Prophylactic Percutaneous Endoscopic Gastrostomy (PEG) - The Importance of Nutritonal Support in Patients with Head and Neck Cancers (HNCs) or Neurogenic Dysphagia (ND)

BACKGROUND

We evaluated the effectiveness and safety of prophylactic PEG performed for the enteral nutrition support during the oncological treatment of patients with HNCs and as a part of the management of neurological patients experiencing neurogenic dysphagia.

METHODS

In 2013 we followed up on a group of 23 HNC patients subjected to prophylactic PEG. We assessed the duration of the procedure, intraprocedural incidents and their causes, time to tube-refeeding and discharge after intervention, post interventional analgesia, early and late complications,toleration, costs and postoperative course of these patients after radical surgery maintaining PEG in place. In parallel we followed up on a group of 10 neurological patients who have undergone a PEG placement to improve the nutrional status and to prevent recurrent chest infections due to ND related silent aspiration.

RESULTS

The procedures were performed under sedation with Midazolam and the mean duration was about 7 minutes.Postoperative analgesia was minimal. Refeeding through the tube was initiated 2-4h hours later and the patients were discharged 12-24h after the procedure. Early complications were not observed and later we noted 2 cases of peristomal infections, succesfully managed conservatively. After oncologic surgery we noted 2 (8.69%) pharyngocutaneous fistulas.Conservative care obliterated the fistulas at 6 weeks, maintaining the feeding tube in place. We also compared the results with a group of 27 patients fed through the naso-gastric tube and a group of 20 cases with open gastrotomy-tube prophylactically inserted. The 10 neurological patients had varied conditions but degenerative diseases like motor neuron disease (3 cases" 30%) and multiple sclerosis (2 cases -20%) took the lead we encountered one case of peristomal infection and one case of tube blockage resolved by replacement. We evaluated the nutritional status by controling the weight of these patients before and after PEG placement. A mean weight gain of 3.1 kg(range 1.2 â€" 7) was documented.

CONCLUSIONS

PEG is a simple minimmaly invasive procedure performed safely under sedation. It takes a very short time and is virtually free of major complications. The requirements of analgesics are minimal. The refeeding is started early and the tube is well tolerated by the patient. PEG has an important role in the conservative healing of pharyngocutaneous fistula.PEG is the procedure of choice for the neurological patients.It prevents weight loss and aspiration pneumonia in patients with neurogenic dysphagia with a low rate of complications.

Localisation and preservation of the autonomic nerves in rectal cancer surgery - technical details

Iatrogenic surgical injury to pelvic autonomic nerves followed by genitourinary dysfunctions are well known problems after total partial mesorectal excision for rectal cancer. The purpose of our paper is to present the useful anatomical landmarks for a safe nerve-sparing surgery in rectal oncology. Over the course of a total mesorectal excision we describe and illustrate the key risk zones of autonomic nerve injury based on our experience in rectal surgery and on the revised literature.

Temporary protective loop ileostomy in open low rectal resection -- an alternative technique

The paper presents a simplified method for performing a temporary protective loop ileostomy as a result of our experience in 33 cases of low rectal resections for cancer.The particularities of this technique are: the skin incision is smaller than the muscle one, the seromuscular layer of the loop is fixed at the skin level only by marking a small portion of the antimesenteric wall, with no mucosal eversion. No supporting rod is used. The reversal requires resection of the thickened freemargins and enterorrhaphy. It involves a direct approach and avoids median laparotomy and segmental bowel resection.There was no case of peristomal abscess, bleeding, prolapse,retraction of the loop after the stoma was formed. Four patients(12.12%) had peristomal dermatitis. Five patients (15.62%) had high output fluid losses with electrolyte disorders, one of them(3.12%) with acute renal failure. Closure was performed after 6 weeks on average for the colorectal anastomoses and 10 weeks for the coloanal ones. We recorded a case (3.12%) of enterocutaneous fistula that was managed conservatively and 4 cases(12.12%) of incisional hernia, all of them surgically treated. No mortality was attributed to either creation or closure of the temporary loop ileostomy. It is a simple and fast technique in accordance with the temporary character of its indication.

Laparoscopic treatment of a hepatic subcapsular abscess secondary to gallbladder perforation: case report

We present a rare case of type II Niemeier gallbladder perforation(GBP) developed as a complication of acute calculous cholecystitis. A 76-year-old man was admitted to our surgical unit with the presumptive diagnosis of acute cholecystitis. CT scan revealed a subcapsular collection developed on the visceral surface of the right hepatic lobe. It was communicating through a thin hypodense band with the cystic duct, distal to an impacted stone. Through laparoscopy the collection was confirmed to be a subcapsular liver abscess secondary to GBP.The cholecystectomy and the abscess cavity treatment were completely handled via laparoscopic approach. The paper demonstrates that laparoscopic approach can be a safe and feasible method in order to treat both the cause and the complication in this situation. Early diagnosis and appropriate minimally invasive approach are the key to manage this rarity.

Analysis of several BRCA1 and BRCA2 mutations in a hospital-based series of unselected breast cancer cases

BACKGROUND

The distribution of BRCA mutations varies significantly between populations. The spectrum of BRCA1 and BRCA2 mutations in breast cancers in the Romanian population is incompletely known. The aim of the present study is to investigate the presence of nine BRCA mutations in patients with breast cancer identified in a surgical clinic from Bucharest.

METHODS

Unrelated women diagnosed with breast cancer from Coltea Hospital (n=114) and healthy controls (n = 150) were selected for this study. Seven mutations in BRCA1 (185delAG, 5382insC, 943ins10, E1250X, 1294del40, E1373X, R1443X) and two in BRCA2 (IVS16-2A4G and 6174delT) were tested using PCR based protocols. In addition, the presence of BRCA1 185delAG, BRCA1 5382insC, BRCA2 6174delT mutations were tested with a post amplification mutation detection system, based on the ELISA method.

RESULTS

Two patients with sporadic breast cancer (2%) and one patient with family history of the disease (7.14%) have the BRCA1 5382insC mutation. No other mutation was detected in patient and control groups. The mutations were not present in the control lot.

CONCLUSIONS

Our results indicate that BRCA1 5382insC is a common mutation in Romanian women with breast cancer (3 114).

Conservative surgery for borderline ovarian tumors--emphasis on fertility preservation. A review

BACKGROUND

Borderline ovarian tumors account for 15-20% of all ovarian epithelial tumors. Since their original description in 1929, our knowledge of their natural history and molecular pathology has advanced most dramatically over the last two decades. This improved knowledge of BOT has permitted to drastically decrease the therapeutics of these tumors, which remains mostly surgical.

METHOD

We studied the available literature on surgical management of BOT accentuating the most important aspects on this topic: radical vs. conservative treatment, fertility preservation.

RESULTS

Although there are conflicting reports about some of the aspects of surgical management of these tumors, since BOTs commonly affect women of reproductive age, who have not completed childbearing, have an excellent overall prognosis and the majority of them (approximately 50% to 85%) are stage I at diagnosis, conservative surgery (unilateral salpingo-oophorectomy or cystectomy) can be safely performed after comprehensive surgical staging, in order to preserve fertility.

CONCLUSION

Conservative surgery could be safely performed in young patients treated for BOT, provided that they are carefully followed-up.

[Synchronous gastrointestinal stromal tumor (GIST) and multiple digestive neoplasms, benign and malignant]

Gastrointestinal stromal tumors (GIST) are a broad category of mesenchymal, non-epithelial primary tumors of the digestive tract, located in the wall of hollow viscera, from the esophagus to the anus and often in adjacent mesentery and omentum. They are clinically unpredictable (may be discovered incidentally during an imagistic investigation or during surgery for other pathological entity, or at necropsy) and also have an unpredictable behavior (GISTs with very low risk, with low or moderate malignancy, which have benign histopathologic features but can recurr or can metastasize). The case we present here represents a rare association between a synchronous gastrointestinal stromal tumor (GIST) and multiple gastric benign and malignant tumors.

[Adenoid cystic carcinoma of the breast--two case reports]

Adenoid cystic carcinoma is a rare type of breast carcinoma with a good prognosis. It represents less than 0,1% of breast carcinomas. We present two cases of adenoid cystic carcinoma diagnosed in the Surgical Department of Coltea Hospital in the last 3 years. The first case is a 66 years old patient with a breast tumor that has clinical and imagistic features compatible with a benign diagnosis. The frozen sections established the diagnosis of adenoid cystic carcinoma, confirmed by histopathologic examination of paraffin embedded tissue and immunohistochemistry. The second case is a 68 years old patient with a breast tumor located in the central quadrant of the left breast, with skin infiltration. Preoperatory fine needle aspiration is sugestive of a papillary tumor, so the cytologic exam cannot establish malignancy. The frozen sections established the diagnosis of ductal invasive carcinoma and histopathologic examination of paraffin embedded tissue and immunohistochemistry established the diagnosis of adenoid cystic carcinoma associated with ductal invasive carcinoma grade I and adenomyoepitelioma. The cytology had a false papillary aspect, in fact there was amorphous material contained in pseudoluminal spaces. In both cases the treatment was surgical resection with tumor excision and free resection margins. In the second case lymphadenectomy was also performed.

MTRR polymorphism and the risk for colorectal and breast cancer in Romanian patients--a preliminary study

BACKGROUND

The risk of colorectal cancer (CRC) and breast cancer (BC) is influenced by polymorphisms located in the genes encoding enzymes of the folate pathway. The aim of this study was to evaluate if A66G MTRR (rs1801394) polymorphism is involved in predisposition for colorectal and breast carcinogenesis in Romanian patients.

MATERIALS AND METHODS

In the present case-control study, 300 individuals divide in four groups: sporadic CRC patients (n = 120), control CRC (n = 60), BC patients (n = 60) and control BC (n = 60), were genotyped by PCR-RFLP method.

RESULTS

Frequency of genotype AA was 11.7% in CRC control and 5% respectively in BC control. For cancer groups the frequency of genotype AA was 9.2% in CRC and 0% in BC.

CONCLUSIONS

Study results do not demonstrate an association between A66G MTRR polymorphism and CRC or BC in Romanian patients.

[Umbilical hernia in adults: laparoscopic approach with prolene mesh--is it a safe procedure?]

INTRODUCTION

The laparoscopic approach for umbilical hernia is more and more used, but few results are reported. The aim is to evaluate the efficacy and safety of using the Prolene mesh placed laparoscopically in umbilical hernia treatment.

MATERIAL AND METHOD

Between 2004-2006, 21 patients with umbilical hernia, aged of 34 to 77 years, were submitted to intraperitoneal application of a Prolene mesh to cover the umbilical ring. The mesh was sewed by Protack staples or transfascial stitches. Before deflating the patients, the greater omentum was interposed between the mesh and the bowel. It is notice that 8 patients were obese, 6 patients had omental or bowel adhesions to the peritoneal sac and 5 patients had ascites due to liver cirrhosis. The patients were discharged 24 to 48 hours after the operation and followed up for 6 to 12 months.

RESULTS

All patients were alive at the end of follow-up, without hernia recurrence or complications due to the Prolene mesh in the abdominal cavity. In 3 patients we registered subcutaneous seromas for 1 to 3 weeks (imposing evacuation by punction) and 5 patients kept a mildly deformed umbilical scar after the cure of large hernias.

DISCUSSIONS

In the literature are mentioned the techniques using composite or two-layers meshes. Prolene meshes are not agreed by some authors, for the supposed risk of bowel lesions. In our trial were no such complications.

CONCLUSION

Laparoscopic repair using Prolene intraperitoneal mesh in umbilical hernia is a safe, efficient and rapid method, avoiding infections complications in obese or cirrhotic patients.

[The sentinel lymph node technique in colorectal cancer using in vivo dye--utility and limits]

The aim of this work is to analyze the importance of sentinel lymph node technique in the treatment of colorectal cancer. There are presented data from literature concerning sentinel lymph node, especially papers about the place of sentinel lymph node method in the treatment of colorectal cancer. This work also shows the experience of Surgical Clinical Department of Coltea Hospital in the use of sentinel lymph node method in colorectal cancer (8 patients with colon cancer and 9 with rectal cancer). There are presented the criteria for inclusion in the study group (26 patients initially proposed for the study) and the exclusion criteria, the diagnostic method using an in vivo dye and the pathology study. The study of the literature and our experience leads to the conclusion that the identification of the sentinel lymph node in colorectal cancer doesn't modify the dissection of the lymphatic area. This procedure may change the adjuvant treatment for colorectal cancer. The discussion is still open concerning the importance of lymphatic micro metastases found by RT-PCR and immunohistochemistry methods. More studies are necessary to clarify these problems.

[Learning curve and his consequences in laparoscopic antireflux surgery]

The laparoscopic fundoplication became the gold standard of the laparoscopic antireflux surgery (LARS). Our aim is to indicate the evolution of the learning curve as well as its consequences on the patient's outcome. We studied the gastro-esophageal reflux (GER) cases treated laparoscopically in Colţea University Hospital throughout 6 years. We gathered a group of 40 patients with an average age of 54, 57 years and a sex ratio F:M = 1.67. The patients had either a simple GER disease, small and medium hiatal hernias (21 cases) or giant hiatal hernias (GHH--19 cases). Two equal groups resulted: group 1 consisted of the first 20 patients operated from 1999 to 2002, group 2 consisted of the rest of the patients. Operating time, hospital time, complication rate and postoperatory endoscopy were compared. The average of the operating time was calculated. For giant hiatal hernias, a separate average was also taken into account. The total operating time for GER, small and medium hiatal hernias was 115 min in group 1 and 80 min in group 2 meanwhile for GHH it was 143 min vs. 130 min. The average operatory time was 129 min vs. 105 min. All these differences were statistically significant but there were no differences concerning complication rate and post-operatory endoscopy. Although the learning of the laparoscopic fundoplication requires practice, the learning curve does not have influence on the patients' outcome.

[Stromal tumor of Meckel's diverticulum--a rare source of gastrointestinal bleeding and a real diagnostic problem]

Although Meckel's diverticulum is the most common congenital abnormality of the gastrointestinal tract, complications in adults are rare, especially in the elderly. Lower gastrointestinal bleeding as a result of Meckel's diverticulum with ectopic gastric mucosa is unusual among the elderly. The case we report involved a 69 year old man with gastrointestinal hemorrhage found to be due a stromal tumor developed on Meckel's diverticulum. We considered our case interesting because of its rarity and of preoperative diagnosis difficulty.

[The complications of colostomies]

The evaluation of the frequency of complications that arise after colostomies performed for colorectal and genital neoplasm, and also the treatment possibilities for these complications. In Colţea Hospital, Surgical Department during 1984-2002 there have been admitted and surgically treated 891 patients with colorectal cancers, among which, 484 had rectosigmoidal neoplasm. We have treated 25 patients with complicated genital neoplasm (19 rectovaginal and recto-bladder-vaginal fistulas following cervical cancers, 5 pelvic tumoral blocks following ovarian cancers and a vulvar cancer with local invasion). For all these patients we performed: 25 Hartmann resections, 75 Reybard resections, 73 Dixon resections and 147 rectal amputations, with 294 colostomies (30 iliac anus in continuity-Audrey, 18 on a stick, 232 terminal and 14 cecostomies for protection or decompression). There were 48 complications following the colostomies: 10 cases of stenosis, 14 prolapses, 7 intestinal loop necroses and 17 parastomal hernias, all of them surgically managed. Terminal colostomies and colostomies for protection are still frequently used in surgical departments, having strict indications. Because they are frequently performed as emergencies, at patients with poor biological status they are often enough followed by complications, most of them with little gravity. The complications can be avoided by a proper therapeutic choice and in most cases can be managed with a surgical intervention.

[The rectal cancer--between resection and amputation. Surgeon's decalogue]

The surgeon has the opportunity to use a lot of treatment choices taking into account the site, the progression and the aggressiveness of the rectal tumors. If the treatment of anal cancer have been the same over the last years there are a few problems regarding the rectal cancer, especially for the one, which is distal and locally advanced. The therapeutic choice must take into account the following factors: the site of the tumor, the circumferential invasion, the local and distant spread, the complications and loco-regional recurrences, the anatomical shape of the pelvis, the possibility of developing tumor implants on the residual rectum, the equipment of the hospital, the experience of the surgical team, the accuracy of stoma technique, and the previous results in patients survival. In a trial of 381 patients with recto-sigmoidian and anal cancers we performed 171 rectal amputations, 29 Hartmann procedures and 76 laparotomies and colostomies. From the 276 patients with colostomy 172 (62.31%) were followed. The survival rate was: 6-10 months for the patients with laparotomy and colostomy, 16-24 months for those with palliative procedures (55.8%) and 5-17 years for those with radical procedures. From the point of view of the authors the rectal amputation with colostomy it is an alternative between oncological safety and patients comfort. This kind of surgical procedure must be done in specialized centers excepting the emergencies.

[The place of conservative surgery in the complex oncologic treatment of breast cancer]

For a long time, breast-conserving surgery has been a subject of great interest and debate. Many researchers have tried to find strict criteria in selecting the patients who can benefit from such a treatment but this remains a goal to achieve in the future. In our surgical department, from 1984 to 2000, 1152 patients were diagnosed with breast cancer. 741 patients (64.1%) had advanced breast cancer and 411 patients (35.6%) were diagnosed in I and II stages. From the patients with early breast cancer only 57 (14.1%) had benefited of conservative surgery combined with adjuvant radiotherapy and chemotherapy. All patients received hormonotherapy. The surgical treatment consisted in a broad sectorectomy and axillary lymphadenectomy in all cases. We present the criteria for selecting patients in our study. The patients were followed for 2-5 years, with a mean period of 48 months and there were no significant differences between the trial with mamectomy and that with conservative surgery. There is presented a brief review of the literature in this field. Our conclusion is that the conservative surgery for breast cancer is a good method, which can be applied for selected patients and with a good follow-up.

[The therapeutical strategy for locally advanced breast cancer]

As for the other cancers, the strategy of therapy of breast cancers is going to a unitary standardization. In our department between 1984-1999 we are operated 1040 patients with breast cancers, which means 25.3% of all cancers treated. 688 (64.3%) were CMLA, 646 (96.7%) of them were in patients women and 22 (3.3%) men. The mean age was 52.4 years (3-84 years). All patients were divided into two trials and analyzed: retrospectively (A) 312 (46.7%) and prospectively (B) 356 (53.3%) patients, 51.2% of patients was in III and IV TNM stage. The patients from trial B were treated concerning with specific therapeutically protocol, adapted by age, anatomopathological form, volume of tumor, skin or thoracic wall invasion, inflammatory lesions, lymph node invasion and physiological period. The results were: the increase of number of radical surgical interventions, the decrease of the morbidity, the increase of survival and a better quality of life.

[The capacity of preoperative ultrasonography in predicting technical challenges in laparoscopic cholecystectomy]

Ultrasonography is a nonsophisticated, cheap and safe exploration, that makes it the most used non-invasive method in the diagnosis of biliary diseases. Present study aims to evaluate preoperative ultrasonography's capacity of predicting technical challanges in laparoscopic cholecystectomy (LC).

MATERIAL AND METHOD

The trial is represented by a sequence of 100 patients undergoing LC in 2001. The conversions to open procedure were excluded. Patients with certified lithaisis were re-examined by ultrasonography the day before surgery. The sonographic features as size, volume (scleroatrophic gallbladder), function (distension, contraction), wall thickness, hydrops, number and size of stones, infundibular position (impactation) of the stones, perivesicular liquid collections hepatic and pancreatic aspects, main bile duct caliber were registered. During LC, the difficulty in performing the procedure was measured using a 10 points-score of following parameters: 1 peritoneal and perivesicular adhesions; 2. Difficult grasping of the gallbladder; 3. Cystic duct's dissection; 4. Cystic artery; 5. Liver bed; 6. Difficult cystic stappling; 7. Gallbladder's wall efraction; 8. Need for intraoperative cholangiography; 9. operative bleeding; 10. Operative time.

RESULTS

Gallbladder's and the number, the size and infundibular impactation of the stones was significantly associated to ultraoperative difficulties (p < 0.05), the other parameters having not a sensitive influence upon LC procedure.

CONCLUSION

Preoperative ultrasonography is able to furnish valuable data in predicting LC challenges.

[Analysis of 3100 laparoscopic cholecystectomies]

AIM

To evaluate the results of laparoscopic cholecystectomy (LC) in the 8 years period.

PATIENTS AND METHODS

First LC in Coltea Hospital was performed in September 1993 and introduced for treatment of patients with gallbladder disease. From September 1993 to February 2001 LC was performed in 3100 patients. Mean age 51.2 years (ranged from 8 to 87 years) among 2512 women and 588 men. 232 (7.48%) of the cases were patients with acute cholecystitis. Intraoperative cholangiography was performed in 112 cases (3.6%).

RESULTS

Conversion to open cholecystectomy (OC) was necessary in 111 patients (3.58%). Operative complications occurred in 16 (0.5%) patients: CBD lesions in 4 (0.12%) patients, bleeding from cystic artery--12 (0.38%) patients. In one patient CBD injuries was recognized at the time of operation and after conversion to OC primary ductal repair was performed. Postoperative complications occurred in 44 (1.41%) patients: a) local infection--in 15 (0.48%) patients (subhepatic abcess-3, wound infection-9. b) bile leakage--in 21 (0.67%) patients. c) haemoperitoneum because of the bleeding: from the abdominal wall at the trocar insertion site--in 2 patients, from a. cystica-one patient. d) obstructive jaundice due to stone in CBD--in 5 patients (endoscopic papillosphincterotomy and stone extraction was performed). There 21 reoperations due to complications: 13 laparatomies and 8 relaparascopies. Two patients (52 and 64 years old) died after LC-mortality 0.06 per cent. Mean hospitalisation day was 3.8.

CONCLUSIONS

To prevent iatrogenic CBD injuries correct preparation with a clear identification of the anatomic structures is essential. Relaparascopy and endoscopic retrograde cholangyopancreatography can be successfully used in the treatment of complications after LC.

[Merkel cell carcinoma]

Merkel Cell Carcinoma (MCC) is a rare and aggressive neuroendocrine dermal neoplasm. This study is a retrospective outcomes analysis of two cases of MCC with data regarding clinical, histopathological, immunohistochemistry and also surgical, chimio and radiological treatment. MCC is a rare dermal tumors, this tumors are most predictable found on sunexposed sites. Diagnosis is best accomplished by a thorough clinical evaluation coupled with light microscopy and defined panel of immunohistochemical studies which are necessary for the definitive diagnosis of Merkel cell carcinoma (cytokeratins, neuron specific enoiase and chromogranin). A lot of other disease must be included in the differential diagnosis. MCC is an aggressive tumor with local or locoregionale extension and distant spread by hematogen or lymphatic way. Surgical excision of tumor and regional lymphadenectomy is the first step of treatment completed with radiotherapy and chemotherapy bat in advanced studies the rate of local or distant recidives is high.

[Strategy and tactic in the treatment of local advanced rectal cancer]

In local advanced rectal cancer (LARC) was defined at the work group in rectal cancer as a tumour what invade the serosa or neighbouring organs, associated with invaded perirectal or mezorectal nodes, with internal fistulae, peritoneal carcinomatosis and locoregional recidives. On a trial of 97 patients, the authors present personal experience, in comparison with literature data regarding therapeutic strategy and tactic of parameters: operability and the moment of operation, indication of preoperative radiotherapy, the type of operation, excision of the metastasis, adjuvant therapy and attitude of locoregional recidives. The survival of the patients was 21.6% at 3 years and 15.4% at 5 years.

[Incidents, accidents and complications in laparoscopic surgery]

Between 1995-1999 in Colţea Surgical Clinic were performed 2498 laparoscopic operations (1957 cholecystectomies, 541 other procedures). The laparoscopic approach consisted in 1 to 6 ports of 5 to 12 mm. Conversional rate was, 176% and reintervention was required in 0.76% of cases. In 4 cases (0.10%) parietal bleeding imposed conversion or early reintervention. Parietal emphysema was not significant in our trial. Wound infection or chondritis occurred in 0.72% of cases; only one patient had to be reoperated. Post-incisional hernia developed in 0.08% of patients. We don't treat patients with cancer by laparoscopic approach, but the 4 patients with unknown neoplasia in our trial didn't develop port metastases. Our trial suggests the real benefit of the laparoscopic approach also concerning parietal morbidity.

[ Epidemiological and clinical-therapeutical considerations on 500 operated cases of uterine cervix cancer]

AIM

Optimization of the treatment on uterine-cervix neoplasia, in a general surgery department.

MATERIAL AND METHOD

Between 1984-1999, in Colţea Surgical Department were operated 746 uterine-cervix cancers. We selected two trials of 250 females, similarly regarding age and stadium. The A trial (250 females) were treated and operated 1984-1989, the study being retrospectively, and the B trial (250 females) treated and operated between 1990-1995, the study being prospectively by introduction of cisplatyn and carboplatyne chemotherapy in the advanced steadies. In the B trial, on registrated many mutations with negative epidemiological implications as: the grow the number of new cases, the diminution of immunity, the abandon of the screening, a possible grow of irradiations (Cernobâl accident), and the belated of presentation to medical consultation.

RESULTS

The complex treatment, comparative in two trials, show a grow of lifetime, at 5 years in B trial from 82.1-93.4% in the 1st and 2nd steadies, 50.7-60.4% in the II B study and 12.9-28.5% in the III study. In the IV study the grow of lifetime was under 24 month.

CONCLUSIONS

The resumption of the screening. Complexes therapeutical protocols for each study. Widely introduction of polichemotherapy in the advanced steadies.

[Technical solving variants of external biliary and pancreatic fistulas]

Two cutaneous postoperative fistulas--pancreatic and biliary--was solved by an anastomosis of maturate fistulas traject with duodenum and respectively an Y jejuno loop (Roux) with good results.

[The surgical possibilities in locally advanced gastric cancer (LAGC)]

Most frequently the diagnostic of gastric cancer is established in advanced stages. Practically, was noticed that local evolution advances the appearance of metastases. The authors are presenting 159 cases of locally advanced gastric cancer (LAGC) out of 211 gastric cancers submitted to surgery between 1984-1995. The surgical possibilities in such situation specifically adapted to each case, are discussed. The operation has an important role in appreciating local and regional extension, solving complications and even performing radical resections.

[Laparoscopic cholecystectomy in acute cholecystitis]

AIM

Results evaluation of laparoscopic cholecystectomy in acute cholecystitis.

MATERIAL AND METHOD

Between 1994-1997 we performed 65 laparoscopic cholecystectomies for histopathologically proved acute lithiasic cholecystitis. We studied clinic and echographic diagnosis, operative moment, conversion rate, operative time, postoperative morbidity and hospitalization. The cholecystectomy was performed within 72 hours in 18 patients (trial I), 4 to 7 days in 25 patients (trial II) and over 7 days in 22 patients (trial III).

RESULTS

Diagnosis of acute lithiasic cholecystitis was always possible by clinical examination and ultrasonography. We performed 8 conversions in patients of trial II (2) and III (6). The mean operative time was 68 min. Postoperative morbidity consisted in 4 bile leakages in the liver bed, 1 subhepatic abscess, 5 right pleural effusions. The mean hospitalization was 4.4 days.

CONCLUSIONS

Urgent laparoscopic cholecystectomy is a beneficial act for acute lithiasic cholecystitis. The operative moment is the most important factor of influence on conversion rate, operative time and postoperative morbidity.

[The classical or laparoscopic operation in inguinal hernias]

AIM

Results evaluation in two trials of patients undergoing classical or laparoscopic surgery for inguinal hernia.

MATERIAL AND METHOD

We compared 2 homogeneous trials of 80 patients with inguinal hernias treated by classic procedures: Bassini, Shouldice, Lichtenstein (trial I) or by laparoscopic approach with Plastex, Mercilene or Prolene prosthesis (trial II) between 1995-1997.

RESULTS

Postoperative morbidity consisted in trial I in 5 seromas, 2 hematomas, 4 cases with neuralgic pain, 1 with testicular hypotrophy and 4 recurrences. In this trial the mean operative time was 22 min. and the mean hospitalization was 7 days. In trial II we registered a parietal bleeding at a lateral port imposing the conversion, 3 serohematomas, 2 recurrences by displacement of the prosthesis and 2 cases of neurologic pain. The mean operative time was 50 minutes and the mean hospitalization was 3 days.

CONCLUSION

In spite of the longer operative time and the higher cost (the price of the prosthesis), in trial II the benefits of shorter hospitalization, lower morbidity and rapid socioprofessional reintegration are significant.

[The place of laparoscopy in assessing and treating a pain syndrome of the right iliac fossa]

The study is considering a trial of 87 patients (61 women 17 and 76 years old) admitted in our clinic between 1995-1996. The preoperative diagnosis was coincident with the laparoscopic one in 10 cases the laparoscopic one in 10 cases the laparoscopy completed the diagnosis and in 12 cases it showed out other organ's disease, evicting useless operations. In the 87 patients we performed: 53 appendectomies, 20 oophorectomies, 15 partial oophorectomies, 9 right adnexectomies, 2 adhesiolysis, 2 lymph node biopsies, 1 epiploic fringe excision for necrosis, 1 appendicular stump removal. The evolution was favourable in all patients, the mean postoperative hospitalization was 48 hours.

[The place of surgery in the treatment of locally advanced rectal cancer]

We considered as local advanced rectal cancer (LARC) tumours invading the serosa or adherent to neighbouring organs, tumoral fistulas, histopathologically proved invasion of regional lymph nodes, peritoneal carcinomatosis with or without neoplastic ascites. Out of 146 rectal cancers submitted to surgery between 1984-1996, 47 had LARC (19 man and 28 women aged of 19 to 88 years) developed in the inferior 2/3 of rectum. We performed in these cases 11 Miles operations, 12 posterior pelvectomies, 3 Dixon resections, 16 colostomies and 5 exploratory laparotomies. To these were associated 4 partial cystectomies, 4 anexectomies, 4 partial enterectomies and 2 excisions of hepatic metastasis. In 27 patients adjuvant or neoadjuvant therapy was associated. We registered 3 deaths, 6 parietal infections and 1 stercoral fistula. Postoperative survival was 3-6 months for 12 patients, 6-12 months for 13 patients, 1-2 years for 6 patients. After the complex treatment 6 patients were alive at 5 years. Surgery is the essential therapeutic act of LARC. Chemo/radiotherapy association increases the survival, but not significantly.

[Immediate and early reinterventions in the surgery of colorectal cancer]

Out of 584 cases submitted to colorectal surgery 461 (78.92%) were performed for cancer. Thirty-three patients (7.16%) necessitated immediate (1) or precocious reinterventions for bleeding, fistulae, peritoneal infections, bowel occlusion, necrosis or stenosis of the iliac anus. We are out the technical procedures chosen for each class of complications asking for reintervention. We registered 4 deaths, in aged patients with hard associated morbidity, with emergency reinterventions. We appreciate that a correct preoperative preparation reduces the rate of reintervention and an early reintervention reduces the post-operative mortality.

[Clinical study of the efficacy of albendazole treatment in human hydatidosis]

A follow-up study of Albendazol effectiveness therapy in human hydatid diseases was carry out using WHO methodology. Albendazole was given at a dose of 10 mg/Kg body/day in cycles of 28 days separated by 14 days without treatment. The efficacy of chemotherapy was evaluated by clinical improvement and changes in the cyst's morphology (detachment and collapse of the cyst membrane and increased density of the cyst fluid). We performed this study in 134 patients with hydatidosis: 17 patients with pre and post surgery treatment, 50 patients with post surgery treatment and 67 patients with chemotherapy only. Albendazole was effective in the hydatid disease; the patients with complex chemotherapy treatment did not report any secondary hydatidosis during the follow-up period (max. 2 years); the patients with exclusive chemotherapy reported 79% successful response, only 21% of them remained with unchanged cyst's size, but with modified internal structure. The therapeutic response depends of the cyst's size and its visceral site.

[The repair of voluminous postoperative abdominal wall defects with synthetic mesh]

Important postoperative abdominal wall defects, especially recurrent or multirecidivated ones, are raising multiple problems to the surgeon. We are presenting a homogeneous trial of 209 patients with such lesions, in which the abdominal wall repair was made with different kind of synthetic materials, with good results. In a single case the mesh was rejected, because a silent quiescent infection. In three patients undergoing iterative abdominal operations for other diseases we performed optical and electronic microscopical studies showing out that the material integration was done by normal biological reaction. This provides the materials' tolerability and a normal reaction of the organism.

[The role of clivarin in the preventive therapy of thromboembolism]

Our paper represents a synopsis of the main mechanisms by which low-molecular-weight heparins act as pharmacodynamic stabilizing factors of the liquid coagulation balance, in the postoperative period. Today we note three main phases in the coagulation mechanism: 1. partial thrombin activation; 2. positive thrombin-mediated feedback; 3. explosive thrombin formation. Low-molecular-weight heparins (Clivarine-mean molecular weight = 3900 D) act as selective inhibitors an factor X a (anti-thrombotic action), and as weak inhibitors on factor II a. The authors' experience includes 321 patients, who received Clivarin as preventive therapy for thromboembolic disease. Most of the selected patients are included in groups 2 and 3 for thromboembolic risk--and have undergone general surgery and oncological surgery. The dosage and duration of the treatment have been the usual ones. The main clinical observations we noted are: 1. excellent tolerability of Clivarine; 2. no modifications of usual biological values; 3. no adverse reactions were noted. There were no deleterious interferences between Clivarine and the usual postoperative medication of the surgical patient, 4. among the incidents, we note 12 postinjection haematomas, which were spontaneously cured.

CONCLUSIONS

Low-molecular-weight heparins are considered today drugs of election in the medical and surgical thrombosis prophylaxis.

[A comparative study of the laparoscopic and classic treatments of inguinal hernias]

AIM

of this study is to compare two similar groups presenting inguinal herniae, one group having laparoscopic herniography and the other having a Bassini or Fruchaud repair.

METHOD

Since September 1994, in our department, patients presenting with symptoms of unilateral or bilateral inguinal herniae to our practice were offered the transperitoneal or preperitoneal approach as an alternative of open surgical repair. We considered the first 50 patients operated by laparoscopic technic (35 M and 15 F), age between 22-72 years (group A), and similar group operated by Bassini or Fruchaud technic (group B). All the patients had general anesthesia and perioperative antibiotics. In the group A we used Prolene, Mercilene or Plastex mesh. The following parameters were assessed: 1) operative time from incision to closure: 2) amount and type of analgesia required postoperatively; 3) morbidity related to the procedure; 4) interval before returning to full activity; 5) early recurrence rate; 6) hospital cost.

RESULTS

The mean operative time for unilateral herniae in group A was 70 +/- 10 minutes versus 40 +/- 12 minutes in group B. Group A required to return to work was significantly shorter for the patients in group A (7 +/- 3 days) compared with group B patients (25 +/- 10 days). Although no recurrent herniae have yet been found in patients from either group; follow-up was only 2-18 months in the two groups. The cost of hospital care of group A patients exceeded that of group B by approximately 1.7 more.

IN CONCLUSION

was consider that although is more expensive, the laparoscopic procedure in treatment of inguinal herniae, has more benefits for the patients.

[Laparoscopic appendectomy in obese patients. A comparative study with open appendectomy]

The aim of this study is to show the advantages of laparoscopic versus classic appendectomy in obese patients. The trial includes 32 obese patients which underwent laparoscopic surgery for appendicitis in our clinic, compared to a similar trial of patients with open surgery. In both o trials we followed-up the operating time, postoperative pain, hospitalization and social and professional reintegration. We noticed that in laparoscopic appendicectomy patients postoperative pain and hospitalization are reduced, the bowel transit restants rapidly and spontaneously, there are no wound complications and patients recover faster. The disadvantages consisted in longer operative time and higher cost of the laparoscopic operation versus classic appendectomy.

[The need for and efficacy of biliary diversions in icterogenic cancers of the pancreatic head]

The authors present the experience of the clinic on a group of 26 patients admitted and operated in the Clinic of Surgery, the Colţea Hospital, during 1984-1987. The paper reports, in general, on the indications for biliary derivations and then specifies the morphopathological situations met intrasurgically. Their correlation with the indices of postsurgical morbidity (12.5%), postsurgical mortality (0.8%) and length of postsurgical survival (8.2 months) shows their efficiency.

[Intra-anesthetic hypothermia]

Oesophageal temperature was recorded after induction of anesthesia, and further, at one, two and three hours. Temperature in the operation hall was continuously monitored. In relation to the temperature in the operating hall the effects on the patient were of three kinds: 1. operating halls with low temperatures (under 21 degrees C) where all the patients become hypothermic; 2. operating halls with an intermediate temperature (21-24 degrees C), where 67% of the patients remain normothermic; 3. operating halls with high temperatures (above 24 degrees C) where all the patients remain normothermic, although these temperatures are uncomfortable for the medical personnel, and increase the septic risk of the patient. When the oesophageal temperature of the patients falls by 0.5 degrees C chills will occur in 40% of the patients. Thermal falls of less than 0.5 degrees C will also determine chills but in only 10.5% of the cases. Immediate postanesthesia chills are also recorded in normothermic patients, but there is a direct relationship between the temperature in the operating hall, the degree of hypothermia and the frequency of chills, while the site of the surgery or the duration of the operation have but an unsignificant influence on intra-anesthetic temperature.

[Criteria of the indications for surgery in chronic noncalculous cholecystopathies]

The authors present their personal experience on the basis of a retrospective analysis of 127 cases of nonlithiasic cholecystopathies operated between 1984 and 1987. Clinical and radiologic criteria were analyzed, that have led to surgery, and conclusions reflect the postoperative results.

[Primary exertion thrombophlebitis of the upper extremities: clinical and therapeutic aspects]

The authors present 4 cases of "effort" thrombophlebitis of the upper limb that were diagnosed both clinically and thrombophlebographically, and in whom classical therapy was applied: total rest, anticoagulants, elevation of the limb. All the cases had sequels of variable intensity, and in 2 of the patients Roos' transaxillary route was used which revealed a double anterior scalenus muscle insertion, and compressive fibro-sclerous tissue. The pathogeny of the affection makes mandatory the removal of extrinsic or intrinsic factors which may generate a new thrombosis or vascular and neurologic sequels.

[Perforated and hemorrhagic duodenal ulcer: the problems of the surgical procedure and technic]

The authors analyze five cases of concomitant development of two major complications of duodenal ulcers: perforation and haemorrhage. Particular problems of surgical tactic and technique are discussed.