA 3.2 per cent, ECCG 2.4 per cent, DUCA 1.7 per cent; P = 0.013).

CONCLUSION

Despite differences in rates of co-morbidities, oncological treatment strategies, and access to minimal-access surgery, overall complication rates were similar in the three cohorts.

SURGERY OUTCOMES IN PATIENTS WITH SECONDARY HYPERPARATHYROIDISM AND IMPACT OF INTRA-OPERATIVE PTH MEASUREMENT

Context

The current therapeutical management of secondary hyperparathyroidism (S-HPTH) is difficult to obtain due to the lack of kidney donors. Surgical intervention on the pathologic parathyroid tissue has been suggested as a method to alleviate symptoms in patients with chronic kidney disease (CKD).

Objective

The aim of our study was to evaluate the outcomes of parathyroid surgery in patients with S-HPTH and the advantages of intraoperative quick PTH (iqPTH) to improve surgical results.

Material and methods

In a real-life study, we compared one group of S-HPTH with iqPTH performed after removing all suspected glands and before wound suture (Group 1) and one group in that iqPTH was not assessed (Group 2). When iqPTH dropped less than 50%, additional exploration followed.

Results

Eight out of the 34 patients from Group 1, who underwent subtotal parathyroidectomy, showed elevated levels of serum PTH and calcium, which remained elevated during follow-up, thus, suggesting disease persistence. From the 21 patients in Group 2, none showed early postoperative disease persistence. Serum calcium, but not PTH was increased in one patient from the iqPTH group but normalized after one month. Overall, iqPTH allowed detection of a supplementary parathyroid gland in one case, thereby increasing early post-surgery remission to 100% in Group 2 compared to 76.47% in Group 1. Late postoperative remission of hyperparathyroidism with no further increase in the rate of hypoparathyroidism was obtained in Group 2.

Conclusions

Assessment of intra-operative PTH levels proved to be a useful tool in augmenting the outcome of S-HPTH surgery. In patients which are eligible for renal transplantation who undergo a subtotal resection, iqPTH can enhance the post-operative quality of life by lowering disease recurrence rates until the kidney transplant procedure.

GSTM1, GSTT1 and GSTP1 Genetic Variants in Multiple Urologic Cancers

INTRODUCTION

Glutathione S-transferases (GSTs) are phase 2 enzymes responsible for catalyzing the biotransformation of a wide variety of electrophilic compounds, having a crucial role in the detoxification of active metabolites of procarcinogens produced by phase 1 reactions, tying them to glutathione and promoting their excretion in the urine.

OBJECTIVES

we evaluated GSTM1, GSTT1 and GSTP1 genotypes in patients diagnosed with multiple malignancies, of which at least one was found in the prostate, bladder or kidney.

MATERIALS AND METHODS

GSTM1, GSTT1 and GSTP1 genotypes were genetically assessed in 34 patients with multiple urologic cancers and 23 patients with urologic cancer associated with another type of cancer.

RESULTS

in the group of patients with multiple urologic cancers, GSTT1 null genotype was found in 26.4% of patients compared to 0% in controls, 82.35 % of patients and 47% of witnesses carried at least one GSTM1 or GSTT1 null genotype, and in the group with different cancers, GSTM1 null genotype was found in 52.1% of patients compared to 4.3% witnesses in the control group; GSTT1 null genotype was found in 34.7% of patients compared to 4.3% of witnesses, atleast one GSTM1 or GSTT1 null genotype was found in 73.9% of patients compared to 8.6% of controls.

CONCLUSIONS

GSTT1 null genotype is a risk factor for patients with more primitive urologic malignancies (bladder, prostate and kidney); GSTM1 or GSTT1 null genotype is more frequent in patients with multiple urologic tumors; GSTM1 and GSTT1 null genotypes are risk factors in patients with different types of cancer, with at least one affecting the urinary system.

GSTM1, GSTT1 and GSTP1 in patients with multiple breast cancers and breast cancer in association with another type of cancer

INTRODUCTION

breast cancer has the highest incidence in women.Glutathione S-transferases (GSTs) are a large group of enzymes involved in the metabolism of xenobiotics. The members of this gene superfamily are involved in the development of multiple cancers.

OBJECTIVES

the aim of the study was to see whether the GSTM1, GSTT1 and GSTP1 genetic polymorphisms are risk factors for patients diagnosed with multiple malignancies, of which at least one is located in the breast.

MATERIALS AND METHODS

in the period between 2005 and 2012,of the 520 patients diagnosed with breast cancer, 69 had multiple primitive malignant tumors, of which at least one was localized in the breast. The research on GSTM1, GSTT1 and GSTP1 genotypes consisted of 59 patients diagnosed with multiple breast cancers or with breast cancer in association with another type of cancer, compared with a group of healthy controls.

RESULTS

in the subgroup of patients with breast cancer in association with another type of cancer, the GSTM1 null genotype was present in 61.2% of patients, compared to 29% of controls; the subgroup of metachronous breast cancers, the presence of any of the GSTT1 or GSTM1 null genotypes was statistically significantly different from that of controls (65.2%vs. 28.5%); in the subgroup with synchronous cancers, the GSTM1 null genotype was found in 66.6% of patients compared to 9% for the controls, and the presence of any null genotype (GSTM1 and GSTT1) was also statistically significant in the case group.

CONCLUSIONS

the GSTM1 null genotype is a risk factor for synchronous breast cancers and for breast cancer associated with extramammary cancer; the presence of null genotypes(GSTM1 or GSTT1) is a risk factor for multiple breast cancer(bilateral or synchronous); the GSTT1 null genotype and the heterozygous variant allele (Ile105Val) and homozygous variant allele (Val105Val) of GSTP1 are not risk factors for the cases studied.

Multiple malignant tumors

BACKGROUND

Due to the improvement in diagnosis and therapy for certain malignant tumors, we are now faced with patients who develop in time multiple malignancies.

METHODS

We conducted a retrospective analysis of the patients diagnosed with at least two primary cancers that were admitted and treated in Cluj-Napoca Municipal Hospital. The study followed patients for a period of 7.5 years.

RESULTS

We included in the present study 217 patients (4.33%) with two or more malignant primary tumors from 5003 cases diagnosed with a primary cancer. The most common sites for multiple malignant tumors were related to the breast, colorectum, urinary bladder, prostate and kidneys.

CONCLUSIONS

We should always take into consideration the possibility of synchronous tumors and we have to keep in mind that a successful treatment of cancer might not prevent the onset of another primary mass.

GST gene variants in synchronous colorectal cancers and synchronous association of colorectal cancers with other cancers

BACKGROUND

the present study evaluates genetic polymorphisms of three glutathione S-transferases (GSTM1, GSTT1and GSTP1) in patients with synchronous malignant colorectal tumors and the association of synchronous colorectal cancers with other cancers.

MATERIAL AND METHODS

from 420 patients with a colorectal cancer admitted to our hospital between 2005-2012, we selected for genetic analysis 20 patients with multiple synchronous malignant colorectal tumors and 9 patients with asynchronous association of colorectal cancer with another cancer. We searched for GST genotypes, comparing the results with controls.

RESULTS

the genetic analysis was possible only in 19 patients with colorectal synchronous cancers and 9 patients with asynchronous association of colorectal cancer with another cancer; we found a statistically significant difference for null GSTM1 genotype frequency between these patients and the control group; we found no differences regarding the frequency of null GSTT1 genotype and Ile105Val polymorphism of GSTP1 in patients with synchronous cancers compared with the control group.

CONCLUSION

in our study we found the null GSTM1 genotype as a risk factor for multiple colorectal synchronous cancers and for an association of synchronous colorectal with other cancers

Laparoscopic treatment of perforated duodenal ulcer -- a multicenter study

AIM

The aim of this study is to evaluate the results of the laparoscopic treatment of perforated duodenal ulcer performed in 6 Romanian surgical centres with experience in the field of laparoscopic surgery.

MATERIAL AND METHOD

Between 1996 and 2005, 186 patients with perforated duodenal ulcer were operated on in the centers participating in this retrospective study, all patients being ASA I-II. Thirty-nine patients (20.0%) presented mild peritonitis, 120 (64.5%) medium peritonitis and 27 (15.5%) severe (20.0%) simple suture was performed, in 110 (59.1%) suture with epiplonoplasty, for 1 (0.5%) only epiplonoplasty and 1 (0.5%) underwent excision of the perforation and suture.

RESULTS

The operative time was between 30-120 minutes, with an average of 75 minutes. No death was noted. Average hospitalization time was 6 days, with periods varying between 3 and 18 days. Postoperative complications included: 5 patients (2,6%) presented infections of the abdominal walls, 1 patient (0.5%) duodenal fistula, 1 patient (0.5%) intra-abdominal abscess, 1 patient (0.5%) a superior digestive hemorrhage by "mirrored ulcer" and 1 patient (0.5%) duodenal stenosis 6 months after operation. The patients were administered 50% less analgesics, used 70% less dressings, 30% less antibiotics and had 60% less complications in comparison with those operated by the classical approach.

CONCLUSION

The laparoscopic approach of perforated duodenal ulcer constitutes the first choice for patients without important co-morbidities, allowing a quick recovery and a significant reduction in the consumption of analgesics, antibiotics and dressing materials.

Laparoscopic surgery for the treatment of rectal cancer: short-term results

The aim of this study was to establish the efficiency, safety and feasibility of laparoscopic surgery for rectal cancer by assessing the short-term outcomes.

MATERIALS AND METHODS

In this prospective clinical study, from 2008 to 2011, 60 patients with laparoscopic resection for rectal cancer were included, treated in "Prof. Dr. Octavian Fodor" Gastroenterology and Hepatology Institute, Department of Surgery and Surgery Clinic I, Cluj-Napoca.

RESULTS

Surgical procedures included 38 abdominal-perineal resections, 21 anterior resections and 1 Hartmann procedure. Average blood loss was 250 ml (100-800 ml) and median length of postoperative hospital stay was 9 days (4-91 days). Blood loss was significantly higher in patients with low rectal cancer than those with upper rectal cancer (300 ml vs 200 ml, p=0.031). Conversion to open surgery was required in 8 patients (13.3%). Overall postoperative complications were 28.8%. Positive circumferential margins occurred in 1 patient (1.7%), while distal margins were negative in all patients.

CONCLUSIONS

Laparoscopic surgery is safe and feasible in selected patients with rectal cancer, with favorable shortterm results.

Sarcoid flexor tenosynovitis as a single early manifestation of the disease

Sarcoid flexor tenosynovitis is rare. Isolated sarcoid tenosynovitis of the index finger in a young woman as an early manifestation of the disease is reported. Tenosynovectomy was performed as a therapeutic and diagnostic tool, followed by systemic corticosteroids. The patient had no signs of relapse 3 years after surgery.

[Current methods for wound debridement]

Wound management experienced significant changes in the last half century, while acknowledging the concept of "moist wound healing" and the strategy of "wound bed preparation". New solutions in this area have brought by developing new methods of debridement, exudates management and decrease of bacterial load. Debridement is the most widespread used method for conditioning wound and involves the application of interventions that accelerate the healing process. The main objective of this article is to identify current methods of debridement used worldwide in wounds treatment, their indications and recommended guidelines. For this purpose we analyzed reviews, randomized clinical trials, practical guides, meta-analysis, and clinical trials published in the Clinical Core Journals and Nursing Journals from 2006 to 2010. We identified six methods of wound debridement, each with its own advantages and limitations: surgical debridement, mechanical debridement, autolytic debridement, enzymatic debridement, chemical debridement and biological debridement. We found that in literature there is no consensus regarding the most effective debridement method or combination of debridement methods. According to various authors or expert groups' opinions, debridement methods are differentiated by specific properties, different costs and different levels of acceptance from medical staff.

New trends in breast reconstruction

BACKGROUND

Breast reconstruction (BR) after radical mastectomy is intended to recreate symmetrical natural-appearing breasts while preserving patient safety and quality of life.

PURPOSE

To evaluate the esthetic results and the complications of various BR methods after radical mastectomy.

PATIENTS AND METHOD

Between August 2006 and March 2010, 36 women underwent BR after mastectomy in our institution. Their charts were reviewed retrospectively to evaluate the results and complications. We used immediate BR for Stage I and IIa breast carcinoma, and delayed BR for stage IIb and III breast carcinoma.

RESULTS

We performed a pedicled Transverse Rectus Abdominis Muscle flap in 13 cases, pedicled Latissimus Dorsi with silicone implant in 10 cases, free Deep Inferior Epigastric Perforator (DIEP) flap in 9 cases, and other procedures in four cases. The encountered complications were: total flap failure--one case, partial edge flap necrosis--three cases, donor area wound dehiscence--one case, seroma--one case, local infection--one case.

DISCUSSION

Trends in BR in recent years focus more on free perforator flaps, with the DIEP flap being the leader. Internal mammary vessels are most often used as recipient vessels for anasthomoses. Immediate BR when indicated has better aesthetic results. In less well-developed countries, insurance companies do not cover implant expenses and the autologous procedures remain the best option.

[Results and prognostic factors in rectal cancer surgically treated with curative intent--experience of a single tertiary center]

BACKGROUND

Rectal cancer has a paradoxal prognosis in about 25% of patients, although intraoperative parameters and tumor stage are known as major determinants of prognosis.

AIM

This study assessed the prognostic factors in patients with rectal cancer treated without total mesorectal excision in long-term follow-up.

MATERIAL AND METHODS

A single center tertiary population included retrospectively 87 patients with rectal cancer operated between 1992 and 2002 using conventional resection. Some 90.5 per cent of the patients had surgery alone and 9.5 per cent had postoperative radiochemotherapy. Patients who did not have adenocarcinoma, those in whom the curative operation was not done, and those who received preoperative radiotherapy were excluded. Median follow-up was 7 years.

RESULTS

Seven-year cancer specific survival was 52% (95% CI:3.21) and only pT, pN and lymphatic invasion were significant as prognostic factors on multivariate analysis. Disease free cancer survival was 56% and only lymphatic invasion was significant for prognosis. The risk of death was higher for abdomino-perineal resection (APR) than for anterior resection (AR), advanced pT stage, vascular and perineural invasion. Local recurrence and distant metastasis were 12.6 and 26.43 per cent respectively for patients. The risk for local reccurence was higher for advanced pT stage, perineural and lymphatic invasion and distal margin invasion. The risk for metastasis was higher for advanced pT stage and vascular invasion.

CONCLUSION

Advanced tumor stage and lymphatic invasion represent prognostic factors in rectal cancer, suggesting the necessity of adjuvant therapy in cases with lymphatic invasion.

Emergency laparoscopy combined with radiofrequency ablation for hemostasis after percutaneous liver biopsy

There are no data in the literature on the use of radiofrequency ablation (RFA) in emergency laparoscopy as a means of hemostasis after liver biopsy. In this case report we have described a case of a patient with Waldenstrom macroglobulinemia and hypervascularised hepatic tumor who developed severe hepatic bleeding after liver biopsy. Innovative, minimally invasive treatment consisted in a laparoscopic approach with introduction of RFA needle into the biopsy site, followed by immediate hemostasis with no complications. Laparoscopic surgery with RFA avoids unnecessary laparotomy in case of severe bleeding from a known source. It is therefore the optimal choice, even in patients for whom percutaneous biopsy would be a high-risk procedure.

Effects of the radiofrequency interference with modified titanium surgical clips on liver parenchyma--an in vivo experiment

AIM

This study sets out to test the biocompatibility of titanium clips in liver, in the presence of radiofrequency. Biocompatibility is assessed at various distances from the RF electrode and different points in time.

METHOD

It is an experimental study conducted on pigs and makes use of histological changes that occur at the liver-titanium interface in presence of RF to test hypotheses. The titanium clips were modified in high vacuum (10 -5 atm) by heating them at 1000 degrees C and 1150 degrees C. Titanium clips were placed in liver at 0.5, 1.5 and 2.5 cm from RF probe. At 7, 14 and 28 days the inflammation, necrosis and fibrosis were assessed.

RESULTS

The histological alterations decrease with the distance of implantation of titanium clips. The inflammation and necrosis nearby the titanium clips decrease in time, but the fibrosis does not increased, as expected. The modified titanium at 1000 degrees C clips cause less necrosis than commercial titanium clips. The moderator role of clip type between distance and cell alteration is empirically supported only for fibrosis and necrosis. The moderator role between time and cell alteration is supported only for inflammation.

CONCLUSIONS

Experimental data suggests there are no preferred surgical clips in all situations. The biocompatibility of the titanium clips depends on the distance from the RF probe. The commercial ones prove less damaging if they are placed close to the RF probe (less than 1 cm) and those that were treated at 1150 C have a better bio-compatibility if placed more than 1 cm from RF probe.

Gastroduodenal artery pseudoaneurysm ruptured in the common bile duct

A pseudoaneurysm of the gastroduodenal artery (GDA) is the rarest splanchnic artery aneurysm, comprising fewer than 10% of these lesions. Bleeding into the gastrointestinal tract is the most rapidly fatal complication of an arterial visceral pseudoaneurysm, affecting 4-10% of patients. We present an unusual case of a GDA pseudoaneurysm that ruptured in the common bile duct, and that was successfully treated by partial resection and hepatic artery reconstruction. The postoperative evolution was favourable and the CT performed six months later disclosed the absence of a vascular tumour.

Assessement by laser Doppler of the peripheral tumour perfusion after radiofrequency ablation for colorectal liver mestasis--experimental study

Colorectal cancer became one of the most frequent malignant conditions of the past two decades. Non-resecable liver metastases might be destroyed in situ by radiofrequency although the local recurrence is still very important. Laser-Doppler flowmetry has proved to be a simple technique for monitoring the microcirculation, hereby the tissue perfusion at the edge of the post radiofrequency necrosis. The aim of the study was to evaluate microcirculation using lasser-Doppler for hepatic tissue and peripheral tumour perfusion after radiofrequency and the influence of local temperature increasing at 42 degrees C on tissular perfusion. Colorectal adenocarcinoma (CC531s) was used for liver tumour inoculationin on 15 Wag/Rij rats. Twenty-one days after inoculation, perfusion in hepatic tissue, on the tumour before and after radiofrequency treatment was mesured. When hepatic tissue was heated at 42 degrees C there was an increase in tissular perfusion, on the other part, heating the tumoural tissue do not increase perfusion. After radiofrequency in the periphery of necrosis the perfusion was still present, despite a clear drop towards initial level. Assessing the local microcirculation and tissue temperature during RF ablation by Laser-Doppler might be useful not only for RF efficiency evaluation but also as an indication for associating adjuvant local chemotherapy.

Different models of training and certification in plastic surgery

A varying period of training followed by examinations is the usual way to become a specialist in one of the many fields of Medicine. Plastic Surgery is one of the surgical fields that require good technical and cognitive skills. The best way to train and evaluate a candidate is hard to judge. The model of training and board examination varies, every country having its own method. This is a descriptive report presenting the ways of training residents in Plastic Surgery and then examining them in Romania, Israel, U.S.A., Germany and the Netherlands. Specific points regarding the structure and the format are addressed for all models and also for factors that might influence the objectivity of the examination. The authors bring their thoughts on these issues.

Evaluation of the combined laparoscopic and mediastinoscopic esophagectomy technique

BACKGROUND

Laparoscopic esophagectomy is technically difficult especially during dissection in the upper mediastinum. This limitation may be surpassed with the help of mediastinoscopy or of the recently introduced robotic surgical systems. The aim of the present study was to evaluate in an experimental porcine model the feasibility of the combined laparoscopic and mediastinoscopic transhiatal esophagectomy technique and to compare it with the robotic-assisted transhiatal and conventional approaches.

MATERIALS AND METHODS

Transhiatal esophagectomy was performed in Landrace pigs under general anesthesia using three different techniques: Group A (n = 9): combined laparoscopic and mediastinoscopic, group B (n = 4): robotic-assisted and group C (n = 8): conventional "open". The feasibility, difficulty and accuracy of the procedure along with operative time, blood loss, intraoperative incidents and overall satisfaction of the surgical team were assessed for each technique.

RESULTS

Operations in group A were feasible and reproducible. Although the procedure was technically difficult, the constant view on the operative field was highly appreciated by the operative team and facilitated an accurate and safe dissection. The main intraoperative complications were related to the side-effects of tension pneumothorax accompanying pleural injuries. In group B the features of the robotic system reduced the difficulty of dissection and obviated the need for mediastinoscopy. Operations in group C were quick and almost incident-free, facilitated also by the particularities of the animal model that could not reproduce identically the clinical situation.

CONCLUSIONS

The combined laparoscopic and mediastinoscopic esophagectomy technique is feasible and offers certain advantages over the open approach while the robotic-assisted approach is an emerging less difficult alternative. Further studies are required to establish whether the advantages of minimally-invasive approach compensate for the increased technical difficulty and prolonged operative time.

Gas-chamber mediastinoscopy for dissection of the upper esophagus

AIM

Mediastinoscopy has the potential to bring under view the upper mediastinum, the area most difficult to dissect during transhiatal esophagectomy. The aim of the present study was to evaluate in an animal model the feasibility of the gas-chamber mediastinoscopy technique for dissection of the upper esophagus.

METHODS

Operations were performed in nine Landrace pigs using a 30 degrees laparoscope and conventional 35-cm laparoscopic instruments. Through a left collar incision a virtual space was created with sharp and blunt dissection around the cervical esophagus and insufflated with CO2 at a pressure of 5 mmHg. Using one 10-mm optical trocar and two 5-mm working trocars dissection advanced in the periesophageal space with the aim to reach at least to the tracheal bifurcation.

RESULTS

Performed under visual control, the procedure was accurate and safe, the level of tracheal bifurcation being reached in all cases. Anatomical structures such as trachea and its bifurcation, pleura, pericardium, arch of the azygos vein and periesophageal lymph nodes were visible during the operation. There were no major intraoperative incidents and blood loss was minimal.

CONCLUSIONS

The technique of gas-chamber mediastinoscopy is feasible. It allows a fair amount of freedom of movement for the working instruments and offers a good view on the operative field for a controlled and accurate dissection. Further evaluation in experimental and clinical studies is required to establish the role of this procedure in esophageal surgery.

Simultaneous extra-anatomic bypass and abdominal "flag flap" for lower limb salvage in a patient with severe post-bypass anastomotic groin infection

The incidence of prosthetic graft infection after bypass surgery ranges from 0.2 to 5%, depending on location, co-morbid diseases and host defense mechanisms. In spite of surgical treatment, the amputation rate can be up to 67%. Herein, we present our treatment strategy for a patient with severe Methicillin Resistant Staphylococcus Aureus infection and pseudo-aneurysm after a femoropopliteal bypass with a prosthetic graft. An extra-anatomic bypass without touching the previously operated groin area (aseptic time) was done at the beginning. Radical debridement (septic time) and simultaneous abdominal "flag flap" were performed in the same surgical procedure to save the lower limb.

[Nutrition in infants with esophagocolonoplasty for esophageal atresia and tracheoesophageal fistula]

The aim of this clinical prospective study was the follow up of a nutritional management protocol for children with esophageal atresia and tracheoesophageal fistula for whom the esophageal substitution was performed with left vascularized colon. In this study entered infants aged 3 months to 18 months old with a major nutritional deficit, due to respiratory infections complications, parastomal leaks and accelerated gastrointestinal transit. All infants were underweight, with a single exception, who had no preoperative complications. The patient was enterally fed postoperatively, all the other patients receiving combined enteral and parenteral nutrition for 5-6 days. The enteral nutrition was delivered early through a trans-anastomotic feeding tube. In the 5th-7th day, complete enteral nutrition was obtained. The parenteral nutrition followed our own recipe: a 10% amino-acid mixture, 50% glucose and Ringer plus electrolytes and vitamins. There was a critical transitional stage between the gastric tube feeding and the oral nutrition. These infants have the suction and the deglutition reflexes modified, followed by oral sensory and motor deficits. After the release from the hospital the patients have been surveyed, the oldest reaching now the age of 7. The earlier the reconstruction was performed, the less problems in oral nutrition were encountered.

[Colectomy in emergency surgery]

Unlike the standardised surgery of the right sided colic emergencies there is still a matter of debate on the emergency approach of the left colon and rectum. Between 1998 - 2007 on 32 patients (15 males, 17 females) we performed the single stage radical procedure total or subtotal colectomy. In the same period we performed 372 emergency operations for low intestinal occlusion. The patients had ages between 24 - 86 years, the admittance diagnosis was intestinal occlusion. The postoperative diagnosis was left colic carcinoma (n=23), strangulated hernia (n=2) strangulated incisional hernia (n=2), sigmoid volvulus (n=3) and synchronous colic carcinoma (n=2). All cases were submitted to surgery in the first 24 h of admission. Despite the presence of liver metastasis at the time of surgery in 2 patients, this had not contraindicate the radical procedure. 21 patients (65.62%) had a good evolution. The others 11 (34.38%) had postoperative complications: 2 anastomotic leakage (6.25%), 7 parietal infections (21.87%) and 2 death (6.25%). The total colectomy offers oncological radicality and satisfactory functional results. The disadvantage consists in postoperative diarrhea, gradually decreased with time.

[Conservative management in blunt splenic trauma]

We reviewed for analysis the charts of two groups of adults patients with blunt splenic injuries issued from two University Hospital Centers; the group 1 (G1) of 22 patients and the group 2 (G2) of 20 patients. The results of actually therapeutic procedures concerning blunt splenic injuries and subsequently the effectiveness of non operative treatment were evaluated. Splenectomy was performed in G1 for 11 patients, instead of 19 patients in G2 (p = 0.0003), whereas, the non surgical treatment was done in 9 patients and 1 patient, respectively (p = 0.02). The mean Splenic Injury Score (SIS) was 2,95 in G1 and 3.47 in G2 (p = 0.03). The spleen was preserved in G1 for 8 patients, instead 1 patient in G2 (p = 0.04). In G1, the non operative treatment was successfully accomplished in 66% of patients. It was obtained with lack of mortality, with a lower overall morbidity and a lower length of hospital stay than in splenectomized patients, but the latter group accounted higher values of Injury Severity Scores (p < 0.05). If proper selection criteria for non operative management are used, more than a third of patients with blunt splenic injury can be treated by splenic preservation at least as safely as splenectomized patients.

[The experimental heterotopic transplantation of an isolated segment of colon]

The heterotopic transplantation of isolated colon segment was achieved in the cervical region, for to study the behaviour of the colon in this new situation. The study included 20 dogs from which there were taken segments of 10 cm length from, the left colon. Then was prepared the common carotid artery, superficial jugular vein and their branches. In 5 dogs the cervical esophagus was resected. Then was performed the transplant using micro-surgical techniques. In 15 dogs the colon was exteriorized at the skin and in 5 dogs the colon was placed between the ends of the esophagus. In 76% of cases the postoperative evolution was good. From the viable colon transplants were taken fragments for histologic examinations after 1, 2 respectively 4 weeks postoperative. The results obtained, recommend the colic transplant as a possible graft for repairing the cervical esophagus defects.

Two different primary ophthalmic cancers in a 39-year-old female patient

The clinical and histopathological findings are described in a 39-year-old female patient with two different primary ophthalmic cancers, involving the adnexa and ocular globe of the same eye. The first primary tumor was a malignant fibrous histiocytoma of the left lower eyelid aggressively invading the nasogenian region, bulbar conjunctiva, episclera, and the cornea over a 36-year follow-up period. The second primary cancer was an unsuspected choroidal malignant melanoma unexpectedly found at histology. The possible correlations between these two malignancies are discussed.

[Clinical, diagnostic and therapeutic problems in the postthrombotic syndrome. Our experience]

An analysis is presented, of the experience acquired in the II-nd Surgical Clinic of Cluj-Napoca in connection with 150 cases of postthrombotic syndrome followed and treated over the last 5 years (1983-1987). Considerations are made concerning terminology, and evaluation of diagnostic and therapeutic means applied. The post-thrombotic syndrome develops in a variable interval after the thrombophlebitis (months and even years). A series of factors prevent of enhance the development of the syndrome (98% diagnostic errors and therapeutic failures). Phlebography is mandatory in cases where surgery is considered. Noninvasive explorations (Doppler, plethysmography) limit the use of phlebography. The most efficient treatment is prophylaxis (consisting in the prophylaxis and the correct treatment of thromboembolic disease). The usual treatment is mainly medical and conservative (59.4%). Surgery is carried out in cases where the superficial, the communicating and the deep venous systems are involved.