The Predictive Role of Serum Lipid Levels, p53 and ki-67, According to Molecular Subtypes in Breast Cancer: A Randomized Clinical Study

Dyslipidemia is a component of metabolic syndrome, having an important role in the carcinogenesis of different tumor types, such as prostate, ovarian, or renal cancer. The number of studies on the predictive potential of the different components of the lipid profile with a predictive potential in breast cancer is quite low. The evaluation of the lipid profile was carried out for the 142 patients who benefited from neoadjuvant therapy (NAC) in order to identify a potential predictive biomarker. The serological sample collection was performed sequentially according to a standardized protocol, pre-NAC, post-NAC and 6 months post-NAC after a 6-h pre-collection fast. We also investigated in the general group the presence or absence of the p53 mutation (TP53) and of the mitotic index ki-67, respectively, in relation to the molecular subtypes. The menopausal status, tumor size, family history, grading, Ki-67, p53 and LN metastases have a predictive nature regarding overall survival (OS) (p < 0.05), while for disease free survival (DFS), only tumor size, tumor grading, Ki-67 > 14, and p53+ are of predictive nature. The genetic and molecular analysis carried out in our group indicates that 71.67% have a Ki-67 score higher than 14%, and 39% of the patients have the positive P53 mutation. The multivariate analysis in the case of patients included in the TNBC subtype showed that the increased tumor volume (p = 0.002) and increased level of HDL (p = 0.004) represent predictive factors for the tumor response rate to NAC. High HDL-C levels before NAC and increased LDL-C levels after NAC were associated with the better treatment response in ER-positive and HER2+ breast cancer patients. Increased HDL-C values and tumor volume represent predictive factors as to the response rate to NAC in the case of patients included in the TNBC subtype. Regarding the ER+ and HER2+ subtypes, increased levels of HDL-C pre-NAC and increased levels of LDL-C post-NAC were associated with a better therapeutic response rate. Tumor grading, Ki-67, p53, and LN metastases have a predictive nature for OS, while tumor size, tumor grading, and Ki-67 > 14, and p53+ are predictive for DFS.

VRAM Flap for Pelvic Floor Reconstruction after Pelvic Exenteration and Abdominoperineal Excision

Due to the still large number of patients diagnosed with pelvic neoplasms (colorectal, gynecological, and urological) in advanced stages right from the initial diagnosis, surgery represents the mainstay of treatment, often implying wide, eventually multi-organ resections in order to achieve negative surgical margins. Perineal wound morbidity, particularly in extralevator abominoperineal excision, leads to complications and local infection rates of up to 40%. Strategies to reduce postoperative wound complications are being pursued to address this issue. The VRAM flap remains the gold standard for autologous reconstruction after pelvic oncological resection; it was initially designed for abdominal wall defects and later expanded for large pelvic tissue defects. The flap's application is based on its physical characteristics, including abundant tissue and a generous skin paddle, which effectively obliterates dead space after exenterations. The generous skin paddle offers good cosmetic and functional outcomes at the recipient site. This article describes the case of a patient histopathologically diagnosed with stage IIIA squamous cell carcinoma of the uterine cervix who received multimodal onco-surgical treatment. The surgical mainstay of this treatment is pelvic exenteration. Pelvic reconstruction after this major surgery was performed using a vertical flap with the rectus abdominis.

The Cavernous Nerve Injury Rat Model: A Pictorial Essay on Post-Radical Prostatectomy Erectile Dysfunction Research

Understanding and addressing post-radical prostatectomy (RP) erectile dysfunction (ED) is of paramount importance for clinicians. Cavernous nerve (CN) injury rat model studies have provided consistently promising experimental data regarding regaining erectile function (EF) after nerve damage-induced ED. However, these findings have failed to translate efficiently into clinical practice, with post-RP ED therapeutic management remaining cumbersome and enigmatic. This disparity highlights the need for further standardization and optimization of the elaborate surgical preparation protocols and multifaceted reporting parameters involved in reliable CN injury rat model experimentation. Even so, despite its technical complexity, this animal model remains instrumental in exploring the functional implications of RP, i.e., surgical lesions of the neurovascular bundles (NVBs). Herein, besides cavernous nerve (CN) dissection, injury, and electrostimulation, multiple pressure measurements, i.e., mean arterial pressure (MAP) and intra-cavernosal pressure (ICP), must also be achieved. A transverse cervical incision allows for carotid artery cannulation and MAP measurements. Conversely, ICP measurements entail circumcising the penis, exposing the ischiocavernous muscle, and inserting a needle into the corporal body. Finally, using an abdominal incision, the prostate is revealed, and the major pelvic ganglia (MPG) and CNs are dissected bilaterally. Specific surgical techniques are used to induce CN injuries. Herein, we provide a narrative and illustrative overview regarding these complex experimental procedures and their particular requirements, reflecting on current evidence and future research perspectives.

Pneumorrhachis Secondary to a Locally Advanced Rectal Cancer with Pre-Sacral Abscess-Case Report and Review

The occurrence of pneumorrhachis (PR), defined as the presence of air within the spinal canal, presents a complex clinical picture with diverse etiological factors. We report an exceedingly rare case of PR arising from locally advanced rectal cancer accompanied by a pre-sacral abscess. This report aims to enhance awareness and understanding of rare causes of PR within the medical community, particularly among surgeons engaged in emergency procedures. The patient survived the acute phase of the disease through multiple surgical interventions and admission to the intensive care unit, but succumbed to cardiovascular complications three weeks later. We also offer a brief review of the literature concerning PR originating from the colorectal lumen.

The Value of Tumor Infiltrating Lymphocytes (TIL) for Predicting the Response to Neoadjuvant Chemotherapy (NAC) in Breast Cancer according to the Molecular Subtypes

INTRODUCTION

The antitumor host immune response is an important factor in breast cancer, but its role is not fully established. The role of tumor infiltrating lymphocytes (TIL) as an immunological biomarker in breast cancer has been significantly explored in recent years. The number of patients treated with neoadjuvant chemotherapy (NAC) has increased and the identification of a biomarker to predict the probability of pCR (pathological complete response) is a high priority.

MATERIALS AND METHODS

We evaluated 334 cases of BC treated with NAC followed by surgical resection from 2020-2022 at the Ist Clinic of Oncological Surgery, Oncological Institute "Prof Dr I Chiricuta" Cluj Napoca. Of the above, 122 cases were available for histological evaluation both in pre-NAC biopsy and post-NAC resection tissue. Evaluation of biopsy fragments and resection parts were performed using hematoxylin eosin (H&E). The TIL evaluation took place according to the recommendations of the International TIL Working Group (ITILWG).

RESULTS

There was a strong association between elevated levels of pre-NAC TIL. At the same time, there is a statistically significant correlation between stromal TIL and tumor grade, the number of lymph node metastases, the molecular subtype and the number of mitoses (p < 0.005). Intratumoral TIL showed a significant correlation with tumor size, distant metastasis, molecular subtype, number of mitosis, stage and lymph node metastasis (p < 0.005). We also demonstrated that high pre-NAC STIL represents a strong predictive marker for pCR.

CONCLUSION

This study reveals the role of TIL as a predictive biomarker in breast cancer not only for the well-established TNBC (triple negative breast cancer) and HER2+ (Her2 overexpressed) subtypes but also in Luminal A and B molecular subtypes. In this scenario, the evaluation of sTIL as a novel predictive and therapy-predicting factor should become a routinely performed analysis that could guide clinicians when choosing the most appropriate therapy.

Unraveling the Metabolic Changes in Acute Pancreatitis: A Metabolomics-Based Approach for Etiological Differentiation and Acute Biomarker Discovery

Acute pancreatitis (AP) remains a challenging medical condition, where a deeper metabolic insight could pave the way for innovative treatments. This research harnessed serum metabolomics to discern potential diagnostic markers for AP and distinguish between its biliary (BAP) and alcohol-induced (AAP) forms. Leveraging high-performance liquid chromatography coupled with mass spectrometry, the metabolic signatures of 34 AP patients were contrasted against 26 healthy participants, and then between different etiologies of AP. The results identified metabolites primarily from glycerophospholipids, glycerolipids, fatty acyls, sterol lipids, and pteridines and derivative classes, with the Human Metabolome Database aiding in classification. Notably, these metabolites differentiated AP from healthy states with high AUROC values above 0.8. Another set of metabolites revealed differences between BAP and AAP, but these results were not as marked as the former. This lipidomic analysis provides an introduction to the metabolic landscape of acute pancreatitis, revealing changes in multiple lipid classes and metabolites and identifying these metabolites. Future research could add and discover new diagnostic biomarkers and therapeutic strategies enhancing the management of acute pancreatitis.

Pentraxin-3 and Other Inflammatory Markers for an Infected Diabetic Foot Ulcer Diagnosis: A Prospective Study

Strategies have been researched and implemented to reduce the number of people with diabetic foot ulcers (DFUs). One problem is the accurate assessment of DFU severity, which is the main factor in resource allocation and treatment choice. The primary objective of this study was to assess pentraxin-3 as a biomarker of an infected DFU (IDFU), the limb amputation level prognosis, and patient survival. The secondary objectives were to evaluate and compare other markers, including white blood cells (WBCs), C-reactive protein (CRP), the erythrocyte sedimentation rate (ESR), and procalcitonin (PCT), for identifying IDFUs. Over a period of two years, 145 patients were followed; 131 of these were analyzed for this study. Pentraxin-3 was found to be a good predictor of death (p = 0.047). A comparison between IDFUs and DFUs revealed the following differences: PCT had the highest AUROC of 0.91, sensitivity of 93.7, and specificity of 83.3%. CRP had a cutoff value of 226 mg/L, an AUROC of 0.89, a sensitivity of 95.5%, and a specificity of 83.3%. Fibrinogen had an AUROC of 0.87 at a cutoff value of 5.29 g/L, with a good sensitivity and specificity of 85% and 87%, respectively. ESR had a cutoff value of 46 mm/h, an AUROC of 85%, a sensitivity of 83.7%, and a specificity of 83.3%. Pentraxin-3 showed promising results in predicting IDFUs and DFUs, and it served as a marker for the risk of death in IDFU patients during the 6 month follow-up. Other markers, including CRP, PCT, ESR, and fibrinogen, were more effective in differentiating between IDFUs and DFUs.

Health-Related Quality of Life and Stress-Related Disorders in Patients with Complicated Diverticular Disease under Conservative Management

Diverticular disease is a common gastrointestinal disorder with increasing prevalence in advanced age. This study aimed to investigate the impact of age and complexity of diverticulitis on health-related quality of life (HRQoL) and stress-related disorders. A cross-sectional study was conducted on 180 patients, including adults (18-64 years) with complicated diverticular disease, the elderly (≥65 years) with complicated diverticular disease, and a control group with uncomplicated symptomatic diverticular disease. HRQoL and stress-related disorders were assessed using the SF-36, GIQLI, HADS, and PHQ-9 questionnaires at baseline and six months after the initial episode of diverticulitis. At diagnosis, the adult group had significantly lower mean physical and mental scores compared with the elderly and control groups (p < 0.001). At the 6-month follow-up, the mean physical score increased for all groups, but the difference between adults and the elderly remained significant (p = 0.028). The adult group had a significantly lower mean GIQLI score at diagnosis compared with the elderly and control groups (p < 0.001), although after 6 months it increased and the difference became insignificant. Anxiety scores at diagnosis were significantly higher in the adult group compared with the control group (p = 0.009). The complexity of diverticulitis and age significantly impacted HRQoL at diagnosis, with adults having lower physical and mental scores compared with elderly patients and controls. Although improvements were observed after 6 months, the difference between adults and the elderly remained significant for physical HRQoL scores. This highlights the need for tailored management strategies and psychosocial support to optimize patient outcomes across age groups and diverticulitis complexity.

The Use of Wound Infiltration for Postoperative Pain Management after Breast Cancer Surgery: A Randomized Clinical Study

(1) Background: The present study aims to evaluate the reduction of postoperative pain in breast surgery using a series of local analgesics, which were infiltrated into the wound; (2) Methods: Envelopes containing allocation were prepared prior to the study. The patients involved were randomly assigned to the groups of local anesthesia infiltration (Group A) or normal pain management with intravenous analgesics (Group B). The random allocation sequence was generated using computer-generated random numbers. The normally distributed continuous data were expressed as the means (SD) and were assessed using the analysis of variance (ANOVA), independent-sample t-test, or paired t-test; (3) Results: The development of the postoperative pain stages was recorded using the VAS score. Therefore, for Group A, the following results were obtained: the VAS at 6 h postoperatively showed an average value of 0.63 and a maximum value of 3. The results for Group B were the following: the VAS score at 6 h postoperatively showed an average value of 4.92, a maximum of 8, and a minimum of 2; (4) Conclusions: We can confirm that there are favorable statistical indicators regarding the postoperative pain management process during the first 24-38 h after a surgical intervention for breast cancer using local infiltration of anesthetics.

Risk of endometrial cancer in patients with polycystic ovarian syndrome: A meta‑analysis

While existing literature suggests an association between polycystic ovarian syndrome (PCOS) and endometrial cancer, the sparsity and inconsistency of current evidence indicates a lack of clarity regarding the exact strength of this association. It also remains uncertain whether the degree of risk of disease is affected by confounding factors, such as age and body mass index (BMI). The present meta-analysis is aimed to quantify the risk of endometrial cancer in female subjects with PCOS compared to those without PCOS. PubMed, MEDLINE, EMBASE, Scopus and Cochrane were searched from inception to October 31, 2022, to identify peer-reviewed case-control, cohort and cross-sectional studies that assessed the association between endometrial cancer and PCOS and contained original data. Two researchers independently extracted data and performed quality assessment using the Newcastle-Ottawa criteria. Pooled odds ratios (ORs) were calculated using the random-effect model and inverse variance. The degree of heterogeneity was assessed using I² statistics. A total of 10 relevant studies were identified and included in the meta-analysis (comprising 12,248 female patients with PCOS and 54,120 controls). Females with PCOS had a significantly increased odds of developing endometrial cancer as compared to those without PCOS [OR, 4.07; 95% confidence interval (CI), 2.13-7.78; P<0.0001]. When postmenopausal subjects (age, >54 years) were excluded from the meta-analysis, the odds increased further (OR, 5.14; 95% CI, 3.22-8.21; P<0.00001). Patients with PCOS are up to 5 times more likely to develop endometrial cancer compared to those without PCOS. Larger, prospective studies that are well-controlled for confounding factors, such as BMI, are required.

The Challenges of Colorectal Cancer Surgery during the COVID-19 Pandemic in Romania: A Three-Year Retrospective Study

The predictions on the influence of the SARS-CoV-2 pandemic on access to medical services in Romania predicted a 35% drop in oncological hospitalizations in 2020 compared to the previous decade, raising the hypothesis that patients with colorectal cancer can become indirect victims of the ongoing pandemic. Therefore, the aim of the current research was to observe how the COVID-19 pandemic influenced colorectal cancer surgery in Romania, to determine the level of addressability towards specialized care, to compare the cancer staging between the pandemic and pre-pandemic periods, and to observe the risk factors for disease progression. This retrospective study was spread over three years, respectively, from March 2019 to March 2022, and included a total of 198 patients with a history of colorectal cancer surgery. It was decided to perform a parallel comparison of 2019, 2020, and 2021 to observe any significant changes during the pandemic. Our clinic encountered a significant decrease in all interventions during the pandemic; although the number of CRC surgeries remained constant, the cases were more difficult, with significantly more patients presenting in emergency situations, from 31.3% in 2019 to 50.0% in 2020 and 57.1% in 2021. Thus, the number of elective surgeries decreased significantly. The proportion of TNM (tumor-node-metastasis) staging was, however, statistically significant between the pre-pandemic and pandemic period. In 2019, 13.3% of patients had stage IIa, compared with 28.8% in 2020 and 13.1% in 2021. Similarly, the proportion of very advanced colorectal cancer was higher during the pandemic period of 2020 and 2021 (12.0% in 2019 vs. 12.5% in 2020 and 25.0% in 2021), which was represented by a significantly higher proportion of patients with bowel perforation. Patients with an advanced TNM stage had a 6.28-fold increased risk of disease progression, followed by lymphovascular invasion (HR = 5.19). However, the COVID-19 pandemic, represented by admission years 2020 and 2021, did not pose a significant risk for disease progression and mortality. In-hospital mortality during the pandemic also did not change significantly. After the pandemic restrictions have been lifted, it would be advisable to conduct a widespread colorectal cancer screening campaign in order to identify any instances of the disease that went undetected during the SARS-CoV-2 pandemic.

Hypertriglyceridaemia-Induced Acute Pancreatitis: A Different Disease Phenotype

Acute pancreatitis (AP) is the most common gastrointestinal indication requiring hospitalisation. Severe hypertriglyceridaemia (HTG) is the third most common aetiology of AP (HTGAP), with a complication rate and severity that are higher than those of other aetiologies (non-HTGAP). The aim of this study was to evaluate the supposedly higher complication rate of HTGAP compared to non-HTGAP. The secondary objectives were to find different biomarkers for predicting a severe form. This was a retrospective study that included patients admitted with AP in a tertiary department of gastroenterology and hepatology. The patients were divided into two groups: HTGAP and non-HTGAP. We searched for differences regarding age, gender, the presence of diabetes mellitus (DM), the severity of the disease, the types of complications and predictive biomarkers for severity, hospital stay and mortality. A total of 262 patients were included, and 11% (30/262) of the patients had HTGAP. The mean ages were 44.4 ± 9.2 in the HTGAP group and 58.2 ± 17.1 in the non-HTGAP group, p < 0.0001. Male gender was predominant in both groups, at 76% (23/30) in the HTGAP group vs. 54% (126/232) in non-HTGAP, p = 0.02; 53% (16/30) presented with DM vs. 18% (42/232), p < 0.0001. The patients with HTG presented higher CRP 48 h after admission: 207 mg/dL ± 3 mg/dL vs. non-HTGAP 103 mg/dL ± 107 mg/dL, p < 0.0001. Among the patients with HTGAP, there were 60% (18/30) with moderately severe forms vs. 30% (71/232), p = 0.001, and 16% (5/30) SAP vs. 11% (27/232) in non-HTGAP, p = 0.4 Among the predictive markers, only haematocrit (HT) and blood urea nitrogen (BUN) had AUCs > 0.8. According to a multiple regression analysis, only BUN 48 h was independently associated with the development of SAP (p = 0.05). Diabetes mellitus increased the risk of developing severe acute pancreatitis (OR: 1.3; 95% CI: 0.1963−9.7682; p = 0.7). In our cohort, HTGAP more frequently had local complications compared with non-HTGAP. A more severe inflammatory syndrome seemed to be associated with this aetiology; the best predictive markers for complicated forms of HTGAP were BUN 48 h and HT 48 h.

The BISAP score, NLR, CRP, or BUN: Which marker best predicts the outcome of acute pancreatitis?

Acute pancreatitis is a common disease, and the mortality rate can be high. Thus, a risk assessment should be performed early to optimize treatment. We compared simple prognostic markers with the bedside index for severity in acute pancreatitis (BISAP) scoring system to identify the best predictors of severity and mortality.This retrospective study stratified disease severity based on the revised Atlanta criteria. The accuracies of the markers for predicting severe AP (SAP) were assessed using receiver operating characteristic curves. The sensitivity, specificity, positive predictive value, and negative predictive value were calculated for each marker. Multivariate logistic regression analyses were used to identify independent predictors of SAP and mortality.The area under the curve (AUC) for the BISAP score was classified as fair for predicting SAP. The neutrophil-to-lymphocyte ratio at 48 hours (NLR48 h) and the C-reactive protein level at 48 hours (CRP48 h) had the best AUCs and were independently associated with SAP. When both criteria were met, the AUC was 0.89, sensitivity was 68%, and specificity was 92%. CRP48 h and hematocrit at 48 hours were independently associated with mortality.NLR48 h and CRP48 h were independently associated with SAP but not superior to the BISAP score at admission. Assessing NLR48 h and CRP48H together was most suitable for predicting SAP. The CRP level was a good predictive marker for mortality.

Distal resection margins in rectal cancer specimens: differences in assessment between surgeons and pathologists and the influence of neoadjuvant chemoradiation

To investigate the discrepancy between the distal resection margin (DRM) assessed by surgeons and pathologists, and the impact of neoadjuvant chemoradiotherapy (nCRT) on DRM. This study included 67 rectal cancer patients undergoing elective surgery. DRMs were assessed through four different techniques: in vivo subjective estimative, made by the surgeon before the rectal resection (by palpation and visual estimative); in vivo objective, measured with a ruler before the rectal transection; ex vivo objective, measured right after resection of the specimen; post-fixation objective measurement, conducted by the pathologist. The DRMs subjectively and objectively assessed by the surgeons were not significantly different (3.40 cm vs. 3.45 cm). There was a mean reduction in the length of DRMs of 35.6%, from 3.45 cm objectively measured by the surgeon to 2.20 cm measured by the pathologist. This difference was significant among patients that did not receive nCRT (3.90 cm vs. 2.30 cm, P < 0.001), but not among those who received nCRT (2.30 vs. 2.05 cm). Surgeons are accurate in assessing rectal cancer DRMs. There are significant differences between intraoperative measurements of DRMs and the final pathologic results. However, these differences are not seen when nCRT is used, a finding that may be useful when sphincter preservation is being considered.

Ghrelin Levels and Hunger Sensation after Laparoscopic Sleeve Gastrectomy Compared with Laparoscopic Greater Curvature Plication in Obese Patients

BACKGROUND

The aims of our study were to compare serum acylated ghrelin (the active form of ghrelin) concentrations before and after the surgery of patients undergoing laparoscopic sleeve gastrectomy (LSG) or laparoscopic greater curvature plication (LGCP) and to correlate these levels with excess weight loss and hunger sensations on a short-term basis.

METHODS

The patients included in the study had either (1) a body mass index (BMI) over 35 kg/m2 and one comorbidity or (2) a BMI over 40 kg/m2. Ghrelin levels were measured on the day of the surgery, 1 month after the procedure, and 3 months after the procedure. A questionnaire about hunger sensation was administered to the patients, and changes in the patients' weights were evaluated on the same timeline as the measurement of the ghrelin levels.

RESULTS

Eighteen obese patients were included in the study, including 10 patients in the LSG group and 8 patients in the LGCP group. All the procedures were performed laparoscopically. The average level of preoperative ghrelin in the LSG group was 212.21 pg/mL ± 140.57 SD. After 1 month, the average ghrelin level in the LSG group was 74.47 pg/mL ± 29.55 SD (p = 0.01), and it was 41.47 pg/mL ± 15.19 SD (p = 0.002) after 3 months. The average level of preoperative ghrelin in the LGCP group was 318.08 pg/mL ± 161.70 SD. It decreased to 190.58 pg/mL ± 116.75 SD (p = 0.01) after 1 month and to 91.57 pg/mL ± 56.70 SD (p = 0.004) after 3 months. Comparing the two groups, hunger sensation had decreased more in the LSG group (p = 0.03) 3 months after the surgery.

CONCLUSIONS

Laparoscopic sleeve gastrectomy (LSG) and laparoscopic greater curvature plication (LGCP) produced the same weight loss and diminished hunger sensation in the short term on the selected patients. LSG had an increased effect on ghrelin levels when compared with LGCP at 1 month after the procedure and 3 months after the procedure.

Plasma ghrelin, adiponectin and leptin levels in obese rats with type 2 diabetes mellitus after sleeve gastrectomy and gastric plication

The prevalence of obesity has increased in recent decades and has become a public health problem. In obesity patients the metabolism of almost all adipokines is markedly dysregulated. Studies regarding levels of ghrelin, leptin, and adiponectin after bariatric surgery reveal contradictory results. The purpose of the present study was to analyze modification of body weight and plasma levels of fasting glucose, ghrelin, adiponectin and leptin, in obese rats with T2DM after sleeve gastrectomy (SG), gastric plication (GP) and sham-operated (SO). Eighteen specimens where randomized to three weight-matched groups: Group SG underwent sleeve gastrectomy (n=6), group GP underwent gastric plication (n=6) and the control group SO underwent sham surgery (n=6). Upon surgery a normal rat chow diet (Bio-Serv^® product no. F4031) was fed to the rats until the end of the experiment. Additional blood samples were harvested after 4 weeks. The results revealed that body mass decreased in the SG (783.17±101.39 vs. 658.33±86.57 g; P<0.0001) and the GP (781.33±103.12 vs. 702.33±84.06 g; P=0.004) rats after surgery. There were significant lower fasting glucose levels at 4 weeks postoperative in the SG group compared to the SO group (83.1±12.81 vs. 104.5±9.81 mg/dl; P=0.016). The same trend was observed in the GP group vs. the SO group (86.7±11.43 vs. 104.5±9.81 mg/dl; P=0.026). There was no difference regarding mean glucose levels between the SG group compared to the GP group (P>0.05). Plasma acylated ghrelin and leptin levels decreased four weeks after surgery compared to preoperative levels, while adiponectin levels increased four weeks after surgery in the SG and GP groups, respectively. The present study revealed that plasma glucose levels, ghrelin and leptin levels decreased after SG and GP, while adiponectin levels improved. This suggests that there may be hormonal contribution in weight loss.

The Correlation between Specific Biochemical Parameters, Radiological data and clinical sings for practicing laparoscopic cholecystectomy in the first 24 hours for acute cholecystitis. How safe it is?

The best timing of cholecystectomy on patients with acute gallbladder pathology is still unclearly defined. Some studies have reported that cholecystectomy during the index acute admission presents an increased morbidity rate, extended duration of stay and increased costs. The study below is aiming at finding the most accurate moment to practice the surgery when acute cholecystitis is confirmed. Consequently, 368 patients admitted to hospital from January 2013 to December 2015 with the diagnosis of acute cholecystitis (AC) who underwent cholecystectomy in the 2nd Department of Surgery, Emergency County Hospital, Timi�oara, Romania constituted the two lots. The cases were retrospectively identified, introduced into the database and the data were subsequently analyzed according to various parameters. The study results reveal that laparoscopic cholecystectomy (LC) in the first 24 hours is safe procedure on the majority of the cases. Also, our findings sustain that emergency cholecystectomy can reduce the length of hospital stay, having similar rates of conversion to open surgery, complications and outcome compared with a delayed operation.

A Pilot Study for Testing the Efficiency of a Novel Integrated On-line Platform Using Tumoral Biomarkers Evaluation in Colorectal Cancer

Colorectal cancer (CRC) is one of the leading causes of death among cancer patients in Romania. It is known as a heterogeneous disease, characterized by diversion in multiple molecular pathways during its evolutionary process. This research was focusing on the two biomarkers that are related to CRC, specifically Carcinoembryonic Antigen (CEA) and Carbohydrate Antigen 19-9 (CA 19-9). Being an integral part of a wider study, we explored the use of a novel platform to support the strictly controlled process of data collection on colorectal cancer cases. We collected data about the patients regarding baseline clinical parameters, medical history, important comorbidities, intraoperative findings and adverse events, tumor characteristics, histological findings and main laboratory data (blood cell count, serum protein electrophoresis, liver and kidney function tests, serum levels of CEA and CA19-9). The results suggest that these two biomarkers are useful preoperative indicators of local recurrences and prognosis in colorectal cancer. Increased levels of both tumor markers are correlated with an advanced stage of the disease and a poor prognosis. Finally, this study aims to provide the necessary infrastructure, geared towards efficient, safe and comprehensive clinical evaluation of CRC cases.

Metabolic and Weight Changes After Bariatric Surgery in a Rat Model of Induced Type 2 Diabetes Mellitus and Obesity

Sleeve gastrectomy (SG) and gastric plication (GP) are surgical procedures providing weight loss through several mechanisms incompletely understood. Rat models allow the possibility of tight regulation of experimental conditions, making them the ideal candidates for animal models in bariatric surgery. The aim of this study was to compare the weight and metabolic changes between sleeve gastrectomy and gastric plication in a rat model with type 2 induced diabetes mellitus and obesity. Fifteen male Wistar rats were fed with DIO food (Bio Serv �F3282 - Mouse Diet, High Fat, Fat Calories -60%), after 36 weeks were allocated to the study three arms-SG, GP and sham operation (SO). Four weeks after the surgery the rats were weighted again. Blood tests were performed before surgery and four weeks after surgery searching for blood glucose, total cholesterol, HDL, triglycerides, and LDL. At the onset of the study, the rats were 9 weeks old and had an average body mass of 231.6g � 31.58. After 36 weeks of DIO, one day preoperatively body weight was 774.93g � 95.02. The preoperatively average of body weight in the SG group was 777.4g �104.66, 775.4 g �104.6 in the GP group, respectively 772g �79 in the SO group. 4 weeks after surgery the mean body weight in the SG group was 648.8g �99.09, in the GP group was 695.6g �99.09, respectively 825.4g �79.87 in the SO fed ad libitum group. There was a significant decrease of mean fasting glucose levels at 4 weeks postoperative in the SG group compared to the SO group (87.4mg/dL�8.73 versus 103.6 mg/dlL�4.66, p= 0.01). The same trend of mean fasting glucose was registered in the GP group versus the SO group (92.8 � 5.67 mg/dl vs 103.6 mg/dl � 4.66, p=0.01). Our study provides evidence of the positive effects of bariatric surgery for treating patients with morbid obesity associated with diabetes mellitus and dyslipidemia and the use of rats to study the mechanisms of weight reduction and metabolic changes in bariatric surgery.

Laparoscopic repair of perforated peptic ulcer

INTRODUCTION

Perforations of the peptic ulcers (PPUs) are the most common cause of emergency surgery among the complications of the gastroduodenal ulcers and the leading cause for morbidity and mortality due to secondary peritonitis and sepsis. PPU is a condition in which laparoscopic perforation repair (LPR) is an optimal solution. It makes possible the identification of the perforation's site and allows closure of the perforation and the subsequent peritoneal lavage, as in an open repair (OR) but without the large upper mid-abdominal incision. The main objective of this review was to evaluate the latest reported results in the laparoscopic treatment of the PPU.

EVIDENCE ACQUISITION

Using PubMed and EMBASE databases between 1989 and June 2017 we did an extensive electronic literature search. The search terms used were "laparoscopic perforated peptic ulcer." Inclusion criteria were all the published studies that reported the outcomes of LPR and LPR compared with OR for PPU were included in the analysis. The exclusion criteria included animal or laboratory studies, pediatric surgery trials, papers reporting less than 30 cases of LPR, clinical trials without major outcomes, and other language then English.

EVIDENCE SYNTHESIS

There were 32 studies included, counting 3488 patients with LPR and 5208 with OR. OR patients had more frequent shock at admission and had a higher ASA risk class. LPR patients had shorter hospital stays with two days, morbidity (11.12% vs. 14.71% OR) and mortality (1.95% vs. 8.35% OR) were lower. Leakage was three times higher in LPR arm (2.18% vs. 0.79% OR). Conversion occurred in 4.18% overall. The three primary reasons for conversions were the size of the perforation, the inability to locate the perforation and technical difficulties.

CONCLUSIONS

LPR showed similar or better results than OR in terms of morbidity, mortality, operation time and hospital stay, caution is needed as the OR patients tend to be more shocked or with higher ASA at presentation. The higher leakage rate after LPR should be addressed in the training of the laparoscopic surgeons or other safety measures should be developed and employed.

Laparoscopic Repair for Perforated Peptic Ulcer: A Retrospective Study

BACKGROUNDS

The incidence of patients presenting with perforated peptic ulcers (PPU) has decreased during the last decades. At the same time, a laparoscopic approach to this condition has been adopted by increased number of surgeons. The aim of this study was to evaluate the early postoperative results of the laparoscopic treatment of perforated peptic ulcer performed in eight Romanian surgical centers with extensive experience in laparoscopic surgery.

METHODS

Between 2009 and 2013, 297 patients with perforated peptic ulcer were operated in the eight centers participating in this retrospective study. The patients' charts were reviewed for demographics, surgical procedure, complications and short-term outcomes.

RESULTS

Boey score of 0 was found in 122 patients (41.1%), Boey 1 in 169 (56.9%), Boey 3 in 6 (2.0%). For 145 (48.8%) patients, primary suture repair was performed, in 146 (49.2%) primary suture repair with omentopexy. There were 6 (2.0%) conversions to open surgery. The operative time was between 25 and 120 min, with a mean of 68 min. Two (0.7%) deaths were noted. Mean hospital stay was 5.5 days, ranges 3-25 days. Postoperative complications included: 7 (2.4%) superficial surgical site infections, 5 (1.6%) cardiovascular, 3 (1.0%) pulmonary, 2 (0.7%) duodenal leakages, 3 (1.0%) deep space infections and 1 (0.3%) upper digestive hemorrhage.

CONCLUSIONS

This study shows that the laparoscopic approach for PPU is feasible; the procedure is safe, with no increased risk of duodenal fistulae or residual intraperitoneal abscesses. We now consider the laparoscopic approach for PPU as the "gold standard" in patients with Boey score 0 or 1.

Laparoscopic Repair of Inguinal Hernia TEP versus TAPP

AIM

The purpose of the study was to compare the results of laparoscopic inguinal hernia repair using two different methods: transabdominal preperitoneal (TAPP) repair and the technique of totally extraperitoneal repair (TEP).

METHODS

In this retrospective study were included 90 cases of inguinal hernia that underwent for laparoscopic approach of inguinal hernia repair at the Emergency County Hospital Timisoara at the 2nd Surgical Clinic between 2012 and 2013. The primary outcome was recurrence of the hernia at two years follow-up. Secondary outcomes were short and long-term complications: hematoma and seroma formation, inflammation of the testis, chronic inguinal pain, reoperation, 30 days mortality.

RESULTS

Of the 90 patients who underwent unilateral hernia repair, 70 were completely followed-up for 24 months, 36 (81.81%) patients with TEP and 34 (73.91%) with TAPP. Regarding the main outcome there was no recurrence of the hernia at two years follow-up.There were two cases of bleeding in the TAPP group;both were managed by laparoscopic sealing of the damaged vessels, 8 cases of post-operative edema of testis in TAPP and 3 cases in TEP. Regarding thesubcutaneous emphysema there were 16 cases in TAPP and 3 cases in TEP.

CONCLUSIONS

Differences between TEP and TAPP in our study were related to minor complications, no major complications occurred. After the two years follow-up of 70 of a total of 90 patients, there was no recurrence of the hernia.

Indocyanine green fluorescent dye during bowel surgery: are the blood supply "guessing days" over?

Assessing the blood supply of the bowel is a difficult task even for experienced surgeons. Laser-assisted indocyanine green (ICG) fluorescent dye angiography provides intraoperative visual assessment of blood flow to the bowel wall and surrounding tissues, allowing for modification to the surgical plan, which can reduce the risk of postoperative complications. ICG angiography was prospectively performed in a single center during a 1-year period for small bowel ischemia and left colorectal resections. ICG angiography played a major role in the intraoperative decision making in 4 of 160 patients, whose clinical and operative details are here reported. In case of acute small intestine ischemia, resection is not warranted unless absolute perfusion units are below 19 (relative 21%). When evaluating blood supply to the left colon prior to anastomosing, resection is recommended with absolute units lower than 18 (relative 31%) even if the bowel appears macroscopically perfused.

Intracorporeal ileocolic anastomosis: a review

This study is a narrative review of the current literature regarding intracorporeal ileocolic anastomosis in laparoscopic right colon resection for benign or malignant diseases of the right colon and terminal ileum. The search strategy included Medline, Embase, CINAHL, ACP Journal Club, and Cochrane databases with laparoscopic right colectomy and intracorporeal anastomosis as keywords. All retrieved references were screened by two independent blinded reviewers. Thirteen papers including 611 patients undergoing laparoscopic right colon resection with intracorporeal ileocolic anastomosis for benign or malignant diseases of the right colon and terminal ileum were identified. There were eight case series and five case control studies. Anastomoses were fashioned as antiperistaltic or isoperistaltic, totally stapled or stapled/handsewn. The mesenteric defect was mostly left open. Overall operating time ranged from 53 to 360 min. The most common specimen extraction site locations were periumbilical, suprapubic, or transvaginal with a median incision length ranging from 3 to 6 cm. The overall rate of surgical site infection was 2.7 %. The anastomotic leak rates varied from 0 to 8.5 %. Postoperative mortality was 0.12 %. Intracorporeal ileocolic anastomosis following laparoscopic resection of the right colon is not commonly performed, but offers potential benefits if carried out by experienced surgeons in selected patients.

Laparoscopic right colon resection with intracorporeal anastomosis

BACKGROUND

This study was performed to evaluate short-term clinical outcomes of laparoscopic intracorporeal ileocolic anastomosis following resection of the right colon.

METHODS

This was a retrospective study of selected patients who underwent laparoscopic intracorporeal ileocolic anastomosis following resection of the right colon for tumors or Crohn's disease by a single surgeon from July 2002 through June 2012. Data were retrieved from an Institutional Review Board-approved database. Study end point was postoperative adverse events, including mortality, complications, reoperations, and readmissions at 30 days. Antiperistaltic side-to-side anastomoses were fashioned laparoscopically with a 60-mm-long stapler cartridge and enterocolotomy was hand-sewn intracorporeally in two layers. Values were expressed as medians (ranges) for continuous variables.

RESULTS

There were 243 patients (143 females) aged 61 (range = 19-96) years, with body mass index of 29 (18-43) kg/m(2) and ASA 1:2:3:4 of 52:110:77:4; 30 % had previous abdominal surgery and 38 % had a preexisting comorbidity. There were 84 ileocolic resections with ileo ascending anastomosis and 159 right colectomies with ileotransverse anastomosis. Operating time was 135 (60-220) min. Estimated blood loss was 50 (10-600) ml. Specimen extraction site incision length was 4.1 (3-4.4) cm. Conversion rate was 3 % and there was no mortality at 30 days, 15 complications (6.2 %), and 8 reoperations (3.3 %). Readmission rate was 8.7 %. Length of stay was 4 (2-32) days. Pathology confirmed Crohn's disease in 84 patients, adenocarcinoma in 152, and other tumors in 7 patients.

CONCLUSION

Laparoscopic intracorporeal ileocolic anastomosis following resection of the right colon resulted in a favorable outcome in selected patients with Crohn's disease or tumors of the right colon.

Massive zosteriform cutaneous metastasis from rectal carcinoma

A 44-year-old man presented with a large and rapidly growing skin lesion approximately six months after resection of a rectal carcinoma. The lesion measured 40 cm in size, extended from the suprapubic area to the proximal half of the left groin, and showed a particular zosteriform aspect. Biopsy confirmed a metastatic skin adenocarcinoma. Cutaneous metastases from rectal cancer are very uncommon. Their gross appearance is not distinctive, although the skin tumors are usually solid, small (less than 5 cm) and painless nodules or papules. Early biopsies for suspicious skin lesions are needed in patients with a history of colorectal cancer.

Thyroid Transcription Factor � 1 (TTF-1) Immunoexpression in Thyroid Carcinoma with Follicular Origin

Differentiated thyroid carcinomas are heterogeneous diseases with clinical and morphological features insufficient to predict their clinical behavior. The expression of tissue-specific transcription factors that control differentiated phenotype can be an additional method in evaluating the aggressiveness of a tumor, when differentiation markers and malignant phenotype of tumor cells are inconclusive. The expression of thyroid transcription factor-1 (TTF-1) is limited to thyroid follicular cells; it is a nuclear protein expressed in the epithelial cells of the thyroid, lungs and diencephalon. Using the monoclonal mouse antibody, clone 8G7G3/1, we examined the immunohistochemical expression of TTF-1 protein in 26 thyroid carcinomas (22 papillary carcinomas � PTC, 2 follicular carcinomas � FTC, 2 anaplastic carcinomas - AC), 4 follicular adenomas � FA, 10 benign thyroid lesions as underlying diseases (multinodular goiter � 3, Hashimoto thyroiditis � 3, Graves Basedow disease - 4) and sections of normal thyroid tissue, assessing the possible correlations with clinical and morphological features, as well as patient outcomes.TTF-1 nuclear expression was identified in 75% of benign thyroid lesions and 18/26 (69.23%) carcinomas. We noted TTF-1 nuclear expression in 68.18% of PTC (10% being associated with recurrent disease) and the absence of immunoreaction in 31.82% of PTC without recurrent disease. In patients with PTC, the risk of recurrence was significantly associated with the presence of nuclear TTF-1 expression in the primary tumor (p[0.001), but was not influenced by the type of surgery performed (p]0.05) or patients� age. TTF-1 nuclear expression did not correlate with patients� gender, tumor size, extent of disease at the moment of diagnosis and multifocal tumors (p]0.05). TTF-1 nuclear reactivity can be elevated in differentiated thyroid tumors (PTC and FTC) with aggressive clinical behavior that will develop recurrent or persistent disease. In anaplastic thyroid carcinomas with fast growth rate, immunoreactivity for TTF-1 and Ki-67 can offer useful information for tumor cell differentiation, while in the case of a mixed thyroid tumor it helps in distinguishing between well differentiated and undifferentiated/anaplastic areas.

[Magnifying colonoscopy in the diagnosis of colorectal carcinoma invading the submucosa in familial adenomatous polyposis]

The development of colonoscopy with image magnification has enable to study the colonic mucosa in detail and to do differential diagnosis between neoplastic and non-neoplastic lesions from the observation of pit patterns. The results are comparable to stereomicroscopy being possible to predict the histologic diagnosis. In a patient with familial adenomatous polyposis magnifying colonoscopy was performed and this method demonstrated a wide variation of benign polypoid lesions and the morphological features of early colorectal cancer. In this patient, the evaluation by image magnification, together with indigo carmin 0.4% chromoscopy, showed a wide variety of lesions in the colon and rectum: laterally spreading tumor in the cecum, with IIIL + IV pits, subpediculate polyp in the transverse colon with approximately 2.0 cm diameter and IV + V pits, flat elevated lesions IIIL type, and in the sigmoid colon IIa + IIc lesion with V type of Kudo's classification were observed. The evaluation of pit patterns of the lesions in the transverse and sigmoid colon has enable to do the endoscopic diagnosis of the lesion with submucosal invasion.

[Resection of a laterally spreading tumor by strip biopsy]

A male white patient 58 years-old was submitted to colonoscopy for follow-up of surgical resection of an advanced colorectal carcinoma 33 months ago. Small polyps were observed in the colons and histopathological examination proved to be tubular adenomas with moderate dysplasia. At the hepatic flexure of the transverse colon a large flat-elevated laterally spreading tumor measuring 2.5 cm in diameter was observed. After spraying of methilene-blue 0.1% the margins of the lesion were demarcated and following saline injection under the lesion it was completely resected in one single procedure. Histologically, the lesion was diagnosed as intramucosal adenocarcinoma.