Cervical Exenteration - Guidelines and Surgical Technique Principles

Introduction: Neoplastic invasion of the structures of the cervical region originating from a malignant tumour developed in one of the viscera of the throat may benefit from cervical exenteration. Defined as resection of the hypopharynx, cervical oesophagus, larynx and cervical trachea, exenteration has limited indications and is mandatorily accompanied by digestive tube reconstruction. The aim of this article is to highlight the indication, surgical strategy and important surgical stages illustrated by images from personal professional experience.

MATERIALS AND METHOD

Pharyngo-laryngo-oesophageal en bloc resection and radical cervical lymphadenectomy were followed by reconstruction via free jejunal transfer or colic pedicle grafting. Between 2000 and 2018 we have performed cervical exenteration in 25 patients with tumours originating in the pharynx, larynx or cervical oesophagus. In the cases of 5 patients in whom we did not obtain the oncological safety margin for oesophageal cancer we performed transhiatal pharyngo-laryngo-oesophagectomy. In these patients, we performed reconstruction of the oesophagus with colonic graft. In 20 cases we performed jejunal autotransplant. Results: We recorded 4 perioperative deaths, due to major arterial vessel haemorrhage (1 case), after jejunal necrosis (2 cases), and mediastinitis after oesophageal striping and colonic graft necrosis (1 case). One patient presented tumour recurrence at the level of the tracheal stump. Survival rate varied between 6 months and 4 years for the group of patients who presented for postoperative follow-ups. Conclusions: Cervical exenteration remains an option for tumour recurrence after radiochemotherapy or for obstructive airway or digestive tract tumours. It can be burdened by complications difficult to treat. The surgical team has to adapt its initial surgical strategy to the reality of the surgical field, both in terms of exeresis and in terms of types of pharyngo-oesophageal reconstruction.

Acute cellulitis as local reaction to orthopedic implant - case presentation

Due to increasing number of arthroplasties and osteosynthesis, foreign body reaction to implants is a major problem for orthopedic surgeons, since it is considered to be responsible for severe complications impairing the outcome of the treatment and requiring multiple surgery. Different mechanisms have been described as being involved, and research is focused on finding biomaterials with increased biocompatibility in order to minimize these complications. The clinical aspect of this reaction is usually dominated by chronic pain, with mild functional deficits, and the diagnosis results from excluding other causes of chronic pain, such as infection, osteoarthritis, peripheral neuropathies or angiopaties. The authors present a case with unusual clinical aspect, that of acute cellulitis, when early proper treatment, represented by implant removal, allowed healing without the onset of infection or other complications; histological evaluation confirmed the reaction to implant, thus concluding that surgical treatment when intolerance to implant is suspected is the only method to prevent future negative events.

Biphasic synovial sarcoma in a 19-year-old pregnant woman: a case report

Synovial sarcoma is a rare malignant tumor of mesenchymal multipotent cells. We hereby present a case of synovial sarcoma of the upper left thigh. A 19-year-old patient was referred to our clinic by another hospital in Bucharest, Romania, for a soft tissue mass in the left upper thigh. Local examination of the left thigh revealed a 15÷13 cm, ovoid, painful upon touch, soft tissue mass occupying the proximal-medial aspect of the thigh. Bilateral inguinal nodes' enlargement was noticed. Upon suspecting regional node involvement, the surgical team decided to perform left limb amputation due to tumor size and the proximity to major arterial and nervous trunks as well as the femoral shaft, making curative surgery and 'free of disease' resection margins improbable. The patient refused the operation. The surgical team (plastic surgeon, orthopedic surgeon) decided to attempt limb-sparing surgery. After tumor resection, free-of-disease surgical margins were achieved. The pathological examination as well as the immunohistochemistry (IHC) diagnosed a large biphasic synovial sarcoma warranting oncologic treatment. The association between tumor growth and pregnancy poses important therapeutic problems, such as the use of preoperative chemotherapy, potential pregnancy termination, limb amputation versus limb salvage intervention and types of protocols of chemotherapy or radiotherapy indicated.

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.

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.

[Accessory renal allotransplantation with internal or external urinary drainage. An experimental model in pig]

This study describes an experimental model of accessory renal allotransplantation in the big laboratory animal (pig). A total of 24 common-breed pigs were used. All allografts were transplanted in an accessory manner and revascularized at the level of the infrarenal abdominal aorta and inferior vena cava. The urinary drainage was performed either through a nexternal uretheroneostomy at the ipsilateral lumbar region (Group A--n=8) or by internal uretheroneocystostomy (Group B--n=8). All transplants were monitored for 8 days postoperatively using translumbar ultrasound-guided biopsies at 1, 4, 7 days. A total of 16 transplants were performed. 1 ectopic donor kidney was found and transplanted in the same fashion. Mean operative time was 125 minutes, immediate postoperative survival was 100% and at 72 hours, 87.5%. The onset of acute rejection was at day 4, by massive lymphocyte infiltration and was directly correlated with the abrupt decrease of the allograft diuresis in Group A, at day 3. At day 7, the rejection was complete. Both methods of urinary drainage are functional and can be employed. This experimental model is a useful tool for training of the transplant surgeons or for transplantation research. The surgical technique for accessory renal allotransplantation in pig is easy to learn and offers the possibility for allograft monitoring until complete rejection without influencing the receptor health condition.

[Tuberculosis of the spleen--very rare site of extrapulmonary TB]

The extrapulmonary tuberculosis (TB) includes all the sites excepting lung, its origin being in the hematogenous disseminating foci within the main infection. The case of a woman, aged 36, is presented suffering of second degree obesity and type II diabetes mellitus under diet. She was admitted in the Surgery Clinics I of Emergency "Floreasca" Hospital (October 21, 2008) for discontinuous pains, relatively strong in the left hypocondrium, vesperal fever, perspirations, symptoms being present for 5 months. The investigations carried out before and after the admission show the presence of a splenomegaly (stage I-WHO), the absence of hypersplenism, portal hypertension, or other objective elements--excepting those mentioned at admittance--as well as the imaging changes (thoracic abdominal CT: spleen with an axis of 17 cm length, multiple solid hypodense lesions with a diameter of 5 cm). The surgical intervention is undergone (laparoscopic splenectomy). The morphological-pathological diagnosis was tuberculosis of the spleen. Considerations are made on this TB rare site.

Surgical treatment of severe acute pancreatitis

Surgical treatment of severe necrotizing pancreatitis (SNP) is still controversial, inadequate indications and timing of operations being associated with high rates of mortality and morbidity. The aim of the present study is to analyze the indications and results of surgery in patients with SNP. Between 1989 and 2005, necrosectomy followed by open packing drainage (OPD) was performed in 80 patients with SNP. Timing of operations was individualized according to presence of pancreatic necrosis infection. Major postoperative complications were present in 34 patients (42.5%), pancreatic, enteric and biliary fistula, sepsis, iatrogenic bleeding and stress-ulcers being among the most frequently encountered. Secondary contamination of sterile pancreatic necrosis after OPD occurred in 13 patients (35.1%). The overall mortality rate was 32.5%, aggravation of MOF and septic shock being the main causes of death. Late surgical cure for OPD-related incisional hernia was required in 10% of the patients. Infection of pancreatic necrosis is an indication for urgent surgical necrosectomy and repeated re-debridements. Due to technical impossibility to perform adequate necrosectomy and the risk of MOF aggravation, early surgery is not recommended in patients with sterile necrosis. It should be postponed beyond the third week, when the biological condition of the patient is improved and delimitation of necrosis is complete. OPD is an adequate and efficient drainage procedure following necrosectomy. "Prophylactic" OPD for sterile necrosis is not recommended because it is associated with high morbidity rates and secondary infection of necrosis.

[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.

[Self-expandable metallic stent for palliative treatment of colorectal malignant obstructions: risk of perforation]

OBJECTIVE

The self-expandable metallic stents are a good alternative to surgery for the palliative treatment of malignant colonic obstructions. The aim of this paper was to emphasize the causes which could increase the risk of perforation.

PATIENTS AND METHODS

From November 2000 to November 2001, 6 patients with malignant colonic obstruction, to whom surgery was denied due to tumor extension and/or poor general condition, have had a palliative treatment (N = 5) or an attempt (N = 1) with self-expandable metallic stents placed by endoscopy.

RESULTS

Only one patient did not developed any complication and died 5 months later of cancer. Five out of the 6 patients (83%) developed a colonic perforation following stenting (N = 4) or the attempt to place the stent (N = 1), two into the first 24 h after the procedure, and three 3, 5, and 10 months later. Subsequent colostomy was done in 2 patients while the 3 others have had an external drainage of the perforation and died postoperatively.

CONCLUSION

The self-expandable metallic stents seems to be a less aggressive alternative therapy to surgery for malignant colonic obstructions. Nevertheless, the high rate of colonic perforations, suggests reconsidering the indications in the definitive palliation of malignant colonic obstructions.

[Stapled anastomoses in colorectal surgery]

The purpose of this paper was to analyze the advantages, indications and results of stapled circular anastomoses in colorectal surgery. In the last four years (1995-1998), fifteen patients underwent stapled anastomoses after Dixon's anterior rectal resection for cancers of upper and midrectum (11 patients), total colectomy with ileorectal anastomosis for malignant familial polyposis (1 patient), segmental colectomy of transverse and descending colon (1 patient with synchronous colic and rectal cancers, having concomitant rectal resection for cancer), previous Hartmann's resection for perforated upper rectal cancer (1 patient) or distal sigmoid diverticulitis (1 patient). The anastomoses have been performed in end-to-end fashion (11 patients), according to the Knight's technique (2 cases) or in side-to-end fashion (2 patients). As most frequent associated technique with stapled anastomoses, anterior rectal resection for cancer was performed with 2 cm of clearance beyond the macroscopic margin of tumor. Distal margin of resection was histologically verified and it proved to be free of tumor cells. There was no operative mortality. Anastomotic leakage occurred in three patients because of imperfection of stapled anastomosis (2 cases) or after local irradiation (1 case). Spontaneous closure was seen in one patients. The other two patients needed reoperation for suture or colostomy. Late clinical, endoscopic and X-ray controls did not discover local recurrences. Functional results were good in terms of stool frequency and continence. In conclusion, stapled fashioned anastomoses have the main indication in sphincter saving Dixon's and Hartmann's procedures. In these cases, stapled anastomoses are easier than manual technique, reduce operative time and improve suture reliability.

[Neurologic manifestation in mumps virus infection]

OBJECTIVE

To study the incidence, clinical manifestations and treatment of mumps virus meningitis.

MATERIAL AND METHOD

Study of 64 patients with mumps virus meningitis, admitted to the Clinic of Infectious Diseases of Iaşi during 1996-1999.

RESULTS

The mumps virus meningitis had a high prevalence în 1998 (39%) most patients being males (62.5%) from the urban areas. 39.06% of cases were on the age group of 5-6 years old, 25% were in the age group 10-14 years old and 18.75% were adults patients. The clinical manifestation were dominated by headache (100%), fever (100%), vomiting (89%), photophobia (43.75%) and meningeal syndrome of contracture. The laboratory diagnosis was established by the cerebro-spinal fluid exam, together with the peripheric blood exam. The treatment was in all the cases with pathogenic (corticotherapy) and symptomatics with a very good evolution.

CONCLUSIONS

All the cases with diagnosis mumps virus meningitis were well going, having good evolution and complete healing under symptomatic and pathogenic therapy.

[The indications for celiostomy in acute necrotizing pancreatitis]

The aim of this study was to analyze the indication and results of open pancreatic drainage by celiostomy in severe necrotizing pancreatitis (SNP). 44 patients with SNP were treated surgically by open lesser-omental sac drainage (celiostomy) in the last nine years (1989-1997). They were classified into three groups according to date (timing) of celiostomy: a group of 23 patients with early celiostomy (in the first week after the onset of pancreatitis); second group of 11 patients with celiostomy in the second and third week after SNP; the third group of 10 patients with late celiostomy (4-12 weeks after pancreatitis). Drainage procedure consisted in marsupialization of lesser omental sac by suturing open gastrocolic ligament to anterior peritoneum, with drains inserted via celiostomy. The indications of celiostomy in the first group were: diagnostic laparotomy for unknown acute abdomen (18 patients), severe acute cholecystitis (1 patient), common bile duct stones (2 patients), persistent MOSF (1 patient). The necrosectomy was technically possible only in eight patients (34.7%) at date of laparotomy. Postoperative infection of necrosis occurred in seven patients (30.4%) and nine patients died postoperatively (39.1%) because of aggravated MOSF. In the second group, celiostomy was carried out for extensive sterile (2 patients) or infected necrosis (9 patients). Good results were obtained in 9 patients and two patients with infected necrosis died postoperatively. In the third group late celiostomy was performed for treatment of the pancreatic abscess, with good results in all patients (0% mortality). In conclusion, celiostomy is drainage procedure of choice for patients with extensive infected pancreatic necrosis or pancreatic abscesses and stable biologic condition. It facilitates intermittent debridements of residual necrosis and purulent foci, without relaparotomies. Early celiostomy is not recommended as it is proved ineffective (nondemarcated necrosis) and may cause aggravation of SNP or exogenous infections of necrosis.

[Total gastrectomy with mechanical sutures]

Between 1994-1996, nine consecutive patients underwent total gastrectomy with stapled sutures for II, III or IV TNM stage carcinoma (8 patients) or lymphoma (1 patient) of the middle or upper stomach. Digestive continuity was established by stapled end-to-side "ended", end-to-side and end-to-end Roux-en-Y (7 patients) and omega loop (2 patients) esophagojejunal anastomoses using circular staplers (EEA or ILS). The duodenal stump and the end of the Roux loop were closed with TA 55 or TA 30 linear stapler. Interjejunal anastomoses were hand sewn. Nasojejunal feeding catheter was placed for ten days in all patients. No postoperative mortality non anastomotic fistula occurred. One patient had duodenal stump leakage which closed spontaneously. In three patients postoperative chemotherapy with 5-FU and Leucovorian was associated. At late follow-up, there were two patients with reflux esophagitis cured by medical treatment and one patient with peritoneal and hepatic metastases at relaparotomy. In conclusion, the use of stapled sutures in total gastrectomy facilitates esophagojejunal anastomosis and improves suture reliability.