Revista de Cirugía

Human history is usually confused with conflagrations history. Since ancient times, wars have led to deaths and injuries, and this has been considered as a normal situation. What has evolved over time was the value of the human life for the army and society in general. Aid to the injured has evolved from comradely aid to the formation of specialized structures, in good part due to the increased 'value' of the soldier, through the investment in his preparation. Only recently, a soldier is regarded as a being with intrinsic value for society, military and family, who is performing a social service, and to whom society owes to protect and do everything it can to save his life or to mitigate the effects of his injuries.

Introduction

Gastroesophageal reflux disease (GERD) is a major public health problem. The "gold standard" in the surgical treatment of this condition is the laparoscopic technique called Nissen fundoplication.

Aim

This paper presents a safer alternative of the laparoscopic Nissen fundoplication, with special focus on the most difficult moment of the intervention, the creation of a retroesophageal passage.

Material and method (presentation of the surgical technique)

The conventional Nissen technique consists of the dissection of the esogastric junction in a clockwise direction, right to left: right pillar, hiatus, left pillar, retroesophageal passage, skeletonization of the fornix and reconstruction of the valve. We decided to perform a technique inspired from laparoscopic sleeve gastrectomy, which starts in anti-clockwise direction, with the skeletonization of the upper third of the greater curvature of the stomach, then continues with the complete dissection of the left diaphragmatic pillar ("left side first") and finally with the dissection of the right pillar and the creation of the retroesophageal passage, thus, the procedure becoming less complicated. A complete decollement of the area nuda is performed, this way avoiding possible complications at this stage, like: bleeding from the area nuda or short vessels, ruptures of the stomach, esophagus, spleen, penetrating the thoracic cavity with a retroesophageal clamp, etc.

Results

Introduced in 2011, this technique was applied with success in all 20 consecutive cases of hiatus hernia operated in our clinic. There were neither intraoperative accidents and conversions nor early or late postoperative complications. 19 cases were primary Nissen while one case was a recurrent hiatal hernia after an insufficient cruroplasty made in another center. There were three cases in which we had to use Parietene Composite type mesh to strengthen the cruroplasty.

Conclusion

The applied modification has improved the original laparoscopic Nissen fundoplication technique, thus this has become a less complicated procedure at the same time providing more security to the patient.

Hydatid disease is a parasitic disease endemic in Romania which occurs frequently in liver and lungs, but it can also be present in almost any part of the body. We present the rare case of a 37-year-old male which was admitted in our service with a large hydatid cyst at the level of the right thoracic outlet and we were not able initially to establish its exact origin, liver or right lung. After imagistic investigations we decided for an abdominal approach considering that the cyst was liver related. Intraoperative findings showed a primary hydatid cyst of the diaphragm, a very rare entity that was successfully treated by the mentioned approach.

Introduction

The perforation of colorectal cancer (CRC) had always had a poor prognosis, regardless of whether the perforation evolved into forming an abscess or it was a free perforation into the abdominal cavity. The associated conditions as elder patients and different comorbidities seems to greatly reduce the chance of survival, as well as limit the therapeutic surgical options. AIM: The aim of this study is to review our surgical department data in order to analyze the outcomes after colorectal cancer perforation.

Material and Methods

A retrospective study was conducted the Department of Surgery of Prahova County Hospital. All the patients admitted for a CRC perforation were included in the study.

Results

During one year, 136 patients with CRC were admitted in our department. Only 7.35% (n=10) had a perforation. The median age was 70 years old. The men to women ratio was 6 to 4. The tumor was located on the right colon in 40% (n=4), on the left colon in 30% (n=3) and on the rectum in the other 30% (n=3). There were performed 4 right colectomies, 5 Hartmann resections and in one case, a colostomy. The postoperative mortality was null. A review of the literature data was also performed.

Conclusions

Perforated CRC is more frequent in elderly patients, with neglected cancers. The choice of surgical procedure has to be appropriate to the cancer site and patient’s comorbidities and general condition.

Cervical cancer is currently the second most common form of neoplasia worldwide and third in the female population. Dissemination can occur directly (isthmus, parametrium, vagina, urinary bladder and/or rectum), through the lymphatic system (parametrium, internal iliac, external iliac, common iliac, obturator lymph nodes and rarely in the inferior gluteus, superior gluteus, superior rectum, sacrum, aortic lymph nodes) and through the circulatory system (lung, mediastinum, bones, liver). The risk of pelvic lymph nodes invasion in stage IB (FIGO) is 9-17%. The standard surgical treatment, for stages IA2-IIA, is radical hysterectomy with pelvic lymphadenectomy. The risk of intraoperative (vessel or nerve damage) or postoperative complications (lymphedema) is not negligible. The sentinel node concept refers to the first lymph node in which the cancerous lymphatic drainage takes place. This idea has radically changed the therapeutic approach in the treatment of breast cancer and melanoma. In cervical cancers, this technique is 92% accurate with only an 8% false negative rate. Currently, the sentinel node protocol is not included in the standard treatment for cervical cancer because certain issues need to be addressed (the sensitivity of the frozen section examination, the pathologist’s subjectivity, the uniformity of the protocol, the surgical experience, the size of the tumor).

Surgery remains the main treatment for localized resectable esophageal cancer. Open esophagectomy is still the standard surgical approach for esophageal cancer but it has a lower patient satisfaction when compared with other treatment options. In the era of “key-hole” surgeries, minimally invasive esophagectomy (MIE) stands as a solution to improve the results after standard open esophagectomies. The aim of the present paper is to provide a short update regarding the minimally invasive esophagectomy, with special emphasis on its indications, results and current controversies.

Aims: Studies that recommend laparoscopic right hemicolectomies within an Enhanced Recovery After Surgery (ERAS) programme are based on data from all types of colorectal procedures. This study compares short-term outcomes following right hemicolectomies within an ERAS setting.

Methods: Retrospective analysis of elective right hemicolectomies carried out between October 2008 and April 2012. Exclusion criteria:- patients not managed with an ERAS programme; inflammatory bowel disease; ASA IV and above; extended right hemicolectomy; formation of a stoma. Patients were split into laparoscopic (Group A) and open procedure (Group B). Patient demographics, hospital stay, operative details, tumour characteristics, analgesia usage and complications were compared between the two groups. Discharge criteria was standardised for both groups. Significance was taken as p <0.05.

Results: 32 patients were included in Group A and 37 patients in Group B. No significant difference in terms of sex, mean age, ASA grade, tumour stage, lymph node yield and epidural usage. BMI was statistically higher in Group A (27.9 vs. 24,8 kg/m2). Four laparoscopic procedures were converted to open. There were two anastomotic leaks in group B. No significant difference in complication rates. Median post-operative stay for Group A was significantly less at 5 days compared to 7 days for Group B. Patients in Group A also opened their bowels earlier (median day 4 vs. 5).

Conclusions: Our study demonstrates that in the setting of ERAS, laparoscopic right hemicolectomies are associated with a shorter hospital stay without an increase in complication rate compared to the open method.

Advance breast cancer still becomes a debate among surgeons either to act aggressively in view of the survival outcome. However the problem may arise from the disease progress which can be complicated by sepsis due to infection, severe bleeding, foul odour and sensation of heaviness. The decision will be more complicated if it occurs among geriatric patients. Here we presented a case of neglected right breast cancer which was treated late when it occupied the whole breast. The histopathological results revealed Poorly Differentiated Infiltrating Ductal Carcinoma and CT Scan showed liver and lung metastases (Stage IV). Palliative mastectomy was done to prevent complication such as infection and sepsis, bleeding and to reduce the sensation of heaviness. The discussion focused on the role of mastectomy to improve quality of life in elderly with advance breast cancer.

Background: Leiomyosarcoma is a common retroperitoneal sarcomas mostly originating from muscles. Only about 5% of leiomyosarcomas arise directly from large blood vessels and more than 50% of cases originate from inferior vena cava. Primary leiomyosarcomas of renal veins are extremely rare (30 cases). Mostly diagnosed at advanced stages because of nonspecific clinical signs.

Case: A 40-year-old woman was evaluated of a left retroperitoneal mass with severe back pain. CT scan revealed a left retroperitoneal mass 7 cm. in size adjacent to left renal hilum. During the operation; a multilobular, solid tumor in 7 x 6.5 x 3 cm size, surrounding the left renal vein was observed. Further dissection revealed that the tumor was originated from left renal vein wall. Total devascularization and partial left renal vein resection with tumor and end to end anastomosis was performed. Vascular outflow was confirmed with intraoperative and postoperative doppler examination. Pathology was reported as moderately differentiated leiomyosarcoma, originated from renal vein wall with tumor free resection margins and the patient was discharged with adjuvant chemoradiotherapy.

Conclusion: Although the radical nephrectomy is the gold standard approach for malign tumors of the kidney, kidney preserving tumor free resection with vascular reconstruction is a feasible alternative followed by adjuvant chemoradiotherapy and close follow up. Kidney preserving tumor free resection with vascular reconstruction and followed by adjuvant chemoradiotherapy is a feasible alternative instead of radical nephrectomy.

Colonoscopy remains a widely used diagnostic and therapeutic procedure. However, like any invasive investigation it has the potential of complications; extraperitoneal perforation with pneumoretroperitoneum and subcutaneous emphysema being an extremely rare example.

We report such a case in a57 year old woman who presented to the emergency department with abdominal pain and diffuse chest, neck and facial surgical emphysema following a routine colonoscopy with hot snarepolypectomy.

Gastric ulcers, with a long duration of the disease, can lead to an inflammatory process in the upper abdomen (supramesocolic floor), with repercussions on the surrounding structures. Such ulcers can penetrate the gastric wall, toward the pancreas and hepatic hilum, the inflammatory process can lead to splenic vein trombosis and teh appearance of a portal cavernoma. A complication of the portal cavernoma and the portal hypertension is the formation of esophageal varices. This paper reports the case of a 58 years old patient with multiple episodes of upper gastrointestinal bleeding, determined by both, esophageal varices and existing gastric ulcers. This patient was initially diagnosed with portal cavernoma and the esophageal varices were considered the cause of gastrointestinal bleeding. A spleno-renal shunt was proposed, but intraoperative it was found that this was not necessary because the portal vein was thrombosed and the bleeding was probably caused by the gastric lesions. We performed a distal spleno-pancreatectomy associated with a cuneiform resection of the gastric lession, as well as the resection of the hepatic tumor. The patient had a favorable postoperative outcome.

Brucella infection associated with arthroplasty is a rare event. An unspecific clinical symptomatology is associated with unclear radiographic signs of periprosthetic bone halisteresis. Only a positive anamnesis combined with an antibiogram of the joint liquid and a high serum antibody titer can lead to a definitive diagnosis. We herein report a case of Brucella melitensis infection in a patient who underwent total knee arthroplasty 2 years earlier. Plain radiography and bone scintigraphy confirmed septic loosening. The patient was successfully treated with two-stage revision arthroplasty.

Background: The main surgeries that can be performed in upper and mid rectal cancer are low anterior rectal resection (LAR), lateral colostomy (LC), and extended Hartmann operation with mesorectal excision (EHO). Compared to lateral colostomy, EHO is a curative surgery; it also takes a shorter time to perform and has a lower mortality compared with LAR.

Objective: The aim of this study was to analyze the postoperative surgical complications in patients who underwent LAR, LC, or EHO.

Methods: The study is a prospective analysis based on a Surveillance protocol for patients with liver metastases of colorectal origin used in First Surgical Oncology Unit, Regional Institute of Oncology Iaşi, Romania. The postoperative complications occurring within 60 days postoperatively were analyzed.

Results: In the interval June 2012 – May 2014, 87 patients were diagnosed with upper and mid-rectal cancer and liver metastases; LAR was performed in 18 patients, LC in 19 patients and in 50 patients EHO with pelvic drainage abdominally exteriorized or perineally (37 and 13 patients, respectively). The postoperative complications related to surgical wound, stoma, pelvic abscess, postoperative bleeding, prolonged postoperative ileus, anastomotic leakage, reinterventions, readmissions, and mortality were analyzed. A higher rate of pelvic abscesses was found in EHO patients (24%, n=12), of which 9 patients (18%) required reinterventions for drainnage of pelvic fluid collection; all these patients had pelvic drainage exteriorized abdominally. No presacral abscesses were recorded in patients with pelvic drainage exteriorized perineally.

Conclusions: Extended Hartmann Operation (EHO) remains a safe technique, that shares some indications with LAR and LC; however, it is associated with a higher percentage of pelvic abscesses and reinterventions that can be avoided by postoperative perineal drainage of the presacral space

Background: Intertrochanteric femur fractures are common in older people. In high-risk patients, especially American Society of Anesthesiologists (ASA) scores 3 and 4, surgery with internal fixation can cause excessive stresses. Therefore, external fixation is another option for treating these patients.

Objective: To evaluate the results and complications of external fixation in elderly patients with intertrochanteric fractures.

Methods: Twenty-six surgically high-risk patients with intertrochanteric fractures admitted to our clinic were treated with external fixation (January 2010- November 2011). Epidemiological and radiological data and also complications were recorded at each follow-up.

Results: No complications occurred in 13 patients. The remaining 13 patients had complications after surgery: Of the patients, 10 had implant failure (6 pin migration and 4 pin cut-out) and 3 had pin tract infections. Six patients who had implant failure (2 pin migration and 4 pin cut-out) underwent revision. Unrevised complicated patients (4 pin migration) and 2 of 3 patients with pin tract infections had malunion and shortening. High risk older patients with external fixation had a high complication and morbidity rate.

Conclusion: We do not recommend using pertrochanteric external fixators in high-risk patients due to the high revision rate and serious complications.

Colorectal cancer is a major public health problem worldwide, and a major cause of mortality and morbidity. Correct pretherapeutic staging has the role of guiding the management of colon cancer patients. The diagnosis is guided by the clinical symptoms. Chemotherapy is an important part of colon cancer treatment. Chemotherapy regimens are adapted to tumor stage and patient status and have various side effects and variable survival outcomes. International guidelines recommend different treatments depending on the presence or absence of metastases. The primary goal of treatment in nonmetastatic colon cancer is surgical removal of the tumor which could be the first step of the complex therapy or preceded by neoadjuvant therapy, depending on pretherapeutic staging. In resectable nonmetastatic tumors the preferred surgical procedure is colectomy with en bloc removal of regional lymph nodes. The extent of colectomy should be based on tumor location. The management of metastatic colon cancer also targets the therapeutic approach of the metastatic disease. Therapy is standardized and applied according to tumor stage. Surveillance has a major role in therapeutic success, reason why a time schedule and a protocol adapted to the primary lesion are essential. The goal of implementing the recommendations of international guidelines for the treatment of colon cancer is to provide a uniform treatment for this disease in view of improving overall survival of patients.