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Jurnalul de Chirurgie, Iai, 2009, Vol. 5, Nr.

1 [ISSN 1584 9341]

Jurnalul de chirurgie i propune s devin n scurt timp o publicaie cu impact n activitatea de cercetare chirurgical i de pregtire profesional continu. Jurnalul apare ca o necesitate n condiiile cerute de noile forme de pregtire a rezidenilor n chirurgie i se angajeaz s pun la dispoziia tinerilor chirurgi din diverse specialiti, cunotinele i modelele de baz a pregtirii lor ca specialiti pentru noul mileniu.
Comitet tiinific Alexander Beck (Ulm, Germania) Pierre Mendes da Costa (Bruxelles, Belgia) Gheorghe Ghidirim (Chiinu, Moldova) Christian Gouillat (Lyon, Frana) Vladimir Hotineanu (Chisinau, Moldova) Lothar Kinzl (Ulm, Germania) Jan Lerut (Bruxelles, Belgia) C. Letoublon (Grenoble, Frana) Phillipe van der Linden (Bruxelles, Belgia) John C. Lotz (Staffordshire, Marea Britanie) Iacob Marcovici (New Haven, SUA) Francoise Mornex (Lyon, Frana) Andrew Rikkers (SUA) Michel Vix (Strasbourg, Frana) Giancarlo Biliotti (Florena, Italia) Gianfranco Silecchia (Roma, Italia) Monica Acalovschi (Cluj) Nicolae Angelescu (Bucureti) Gabriel Aprodu (Iai) erban Bancu (Tg. Mure) Eugen Bratucu (Bucureti) N.M. Constantinescu (Bucureti) Silviu Constantinoiu (Bucureti) Constantin Copotoiu (Tg. Mure) Nicolae Danil (Iai) Corneliu Dragomirescu (Bucureti) tefan Georgescu (Iai) Virgil Gheorghiu (Iai) Ioana Grigora (Iai) Avram Jecu (Timioara) Rducu Neme (Craiova) Alexandru Nicodin (Timioara) Dan Niculescu (Iai) Mircea Onofriescu (Iai) Florian Popa (Bucureti) Irinel Popescu (Bucureti) Doinia Rdulescu (Iai) Vasile Srbu (Constana) Viorel Scripcariu (Iai) Liviu Vlad (Cluj Napoca)

Editor emeritus Robert van Hee (Belgia) Editor ef Eugen Trcoveanu Redactor ef Radu Moldovanu Redactori Dan Andronic Radu Danil Gabriel Dimofte Daniel Lzescu Liviu Lefter Cristian Lupacu Sorin Lunc Cornel-Nicu Neacu Drago Pieptu Alin Vasilescu Nutu Vlad Corector Oana Epure

ntreaga responsabilitate a opiniilor exprimate n articolele Jurnalului de chirurgie revine autorilor. Republicarea pariala sau n ntregime a articolelor se poate face numai cu menionarea autorilor i a Jurnalului de chirurgie. Includerea materialelor publicate pe acest site pe alte site-uri sau n cadrul unor publicaii se poate face doar cu consimmntul autorilor. Copyright Jurnalul de chirurgie, Iai, 2005-2009

Jurnalul de Chirurgie, Iai, 2009, Vol. 5, Nr. 1 [ISSN 1584 9341]

Manuscrisele trebuie s ndeplineasc condiiile cerute de International Committee of Medical Journal Editors. Informaii detaliate i actualizate sunt disponibile la adresa http://www.icmje.org. Standard de redactare
Iniializare pagin: Format A4, margini de 2,5 cm. Titlul: Times New Roman, 14, aldin (bold), centrat, la un rnd; trebuie s fie ct mai scurt i elocvent pentru coninutul articolului; Autorii, instituia: Times New Roman, 12, normal, centrat, la un rnd; prenumele precede numele de familie i va fi scris n ntregime numai pentru sexul feminin; trebuie precizat adresa de coresponden (de preferat email). Rezumat n englez minim 200 cuvinte: Times New Roman, 10, la un rnd, fr aliniate i precedat de titlul articolului scris n englez, cu majuscule, urmat de cuvntul abstract (n paranteza, italic). La sfritul rezumatului se vor meniona cu majuscule, cuvintele cheie. Textul: Times New Roman, 12, la un rnd, structurat pe capitole: introducere, material i metod, discuii, concluzii etc. Tabelele vor fi inserate n text i nu vor depi o pagin; titlul tabelului va fi numerotat cu cifre romane: Times New Roman, 10, aldin, la un rnd, deasupra tabelului; Figurile (inserate n text) vor fi menionate n text; titlul i legenda vor fi scrise cu Times New Roman, 10, aldin, la un rnd i vor fi numerotate cu cifre arabe. Bibliografia va fi numerotat n ordinea apariiei n text; Times New Roman, 10, la un rnd, redactat dup cerinele internaionale - vezi http://www.nlm.nih.gov/bsd/uniform_requirements.html . Articolele multimedia: filmele i fiierele Microsoft Power Point (cu extensia .ppt) vor fi nsoite de un rezumat consistent n englez; dimensiunea fiierelor *.ppt < 5 Mb cu un numr de slide-uri < 50. Articolele vor fi adresate redaciei n form electronic (e-mail, CD, DVD, floppy) i eventual tiprit. Articolele nu vor depi: - lucrri originale 15 pagini, - referate generale 20 pagini, - cazuri clinice 8 pagini, recenzii i nouti 2 pagini, - articole multimedia Power Point 5 Mb i 50 slide-uri.

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Articolele vor fi publicate numai dup evaluarea lor de comitetul de redacie. Procesul de evaluare const n: - evaluarea formal a articolului (din punct de vedere al criteriilor de tehnoredactare) realizat de membrii colectivului editorial; - evaluarea calitii informaiei tiinifice realizat iniial de membrii colectivului editorial i apoi de membrii comitetului tiinific, conform unui formular standardizat. Autorii vor fi informai dac articolul este acceptat sau nu spre publicare precum i despre eventualele corecturi / completri necesare pentru a ndeplini criteriile de publicare. Dup ce articolul a primit avizul de publicare, va fi publicat n funcie planul editorial (numere tematice, valoarea tiinific a articolului).

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CUPRINS

EDITORIAL MONITORING INTRABDOMINAL PRESSURE SOMETHING OLD, SOMETHING NEW, SOMETHING BORROWED..............................1 Ioana Grigora Anesthesia and Intensive Care Department, St. Spiridon Hospital University of Medicine and Pharmacy Gr.T. Popa Iai, Romania ARTICOLE DE SINTEZA PRINCIPII ACTUALE DE TRATAMENT N OBSTRUCIILE BILIARE PRIN TUMORI MALIGNE ALE CII BILIARE PRINCIPALE......................................................5 A. Vasilescu, V. Strat Clinica I Chirurgie Tnsescu-Buureanu Iai Universitatea de Medicin i Farmacie Gr.T. Popa Iai CONDUITA N RUPTURILE DE ISTM AORTIC..................................................................26 C. Moroanu, C. Roat, S. Lunc Clinica de Urgene Chirurgicale, Spitalul Clinic de Urgene Sf. Ioan Iai Universitatea de Medicin i Farmacie "Gr. T. Popa" Iai ARTICOLE ORIGINALE MECHANICAL ESOPHAGEAL ANASTOMOSIS: RETROSPECTIVE STUDY OF 56 PATIENTS.......................................................................34 J. Herve, Ch. Simoens, D. Smets, V. Thill, P. Mendes Da Costa Department of Digestive, Thoracic and Laparoscopic Surgery CHU Brugmann, ULB, Brussels, Belgium THYROGLOSSAL DUCT CYST...............................................................................................45 E. Trcoveanu, D. Niculescu, Elena Cotea, A. Vasilescu, Felicia Crumpei, D. Ferariu, Mdalina Palaghia, D. Dorob First Surgical Clinic, St. Spiridon Hospital Iai Gr.T. Popa University of Medicine and Pharmacy Iai, Romania TRATAMENTUL CHIRURGICAL LAPAROSCOPIC AL HERNIEI HIATALE - STUDIU ASUPRA UNUI LOT DE 40 CAZURI.....................................................................52 Lcrmioara Perianu (1), N. Dnil (2), C. Bradea (2) (1) Departamentul de Anatomie; (2) Clinica I Chirurgie Spitalul Sf. Spiridon Iai Universitatea de Medicin i Farmacie Gr.T.Popa Iai

AVANTAJELE TRATAMENTULUI CHIRURGICAL LAPAROSCOPIC N TUMORILE OVARIENE CHISTICE..................................................................................56

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Cristina David (1), Ivona Lupacu (1), E. Trcoveanu (2) (1) Clinica a II-a Obstetric Ginecologie, Spitalul Cuza Vod Iai (2) Clinica I Chirurgie, Spitalul Sf. Spiridon, Iasi Universitatea de Medicin i Farmacie Gr.T. Popa Iai

CAZURI CLINICE LEIOMIOM AL COLONULUI TRANSVERS SURS NEOBINUIT DE PERITONIT..............................................................................68 Gh. Ghidirim, I. Miin, Gh. Zastavnichi Catedra Chirurgie nr. 1 N. Anestiadi Laboratorul de Chirurgie Hepato-Bilio-Pancreatic Universitatea de Medicin i Farmacie N. Testemitsanu Chiinu Spitalul Clinic Municipal de Urgen, Chiinu, Republica Moldova DIVERTICULUL MECKEL CAUZ RAR DE HEMORAGIE DIGESTIV INFERIOAR LA ADULT.........................................................................................................72 R. Neagoe (1), Doina Milutin (2), D. Georgescu (3), Daniela Sala (1), L. Salan (4), M. Eianu (1) (1) Clinica Chirurgie II; (2) Clinica Anatomopatologie; (3) Clinica Medical I Spitalul Clinic Judeean de Urgene Mure (4) Spitalul Municipal Tg. Secuiesc METASTAZ SCAPULAR A CARCINOMULUI HEPATOCELULAR PREZENTARE DE CAZ.............................................................................................................77 N. Vlad (1), R. Moldovanu (1), C. Lupacu (1), G. Rileanu (1), M. Borcea (2), D. Ferariu (3), Liliana Vlad (4) (1) Clinica I Chirurgie I. Tnsescu-Vl. Buureanu Spitalul Sf. Spiridon Iai (2) Clinica ATI Spitalul Sf. Spiridon Iai Universitatea de Medicin i Farmacie Gr.T. Popa Iai (3) Laboratorul de Anatomie Patologic, Spitalul Sf. Spiridon Iai (4) Secia Boli Infecioase, Spitalul Orenesc Hrlu BOALA CROHN ILEO-CECAL MALIGNIZAT, CU FISTUL ILEO-RECTAL PREZENTARE DE CAZ..........................................................................................................82 Elena Gologan (1), A. Pantazescu (2), Iuliana Eva (3), Doinia Rdulescu (4), Doina Butcovan (4) (1) Institutul de Gastroenterologie i Hepatologie, Iai (2) Clinica Chirurgical, Spitalul Clinic de Urgene Sf. Ioan, Iai (3) Laboratorul de Imagistic Medical, Spitalul Militar, Iai (4) Disciplina de Morfopatologie Universitatea de Medicin i Farmacie, Gr.T. Popa, Iai

ANATOMIE SI TEHNICI CHIRURGICALE VIDEO ASSISTED THYROIDECTOMY.................................................................................86 C. Bradea First Surgical Clinic, St. Spiridon Hospital Iai Gr.T. Popa University of Medicine and Pharmacy Iai

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ARTICOLE MULTIMEDIA TYPE II DIABETES MELLITUS: MEDICAL OR SURGICAL DISEASE? .......................89 G. Favia University of Padova Department of Surgical Science and Gastroenterology

ISTORIA CHIRURGIEI PROF. DR. DOC. COSTACHE LAZR..................................................................................100 (1919-2008)

RECENZII I NOUTI CHIRURGIA...............................................................................................................................102 Vol. 103, Nr. 6, Noiembrie Decembrie 2008 MINIMALLY INVASIVE PLATE OSTEOSYNTHESIS IN LONG BONE FRACTURES................................................................................................105 Paul Dan Srbu WORLD JOURNAL OF SURGERY........................................................................................106 Vol. 32, Nr. 12, 2008

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Jurnalul de Chirurgie, Iai, 2009, Vol. 5, Nr. 1 [ISSN 1584 9341]

ntreaga responsabilitate a opiniilor exprimate n articolele Jurnalului de chirurgie revineautorilor. Republicarea pariala sau n ntregime a articolelor se poate face numai cu menionarea autorilor i a Jurnalului de chirurgie. Includerea materialelor publicate pe acest site pe alte site-uri sau n cadrul unor publicaii se poate face doar cu consimmntul autorilor i al redaciei. Copyright Jurnalul de chirurgie, Iai, 2005-2009

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MONITORING INTRABDOMINAL PRESSURE


Something Old, Something New, Something Borrowed Ioana Grigora Anesthesia and Intensive Care Department, St. Spiridon Hospital University of Medicine and Pharmacy Gr.T. Popa Iai, Romania Systematic interest in intraabdominal pressure began about two decades ago. Since than, the amount of scientific data regarding this problem have been risen exponentially. This happened due to several reasons: description of pathophysiological pathways which link intra-abdominal hypertension (IAH) to multiple organ dysfunction syndrome refinement of measurement techniques, emergence of national, international and worldwide scientific organizations dedicated to IAH and the dramatic increase in body of published papers dealing with this topic. The critical mass of this accumulation was reached and the explosive dissemination of data bursted. Intra-abdominal hypertension is defined as sustained or repeated pathological elevation in intra-abdominal pressure (IAP) 12 mmHg. Abdominal compartment syndrome (ACS) is defined as sustained IAP 20 mmHg associated with new organ dysfunction. Three types of ACS were described: primary ACS, caused by a disease in the abdomino-pelvic area, secondary ACS, caused by conditions which do not originate in this region, usually associated with sepsis/systemic inflammatory response syndrome and/or aggressive fluid resuscitation, and recurrent ACS. Measurement of intra-abdominal pressure changed over time regarding techniques and indications, as well. Measurement techniques changed from urinary, gastric or rectal catheter to intravascular (inferior vena cava) evaluation, from large volume to low volume bladder instillation, and special devices were developed and marketed, as a response of companies to increasing interest. Indications for intra-abdominal pressure monitoring were changed, also. Initially indicated in case of abdominal trauma or severe abdominal emergencies (abdominal aorta aneurysm repair, e.g.), than indicated in intra-abdominal/extra-abdominal sepsis, nowadays intra-abdominal pressure monitoring is recommended in nearly all types of critical illness (trauma, surgical and medical). Measurement of IAP should be routine as monitoring of blood pressure, heart rate, temperature, respiratory rate, peripheral oxygen saturation, central venous pressure, and urinary output. What caused this dramatic change of indications? There are several responsible factors: the documented association between IAH and mortality, the description of pathophysiological consequences of IAH and ACS, the association with aggressive fluid resuscitation and/or sepsis and shock, the influence on treatment strategy and the documented interrelation with other compartment syndromes. Lets talk a little bit about them! Figures of IAH prevalence among critically ill patients are amazing (Table I). What is sticking? First, the similar figures between septic patients and the general population of critically ill. This means that, not only septic patients, but all critically ill patients are prone to develop IAH. Secondly, the high incidence of IAH in the medical

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critically ill. In contrast with intuitive expectations, incidence of ACS in medical critically ill patients is higher than in surgical patients. Moreover, Vidal et al (2008) demonstrates that IAP is an independent predictor of mortality [1]. The pathophysiological consequences of IAH are well described: decrease in cardiac output, venous return and arterial blood pressure, increase in central venous pressure and pulmonary artery occlusion pressure, increase in airway pressure, inadequate ventilation with hypoxia and hypercarbia, splahnic hypoperfusion, decrease in urine output and metabolic/mixed acidosis. When the physiological consequences impair function, ACS is present and respiratory, cardio-vascular, renal and digestive compromise may occur.
Table I Prevalence of IAH in critically ill and septic patients IAP 12 mm Hg 15 mm Hg 20 mm Hg + organ dysfunction Critically ill [2] All 58.8% 28.9% 8.2% Surgical 65% 27.5% 5% Medical 54.4% 29.8% 10.5% All 58% 29% 6% Septic [3] Surgical 67% 25.2% 4.1% Medical 52.1% 27.6% 9.3%

IAP=intra-abdominal pressure, pts=patients

IAH and sepsis are intrinsically linked. In sepsis failure to early optimize tissue perfusion may lead to cellular hypoxia, ongoing systemic inflammation and multiple organ dysfunction. But IAH / ACS leads to tissue perfusion compromise and may mimic or augment septic shock. Indeed, patients with septic shock have the highest reported prevalence of IAH / ACS in all critically ill patients. IAH results in intra-/ extra-abdominal organ dysfunction due to pressure induced vascular compression / hypoperfusion and immune mediated organ dysfunction. IAH may act as the second insult in the two-event model of multiple organ dysfunction syndrome [4]. Monitoring of IAP may impact on treatment strategy. Early recognition and treatment of IAH may improve outcome. For instance, IAH increases central venous pressure, but decreases venous return, which may lead to unrecognized and untreated hypovolemia. By the other hand, IAH may be the consequence of aggressive fluid resuscitation or, better said, volume overdose. Measurement of IAP may help to better integrate data about fluid load and optimize treatment. In severe acute pancreatitis IAP monitoring should begin at hospital admission. Once IAH is detected an algorithm-based treatment should guide therapy in order to decrease IAP [5]: percutaneous drainage of cytokines rich peritoneal fluid, early renal replacement therapy or decompressive laparotomy. In order to avoid disadvantages associated with an open abdomen a new method of decompression recommends a subcutaneous linea alba fasciotomy preserving skin as a cover [6]. Since 2007 the polycompartment syndrome (PCS) was described [7,8], which associates increased pressure in different body compartments. Compartment syndromes may be: within the head - intracranial compartment syndrome (CS) (traumatic or hemorrhage intracranial hypertension), and orbital CS (glaucoma or trauma); within the thorax thoracic CS (tension pneumothorax), or cardiac CS (pericardial tamponade); within the abdomen - abdominal CS (trauma and sepsis), or hepatic, or renal, or pelvic CS (trauma); within extremities - extremity CS (crush injuries) (Table II). The PCS

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describes not only the physiological consequences of increased pressure on the surrounding tissues, but also the interactions between different body compartments. The PCS is associated with trauma and results in increased morbidity and mortality. Since 1995 interactions between intraabdominal and intracranial pressures were described. Scalea et al [9] published 2007 a study of 102 patients with severe head injury. In 24 patients combined decompressive craniotomy and decompressive laparotomy resulted in significant decrease in intracranial pressure, documenting the interactions between intra-abdominal and intracranial pressure and the effects of specific interventions.
Table II The four compartments (adapted from Cheatham [8]) Head Syndrome Potential implications Primary physiological parameter Secondary parameter Intracranial CS Brain death Intracranial pressure (ICP) Cerebral perfusion pressure (CPP) ICP: CSF drainage CPP: fluids vasopressors, Decompressive craniectomy Adaptation of ventilatory support essential Chest Thoracic CS Cardio-resp. collapse Intrathoracic pressure (ITP) Peak/mean airway pressure ITP: escharotomy, chest tube Decompressive sternotomy Recognition of syndrome can be life saving Abdomen Abdominal CS MODS Intra-abdominal pressure (IAP) Abdominal perfusion pressure (APP) IAP: ascites APP: vasopressors, fluids Decompressive laparotomy Prevention of bacterial translocation and MODS can be life saving Extremities Extremity CS Extremity loss Extremity compartment pressure (CP) Peripheral arterial perfusion pressure CP: drainage Decompressive fasciotomy Recognition may be limb saving

Therapeutic interventions Resuscitative plan

Importance

CS=compartment syndrome, MODS=multiple organ dysfunction syndrome

Kimball et al [10] concluded in a survey of intensive care physicians published in 2006, that while urgent, aggressive treatment for other compartment syndromes (increased intracranial pressure, tension pneumothorax, pericardial tamponade, extremity compartment syndromes) is standard of care, most intensive care practitioners fail to treat intra-abdominal hypertension and the abdominal compartment syndrome with the same urgency, if at all. In conclusion, measurement of IAP is an old tool. What is new is the recognition of its importance for guiding therapy and for patient outcome. As in case of sepsis, recognition of IAH / ACS should initiate an algorithm-based approach. Something old, something new, something borrowed
1. 2. REFERENCES Vidal MG. Incidence and clinical effects of intra-abdominal hypertension in critically ill patients. Crit Care Med. 2008; 36(6): 1823-1831. Malbrain ML, Chiumello D. Prevalence of intra-abdominal hypertension in critically ill patients: a multicentre epidemiological study. Intensive Care Med. 2004; 30: 822-829.

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Efstathiou M, Zaka J. Intra-abdominal pressure monitoring in septic patients. Intensive Care Med. 2005; 31, Suppl1(131): S183. 4. Kimball W, Mclean B. ACS overview. IAH and sepsis. Available online at: http://www.abdominal-compartment-syndrome.org/acs/sepsis.html 5. Wolfe Tory Medical. ACS overview. IAH and pancreatitis. Available online at: http://www.abdominal-compartment-syndrome.org/acs/pancreatitis.html 6. De Waele JJ. Abdominal Compartment syndrome in Severe Acute Pancreatitis - When to Decompress? Eur J Trauma Emerg Surg. 2008; 34: 11-16. 7. Malbrain MLNG. A new concept: the polycompartment syndrome - Part 1. International Journal of Intensive Care. 2008; 15(3): 93-97. 8. Cheatham M. Compartment syndrome. The four compartment syndromes. Available online at: http:// www.surgicalcriticalcare.net / Lectures / compartment syndrome.pdf 9. Scalea TM, Bochiccio GV, Habashi N. Increased intra-abdominal, intrathoracic, and intracranial pressure after severe brain injury: multiple compartment syndrome. J Trauma. 2007; 62: 647656. 10. Kimball EJ, Rollins MD, Mone MC, Hansen HJ, Baraghoshi GK, Johnston C, Day ES, Jackson PR, Payne M, Barton RG. Survey of intensive care physicians on the recognition and management of intraabdominal hypertension and abdominal compartment syndrome. Crit Care Med. 2006; 34(9): 2340-2348.

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PRINCIPII ACTUALE DE TRATAMENT N OBSTRUCIILE BILIARE PRIN TUMORI MALIGNE ALE CII BILIARE PRINCIPALE
A. Vasilescu, V. Strat Clinica I Chirurgie Tnsescu-Buureanu Iai Universitatea de Medicin i Farmacie Gr.T. Popa Iai
THE ACTUALLY PRINCIPLES IN THE TREATMENT OF BILIARY OBSTRUCTION FROM EXTRAHEPATIC BILE DUCTS CANCER (Abstract): The most common type of extrahepatic bile ducts cancer is the proximal segment which include the bifurcation of common hepatic duct (Klatskins tumors). The diagnosis of these kinds of tumors is always challenging. Magnetic resonance cholangiopancreatography (MRCP) is the best imagistic procedure also for diagnosis and for staging. Surgical resection provides the best chance for cure in patients with biliary malignancy; unfortunately only 30% from patients with Klatskins tumors are diagnosed in resectable stages. The type and extension of the resection depends of the tumor stage and site. Resection of the biliary duct associated with hepatectomy and/or pancreaticoduodenectomy (performed especially for limphadenectomy) has good results, from point of view of disease-free survival. In selected cases, the extrahepatic bile duct resection alone and hepatico-jejunal anastomosis is also considered as curative resection. Portal vein resection may be performed and can improve the prognosis. Palliative procedures of nonresectable bile ducts cancer consist in surgical by-pass, percutaneous biliary drainage and endoscopic endoprosthesis. Because longterm relief of jaundice is difficult without using biliary stenting, a combination of radiation therapy and stent placement is commonly used. As radiation therapy, external-beam radiotherapy is usually performed, but combined use of intraluminal brachytherapy with external beam radiation therapy is more useful for making the treatment more effective. Radiation therapy can be associated with chemotherapy (gemcitabine) in unresectable bile duct cancer to extend survival and improve quality of life. KEY WORDS: MALIGNANT BILIARY OBSTRUCTION, EXTRAHEPATIC BILE DUCTS CANCER, KLATSKIN TUMORS, HEPATIC RESECTION, PERCUTANEOUS BILIARY DRAINAGE, ENDOSCOPIC ENDOPROSTHESIS, RADIATION THERAPY, CHEMOTHERAPY Coresponden: Dr. Alin Vasilescu, medic specialist chirurg, asistent universitar, Clinica I Chirurgie, Spitalul Sf Spiridon, str. Independentei, nr. 1, 700111, Iai; e-mail: vasilescu.alin@gmail.com*

INTRODUCERE Cea mai frecvent localizare a tumorilor maligne ale cii biliare principale este cea proximal, ce cuprinde canalele hepatice drept i stng, convergena i jonciunea lor (tumorile Klatskin), reprezentnd 2/3 din totalul tumorilor maligne, urmate de cele ale segmentului distal retroduodenopancreatic, cele mai rare fiind cele ale segmentului mijlociu. [1] Tumora este mai frecvent la brbai, raportul brbai/femei este de 1,3/1, n decadele V, VI, VII. Tumorile hilare au fost descrise pentru prima dat de Klatskin n 1965 [2]. Hilul hepatic este definit de diviziunea venei porte. Bertrand n 1970 definete termenul de cancer de hil, ca fiind toate tumorile situate n partea superioar a pediculului hepatic, interesnd convergena canalelor biliare [3]. Pentru tumorile cii
received date: 10.10.2008 accepted date: 23.12.2008
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biliare principale proximale aa numitele tumori Klatskin, cea mai utilizat stadializare n practica clinic este stadializarea Bismuth-Corlette (Tabel I) [4].
Tabelul I Clasificarea Bismuth-Corlette Tipul I II IIIA IIIB IV

tumor limitat la canalul hepatic comun tumora intereseaz convergena tumora intereseaz convergena i canalul hepatic drept tumora intereseaz convergena i canalul hepatic stng tumora intereseaz convergena i ambele canale hepatice

n tumorile segmentului distal i mijlociu uzual se folosete stadializarea TNM (AJCC 2002) (Tabel II) [5].
Tabel II Stadializarea TNM a cancerului de ci biliare proximale - AJCC 2002 Tumora primar (T) Tx - tumora primar nu poate fi evaluat T0 - tumora primar nu este evident Tis - Carcinom in situ T1 - tumor limitat la peretele ductal - T1a limitat la mucoas i T1b limitat la muscular T2 - tumora depete peretele ductal T3 - tumora invadeaz organele vecine Stadiul 0 I II III IV A IV B Limfonodulii regionali (N) Nx - limfonodulii regionali nu pot fi identificai N0 - fr metastaze n limfonodulii regionali N1 - metastaze n limfonodulii cistici, pericoledocieni, hilari N2 - metastaze n limfonodulii peripancreatici cefalici, periportali, periduodenali, celiaci, mezenterici superiori Metastazele la distan (M) Mx - metastazele la distan nu pot fi evaluate M0 - nu exist metastaze la distan M1 - metastaze la distan prezente

T(tumora) Tis T1 T2 T1 T2 T3 T1-3

N (limfonoduli) N0 N0 N0 N1-2 N1-2 N0-2 N0-2

M(metastaze) M0 M0 M0 M0 M0 M0 M1

n evoluia bolii se descrie o perioada preicteric, care este de scurt durat si este necaracteristic i o perioad icteric n care pacienii prezint icter progresiv, prurit, hepatomegalie (50-70%), dureri, febr, frisoane i degradarea strii generale. n tumorile situate sub confluena cisticocoledocian, se poate palpa vezicula biliar destins (semnul Courvoiser Terier) [6,7].

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n cadrul explorrilor biologice se constat creterea enzimelor de colestaz (fosfataza alcalin, bilirubina total i direct, GGT), prelungirea timpului de protrombin, scderea albuminelor serice. Se mai poate ntlni modificri ale hemoleucogramei cu scderea hemoglobinei, hematocritului i leucocitoz n cazul angiocolitei asociate. Acestea, ns, nu sunt specifice penru diagnostic. Dozarea markerilor tumorali CA 19-9 i ACE sunt nespecifici pentru diagnostic, dar pot ajuta n evaluarea radicalitii interveniei i n urmrirea postoperatorie, pentru depistarea eventualelor recidive [5]. Explorrile imagistice preoperatorii au un rol determinant n stabilirea celei mai bune tactici chirurgicale [8]. Primul pas n diagnosticul imagistic l reprezint ecografia abdominal care poate detecta dilatarea canalelor biliare extra i intrahepatice i sediul obstruciei. n tumorile Klatskin ecografia transabdominal descoper dilataia bilateral a ductelor intrahepatice i dilataia ductelor hepatice drept i stng, iar tumora apare ca o formaiune hipo sau hiperecogen localizat distal de ductele biliare dilatate (Fig.1).

Fig. 1 Tumor Klatskin aspecte ecografice formaiuni hipoecogene imprecis delimitate, localizate la nivelul convergenei, CBIH dilatate ambii lobi.

n tumorile distale poate arata pe lng dilatarea ductelor biliare extra i intrahepatice i o vezicul biliar destins. Ecografia Doppler color poate detecta tromboza portal i invazia tumoral vascular. De asemenea, ecografia poate detecta prezena metastazelor hepatice. Urmtorul pas n diagnostic este reprezentat de tomografia computerizat (CT) cu variantele spiral multifazic i CT tridimensional, care localizeaz leziunea i arat gradul extensiei tumorale (Fig. 2A), aducnd date importante pentru stabilirea strategiei operatorii evideniind atrofia lobar sau segmentar hepatic cauzat de obstrucia biliar tumoral, ocluzia venei porte i a arterei hepatice [9]. Explorarea de elecie a tumorilor cilor biliare extrahepatice este colangiografia prin rezona magnetic (MRCP), care permite vizualizarea tractului biliar att proximal, ct i distal de obstrucie, a structurilor vasculare, precum i vizualizarea anomaliilor parenchimului hepatic (Fig. 2B) [10,11]. Sensibilitatea MRCP n identificarea sediului obstruciei este de 94%99%, iar n diferenierea stricturilor

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benigne de cele maligne de 70-96% [11]. Dintre metodele nou aprute, colangioscopia percutan flexibil urmeaz a-i dovedi eficiena [12]. O mare importan n diagnostic i n evaluarea rezecabilitii o au explorrile intraoperatorii prin laparoscopie sau laparotomie, putndu-se efectua biopsii, colangiografii intraoperatorii, explorare instrumental a CBP, ecografie intraoperatorie. Laparoscopia diagnostic i ecografia intraoperatorie laparoscopic pot evita o laparotomie inutil n cancerele depite chirurgical. Laparoscopic se pot decela metastazele hepatice, peritoneale i n marele epiplon care se pot biopsia, putndu-se face deasemenea examen citologic prin lavaj peritoneal. Dup Launois criteriile laparoscopice de nerezecabilitate sunt: metastazele hepatice, peritoneale sau ale marelui epiplon; extensie extrahepatic sau intrapancreatic a tumorii, invazie vascular [13].

Fig. 2 Tumor Klatskin A examen CT - formaiune hipodens, imprecis delimitat de 32x35 mm, localizat la convergena canalelor hepatice, canal hepatic drept dilatat de 16 mm; B colangioIRM formaiune hipofixant T1/T2 localizat la nivelul convergenei canalelor hepatice

Tratamentul tumorilor maligne ale cilor biliare extrahepatice este larg dezbtut n literatur, datorit prognosticului rezervat, diagnosticarea bolii avnd loc, de obicei, ntr-un stadiu avansat, n care rezecia tumorii devine imposibil, iar tratamentului adjuvant este relativ ineficient. Progrese notabile s-au nregistrat ns n ceea ce privete conduita chirurgical n tumorile situate la convergena celor dou canale hepatice, tumorile Klatskin. Singurul tratament cu potenial curativ este rezecia, a crei amploare depinde de stadiul Bismuth al tumorii. Rezeciile curative presupun asocierea limfadenectomiei regionale rezeciei de ci biliare, iar uneori este necesar asocierea de rezecii hepatice i vasculare. Rezecia paleativ este preferabila altor metode chirurgicale sau intervenionale de rezolvare a icterului. [14] Drenajul biliar preoperator a fost mult timp controversat, actualmente nemaifiind recomandat dect la pacienii cu stare general alterat, cu icter prelungit i angiocolit. Cel mai utilizat procedeu este drenajul biliar transparietohepatic [5]. n funcie de localizarea anatomic, rezecia cu margini chirurgicale histologic negative rmne singurul tratament cu potenial curativ. Ablaia tumorii se realizeaz prin rezecie de cale biliar i rezecie hepatic n funcie de tipul tumorii. Rezeciile curative presupun asocierea limfadenectomiei regionale. Contraindicaiile tratamentului chirurgical sunt de ordin local (invazie local avansat cu invazie vascular i extensia

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dincolo de a 2-a bifurcaie a canalelor hepatice) sau general (metastaze viscerale, insuficien hepatic sau/i renal, boli grave asociate). Pentru tumorile nerezecabile trebuie asigurat drenajul biliar prin metode chirurgicale (rezecia paleativ este preferabila altor metode intervenionale) sau tehnici de radiologie i endoscopie intervenional. Rata de rezecabilitate a tumorilor hilare este de doar 20-30%, iar rata curativ n jur de 15% [15,16]. Un aspect important al ratei rezecabilitii l reprezint asocierea acestui tip de tumori cu o reacie fibroas periductal important, astfel c leziunile par a fi mai avansate, de aceea aceast chirurgie este recomandat a fi efectuat doar n centre specializate. Odat cu creterea agresivitii chirurgicale i dezvoltrii mijloacelor tehnice a crescut rata rezecabilitii de la 10-15% la 70-80% n ultimele studii care asociaz rezeciilor de ci biliare, rezeciile hepatice i rezeciile vasculare [17]. Criteriile de nerezecabilitate sunt reprezentate de: 1) invazia canalelor hepatice bilateral, dincolo de a doua bifurcaie; 2) invazia bilateral a ramurilor portale sau arteriale lobare; 3) invazia canalului biliar de o parte, deasupra celei de-a 2-a bifurcaii i invazia vascular de partea opus (arterial sau portal) [14]. Astzi, niciunul dintre aceste criterii nu mai pot fi considerat absolut. Se poate practica chiar hepatectomie total i transplant hepatic (doar pe cazuri selecionate) n cazul invaziei ductelor biliare dincolo de a doua bifurcaie, sau invaziei ntregului pedicul vascular. Extinderea proximal hepatic atrage dup sine de cele mai multe ori asocierea de diverse tipuri de rezecii hepatice (hepatectomie dreapt, hepatectomie dreapt extins, hepatectomie stng, hepatectomie stng extins, +/- rezecie de lob caudat, rezecie de segment IVb) [1,5]. Dei hepatectomia asociat rezeciei de cale biliar i limfadenectomie este tratamentul standard n tumorile Klatskin, se asociaz cu o rat mare de mortalitate i morbiditate postoperatorie. Principala complicaie este insuficiena hepatic prin reducerea masei funcionale hepatice. Makuuchi propune embolizarea preoperatorie a ramului homolateral portal cu hipertrofia compensatorie a ficatului controlateral [18], iar Yokoyama Y et al pe un lot de 240 pacieni demonstreaz avantajele acestei tehnici prin creterea rezervei funcionale hepatice i scurtarea spitalizrii [19]. Pentru stadiile Bismuth I i II, rezecia simpl de ci biliare este suficient implicnd rezecia hepaticului comun i a bifurcaiei cu o limit de rezecie cuprins ntre 1-1,5 cm, datorit invaziei la distan de marginea macroscopic a tumorii, n mucoas i submucoas [5,10]. Examenul histologic extemporaneu este obligatoriu, deoarece prezena invaziei microscopice impune recupa sau asocierea hepatectomiei de partea invadat (dac extensia tumoral depete cea de-a doua bifurcaie doar la nivelul unui canal). Dup unele studii afirm c marginea de rezecie este un factor de prognostic pentru recidiva local, nu i pentru supravieuire [20], Endo I et al demonstreaz pe un lot de 101 pacieni c supravieuirea dup rezecia R0 este net superioar rezeciei R1 [21]. Pentru a putea rezeca ct mai mult din canalele hepatice, n cazul unei rezecii limitate se poate asocia rezecia de segment IV, care faciliteaz abordul celor dou canale hepatice n hil [10,13]. Restabilirea continuitii se face prin anastomoza a dou sau mai multe canale hepatice cu ans jejunal n Y. Pentru stadiile Bismuth III A i IV (bifurcaia de ordin II pe stnga liber) sau stadiilor incipiente (I i II) cu invazie vascular lobar dreapt se poate practica hepatectomie dreapt sau dreapt extins. Pentru stadiile Bismuth III B i IV (bifurcaia de ordin II pe dreapta liber) sau stadiilor incipiente (I i II) cu invazie vascular lobar stng se practic hepatectomie stng sau stng extins. n stadiul Bismuth IV cu

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bifurcaia de ordin II pe ambele canale neinvadat se practic hepatectomie central. Rezecia lobului caudat poate fi asociat rezeciei de cale biliar sau hepatectomiei deoarece acesta este frecvent invadat din cauza conexiunilor vasculare i biliare ntre lobul caudat i calea biliar, respectiv vena port i deasemenea, cele mai multe recidive (30%) apar n lobul caudat [14]. Rezecia simpl a cii biliare a fost descris iniial de Cameron JL (1982) i apoi a fost modificat de Lygidakis et al n 1986. Explorarea intraoperatorie va aprecia extensia tumoral, dac depete capsula Glisson sau invadeaz parenchimul hepatic. Aprecierea rezecabilitii se face prin utilizarea cii de abord posterioare a hilului hepatic. Ecografia intraoperatorie poate fi de asemenea de un real folos n aprecierea invaziei parenchimatoase, a trunchiului venei porte sau uneia din ramurile sale. Prin calea de abord posterioar la nivelul hilului se superficializeaz pediculii glissonieni drept i stng. n absena acestei manevre, disecia este limitat la calea biliar intraglissonian, capsula putnd fi invadat microscopic tumoral. Lygidakis recomand disecia pediculului hepatic cu identificarea i izolarea cu la a fiecrei structuri, scheletizarea lor i limfadenectomie. Urmtorul timp este constituit de colecistectomie i secionarea distal a coledocului supraduodenal. Captul proximal este ridicat cranial i se disec cu atenie CBP i cele 2 canale hepatice drept i stng de artera hepatic , vena port i ramurile lor. Este foarte important sa se identifice i ligatura fiecare mic ram vascular originar din port sau artera hepatic. n acest moment al diseciei este descoperit accesul la planul avascular intrahepatic. Se scheletizeaz canalele hepatice drept i stng pn la nivelul bifurcaiei segmentare. Dup expunerea canalelor biliare dilatate, aceste pot fi secionate cu o margine de siguran de 1 cm supratumoral, nti faa anterioar care este reperat, apoi faa posterioar. Pe stnga, canalul hepatic fiind mai lung se poate seciona la o distan mai mare. Canalul hepatic fiind mai scurt exist posibilitatea seciunii i a canalului paramedian drept i lateral drept. Elementul esenial care trebuie s ghideze intervenia chirurgical este rezecia n esut sntos. Deasemenea n cursul diseciei este lezat frecvent canalul biliar al lobului caudat ceea ce duce de multe ori la rezecia segmentului I, de altfel cu efect benefic asupra rezeciei n limite oncologice [22]. Rezecia fiind terminat se restabilete tranzitul biliodigestiv printr-o anastomoz terminolateral cu o ans jejunal n Y trecut transmezocolic, prin sutura cu fire separate, a fiecrui canal biliar sau prin anastomozarea acestora ntre ele cu crearea unei noi convergene i anastomoza acesteia cu jejunul [13,15,16]. Anastomozele biliodigestive pot fi protezate transanastomotic cu tub exteriorizat la Vlker [13]. Se pare ns, c rata morbiditii postoperatorii nu este influenat de protezarea anastomozei [16,22]. Creterea tumorilor cilor biliare ca i procesul lor de metastazare este lent, astfel c rezecia, chiar dac este parial, se asociaz cu o paliaie pe termen lung. Rezeciile complexe presupun asocierea rezeciei de ci biliare cu rezecii hepatice, iar uneori se pot asocia i rezecii vasculare. Asociind rezecia hepatic pe cazuri selecionate, crete rata rezeciilor radicale, care dei sunt asociate cu o mortalitate i o morbiditate mai mare, prezint o supravieuire mai lung i o mai bun calitate a vieii. Principalele complicaii postoperatorii sunt reprezentate de insuficiena hepatic, renal, coagulopatiile i sepsisul. Rezeciile complexe necesit ameliorarea preoperatorie a strii generale, corectarea deficitelor imune, malnutriiei i coagulopatiilor. Unii autori recomand drenajul biliar preoperator, raportnd o mortalitate mai mic. n 1996 Tsuzuki T et al raporteaz 2 cazuri cu reconstrucie de

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ven port cu ocazia unei hepatectomii stngi [23]. Blumgart raporteaz 9 cazuri cu invazia trunchiului venei porte, care au necesitat sutur ntr-un caz, iar n 2 cazuri rezecia bifurcaiei cu ananstomoza trunchiului portal la ramul stng. ntr-un studiu japonez rata rezecabilitii cancerelor biliare a fost de 80,5%, cu hepatectomie asociat n 62,5% din cazuri, iar n 1/3 din cazuri s-a practicat i rezecie de ven port [24]. Tipul de rezecie hepatic se stabilete n funcie de extensia tumorii pe canalul hepatic drept sau stng i invazia parenchimului hepatic i presupune: rezecia lobului caudat (autorii japonezi o recomand n toate cazurile), hepatectomie dreapt sau dreapt extins, hepatectomie stng sau stng extins i hepatectomie central (trisegmentectomia IV, V, VIII) [25]. Tehnica operatorie urmeaz aceeai timpi pn la disecia convergenei, unde se evalueaz cu atenie invazia hepatic i vascular. De real folos este examenul histopatologic extemporaneu, deoarece majoritatea pacienilor prezint invazie difuz microscopic la distan, prin limfaticele din submucoas, perineurale, periductale, periarteriolare i perivenulare [21]. Rezecia hepatic urmeaz principiile oncologice, iniial prin secionarea canalului hepatic drept sau stng, intrahepatic, proximal de tumor i convergen, dup care se practic hemihepatectomie sau trisegmentectomie. n cazul existenei invaziei vasculare, canalele hepatice sunt rezecate la nivelul bifurcaiei segmentare i se pot practica rezecii vasculare (rezecia segmentelor invadate ale arterei hepatice sau venei porte) cu reconstrucii vasculare. Rezecia de ci biliare asociat cu rezecia vascular poate s nu fie asociat rezeciilor hepatice atunci cnd exist doar invazia structurilor vasculare regionale: arter hepatic cu ramurile sale drept i stng sau ven port cu ramurile sale. n cazul invaziei vasculare bilaterale se ncepe cu rezecia hepatic i se continu cu rezecia segmentelor vasculare invadate ale venei porte i arterei hepatice a ficatului rezidual. Reconstrucia vascular se poate face prin sutur, cu grefon venos sau sintetic. Rezecia hepatic i a arterei hepatice controlaterale are rezultate aleatorii. Dac artera hepatic este comprimat sau invadat de tumor cu un flux arterial redus, ligatura sa nu are consecine. Dac fluxul arterial este normal, continuitatea arterial trebuie s fie imperativ restabilit pentru a evita riscul unei necroze hepatice. Lygidakis descrie reconstrucia arterei hepatice cu artera splenic (captul distal se anastomozeaz terminolateral cu artera gastroduodenal) [22]. Rezecia portal este nsoit de o hepatectomie dreapt lrgit la segmentul IV. Dup disecia pediculului hepatic, trunchiul venei porte este clampat la mijlocul pediculului hepatic; de asemenea i ramul stng portal la recesusul lui Rex. n continuare se rezec porta i se restabilete continuitatea venoas prin anastomoza trunchiului portal cu ramul stng. Scizura ombilical este descoperit la dreapta ligamentului rotund i ligamentului falciform unde pediculul segmentului IV este disecat i secionat. Seciunea parenchimatoas se efectueaz pentru a practica n acelai timp hepatectomia cu limfadenectomia i ablaia cancerului ilar [14]. Restabilirea continuitii venoase se efectueaz, n general, fr interpoziie venoas; congruena poate fi facilitat prin incizia marginii inferioare a ramului stng portal. n cazul n care exist o traciune n anastomoz, este preferabil utilizarea unui grefon venos. coala francez recomand utilizarea venei iliace primitive care are un perete solid i un diametru identic cu trunchiul venei porte [13]. Prelevarea sa se efectueaz prin incizie median subombilical. Circulaia venoas a membrului inferior nu este ntrerupt dac grefonul venos este prelevat n aval de vena hipogastric. Se mai poate utiliza grefon venos din jugulara intern sau grefon venos conservat.

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Actualmente, se recomand de rutin rezecia lobului caudat cu beneficii clare n supravieuire i rata recidivelor locale, datorit conexiunilor frecvente vasculare i biliare pe care lobul caudat le are cu trunchiul biliar i vena port i n special cu ramul stng al canalului hepatic [26]. Rezecia poriunii libere a lobului caudat, care mai este numit i lobul Spiegel, sau segmentul I, ncepe cu ligatura ramurilor portale care merg la lobul caudat urmat de ligatura venelor spiegeliene i disecia lobului de faa anterioar venei cave inferioare. n acest moment poate fi secionat de procesul caudat relativ exsang. Uneori este necesar i rezecia procesului caudat i a segmentului IX (poriunea paracav) efectundu-se o rezecie complet a lobului caudat, aa numita high dorsal resection[27]. Disecia, care este mult facilitat de folosirea bisturiului cu ultrasunete, continu pe faa anterioar a venei cave inferioare n planul dintre procesul caudat i segmentele VI i VII pn unde se vizualizeaz att vena hepatic dreapt ct i vena hepatic medie. Rezecia lobului caudat asociat rezecei convergenei reprezint tratamentul standard actual n tumorile Klatskin stadiul I i II, contribuind la creterea ratei de succes a rezeciilor R0 i implicit a supravieuirii [5]. Prin hepatectomia dreapt se rezec segmentele V, VI, VII, VIII, planul anterior fiind reprezentat de linia lui Cantlie (1 cm la dreapta scizurii principale, pn la nivelul marginii posterioare i superioare, 1 cm la dreapta venei cave inferioare), iar inferior i posterior de scizura principal (1 cm la dreapta scizurii principale, pn la marginea dreapt a plcii hilare, trecnd peste procesul caudat, de unde incizia se curbeaz dorsal i merge cam la 1 cm la dreapta venei cave inferioare). Primul timp l constituie mobilizarea ficatului drept prin seciunea ligamentului falciform, triunghiular drept i coronar drept. Dei tehnica Lortat-Jacob (a descris n 1952 prima hepatectomie dreapt reglat) prezint mai puine pierderi sangvine, este dificil de executat n cancerul de convergen, necesitnd abordul pediculului hepatic la nivelul hilului. Pentru o mai bun evidare ganglionar se folosete tehnica transparenchimatoas Ton That Tung cu descoperirea intrahepatic a pediculilor principali la sfritul diseciei parenchimului care se efectueaz prin digitoclazie, cu pensa sau mai uor cu bisturiul cu ultrasunete. Manevra Pringle prin care pediculul hepatic este nconjurat cu degetul (dup seciunea micului epiploon) i ridicat pe un la este util n controlul hemoragiei intraoperatorii, iar n cazul n care disecia se prelungete trebuie fcut intermitent pentru a nu ischemia ficatul. Se disec parenchimul hepatic i se identific, se ligatureaz i secioneaz progresiv vasele i canalele biliare. Trebuie identificate ramurile vasculare importante: ramura segmentului V pentru vena hepatic medie, pediculul glissonian primar al hemificatului drept (la nivelul planului transvers), posterior, colateralele venei hepatice medii (trebuie avut grij ca n timpul diseciei s nu fie lezat trunchiul venei hepatice medii pentru a nu afecta drenajul venos al segmentului IV). Prin deschiderea scizurii principale disecia ajunge pn la marginea dreapt a venei cave inferioare unde se pune n eviden vena hepatic dreapt care este secionat, iar captul dinspre vena cav este suturat cu dublu surjet 5-0 pe pens Satinsky. Ultimul timp l constituie ligatura i seciunea tuturor venelor accesorii care se deschid n vena cav inferioar. n cazul n care nu exist invazie vascular hilar se poate folosi i abordul combinat descris de Bismuth, o combinaie ntre abordul hilar i cel transparenchimatos. Aceast tehnic prezint avantajul identificrii planului de seciune a ficatului cu limitarea concomitent a sngerrii, (abordul hilar), precum i evitarea interceptrii unor elemente bilio-vasculare destinate ficatului rezidual, caracteristic abordului transparenchimatos). Sub numele de hepatectomie stng este cunoscut operaia prin care se rezec segmentele II, III i IV ale ficatului, din clasificarea lui Couinaud. Rezecia curativ n

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cancerul hilar include i segmentul I (lobul caudat) operaia fiind numit hepatectomie stng complet. Planul de rezecie este situat, ca i pentru hepatectomia dreapt, la nivelul scizurii principale a crei proiecie la suprafaa ficatului este linia Cantlie. Inferior, incizia pleac de la nivelul marginii anterioare, de la intersecia cu linia Cantlie, pn la extremitatea dreapt a plcii hilare, continund apoi la 1 cm deasupra plcii hilare pn la nivelul scizurii porto-ombilicale, unde se curbeaz dorsal, de-a lungul plcii ligamentului venos. i n hepatectomia stng primul timp const n mobilizarea ficatului stng prin secionarea ligamentului falciform, triunghiular stng i ligamentul coronar pn la nivelul venei cave inferioare, unde se pune n eviden vena hepatic stng i triunghiul posterior de atac. n tehnica transparenchimatoas Ton That Tung, disecia ncepe anterior spre placa hilar ligaturnd ramurile colaterale drepte ale venei hepatice medii. Deasupra convergenei se disec spre stnga pn la nivelul scizurii portoombilicale, unde este ligaturat i secionat pediculul glissonian al ficatului stng. Urmtorul timp este constituit de eliberarea lobului caudat de vena cav inferioar. Disecia posterioar a parenchimului identific vena hepatic stng care este ligaturat i secionat, uneori fiind necesar chiar ligatura i seciunea trunchiului comun al venelor hepatice medie i stng. O problem important o constitue invazia venei cave inferioare. Dei mult timp era un criteriu de nerezecabilitate, actualmente se poate rezeca o poriune din perete dac invazia este doar anterioar i refcut cu patch venos sau rezecat poriunea afectat n invazia circumferenial i reconstruit cu grefon venos sau sintetic. Pentru hepatectomiile drepte i stngi extinse, majoritatea autorilor opteaz pentru intervenia n 2 timpi dup dup ligatura sau embolizarea selectiv de ven port, urmat de evaluare volumetric a ficatului la 2 luni i rezecie ntr-un al doilea timp, dac s-a produs hipertrofia compensatorie a ficatului controlateral [18,19,27]. Hepatectomia stng extins presupune i rezecia segmentului V, VIII sau ambele (trisegmentectomie). Oncologic trebuie asociat i rezecia segmentului I. Linia de rezecie este situat n planul scizurii laterale drepte, la 1 cm la stnga fa de traiectul venei hepatice drepte. n cursul diseciei parenchimului se vor ligatura i seciona venele hepatice stng i medie, precum i venele segmetelor V i VIII (pediculul medial sau anterior) care se deschid n vena hepatic dreapt. Este necesar prezervarea pediculului lateral (posterior) al venei hepatice drepte pentru a evita o insuficien hepatic postoperatorie, fatal. Rezecia lobului caudat implic aa cum am mai artat eliberarea de faa anterioar a venei cave inferioare cu ligatura i secionarea venelor spiegeliene i a ramurilor caudate ale arterei hepatice stngi i ramului stng portal. Cu toate progresele tehnice, rmne o intervenie cu morbiditate i mortalitate mare (10%) [28]. Hepatectomia dreapt extins presupune i rezecia segmentului IV. Planul de disecie al parenchimului hepatic este reprezentat de planul scizurii porto-ombilicale, delimitat superior de inseria ligamentului falciform, iar inferior de anul venei ombilicale i de anul ligamentului venos (Arantius). Cel mai frecvent pediculul segmentului IV se abordeaz la nivelul scizurii ombilicale prin deschiderea acesteia la circa 1 cm n dreapta ligamentului falciform. La nivelul hilului, disecia se continu transversal, se expune pediculul glissonian al ficatului drept, care va fi ligaturat i secionat. Mai profund, vor fi ligaturate i secionate, intraparenchimatos, vena hepatic medie i vena hepatic dreapt. Intervenia se ncheie cu ligatura i seciunea venelor accesorii ale venei cave inferioare. Rezultate promitoare dup hepatectomia dreapt extins descriu Neuhaus P i Thelen A cu o supravieuire la 5 ani de 60%, fiind singura

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tehnic n care se aplic regula de no-touch, rezecia convergenei facndu-se n bloc cu ramul drept al arterei hepatice [29]. Pentru refacerea continuitii biliare se poate practica, pe cazuri selecionate, pe lng anastomoza cu o ans jejunal n Y i o anastomoz ntre ductul hepatic stng, secionat la baza fisurii ombilicale i coledoc [30]. Hepatectomia central este de fapt o trisegmentectomie IV, V, VIII. Planul de disecie este reprezentat la stnga de planul scizurii porto-ombilicale, delimitat superior de inseria ligamentului falciform, iar inferior de anul venei ombilicale i de anul ligamentului venos (Arantius), iar la dreapta n planul scizurii laterale drepte, la 1 cm la stnga fa de traiectul venei hepatice drepte, care desparte sectorul paramedian (segmentele V i VIII), de sectorul lateral (segmentele VI i VII) ale ficatului drept.. Pediculul segmentului IV se abordeaz la nivelul scizurii ombilicale, cu conservarea pediculilor segmentelor laterale stngi, II i III. n cursul diseciei n planul scizurii laterale drepte, se vor ligatura ramurile colaterale, provenite din segmentele V i VIII pentru vena hepatic dreapt, pstrndu-se trunchiul principal al acesteia. Cele dou planuri de seciune vor fi unite printr-o linie transversal care trece la circa 1 cm deasupra hilului. Dup separarea complet a ficatului central se ligatureaz i secioneaz vena hepatic medie. Se obin astfel 2 trane hepatice pe care se observ vena hepatic dreapt, stng i posterior, vena cav inferioar. Procentul cel mai mare de rezecii curative R0 (93%) a fost constatat dup hepatectomia total cu rezecie de pedicul hepatic, duodenopancreatectomie cefalic i limfadenectomie extensiv, dar cu rat mare de morbiditate i mortalitate [2,5]. Rezecia complet, incluznd hepatectomia ca o component obligatorie a tratamentului chirurgical rmne singura opiune de tratament ce ofer o supravieuire pe termen lung. Dac comparaiile ntre supravieuirea pacienilor cu rezecii radicale R0 i rezeciile R1 (examenul piesei de exerez evideniaz esut microscopic tumoral la nivelul marginilor de rezecie) sunt controversate, n ceea ce privete supravieuirea pacienilor cu rezecie R2 (esut tumoral restant macroscopic), aceasta este echivalent cu cea a pacienilor cu tumor nerezecabil [5,14]. Prognosticul neoplasmului de cale biliar rezecat depinde de tipul rezeciei, radical (R0 - supravieuirea la 5 ani 25-50%) sau paleativ (R1, R2), invazia limfonodular (invazia N2 fr supravieuire la 2 ani), extensia perineural, invazia vascular, tipul histologic i gradingul tumoral [14]. Prognosticul este mai favorabil pentru carcinoamele papilare, acestea fiind tumorile cu cel mai nalt grad de rezecabilitate. Leziunile localizate poriunea distal i mijlocie a cii biliare principale (CBP) au un prognostic mai bun dect tumorile Klatskin. Transplantul hepatic pentru colangiocarcinoamele hilare rmne n continuare controversat. El a fost practicat att pentru cancere hilare rezecabile, ct i pentru cele nerezecabile. Incidena mare a invaziei limfonodulare a fcut ca aceast indicaie de transplant s nu intre n practica de rutin. Pichlmayr et al au raportat o serie de 249 de pacieni cu cancer de hil pentru care, la 125 dintre ei s-a practicat rezecie, iar la 25 transplant hepatic. Ei au constatat c rata supravieuirii la 5 ani dup rezecie este echivalent sau superioar transplantului (27,1% versus 17,1%) n toate stadiile bolii [31]. Klempnauer et al raporteaz supravieuire la 5 ani de doar 4(12.5%) pacieni din 32 la care s-a practicat transplant hepatic pentru colangiocarcinom hilar. n aceeai perioad 151 de pacieni au suferit rezecii curative i 28(18.5%) de pacieni au supravieuit la 5 ani [32]. Chamberlaine i Blumgart recomand rezecia radical ca fiind singurul tratament care prelungete supravieuirea cu o bun calitate a vieii

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[10,16]. Pe de alt parte Rea i colab. a demonstrat c dup chimioterapie neoadjuvant i transplant hepatic, rata recidivelor este semnificativ mai mic dect dup rezecie (13% vs 27%). [33] n cancerului segmentului mijlociu al cii biliare principale (hepatocoledoc) tratamentul chirurgical curativ const n rezecie de la convergen pn imediat supraduodenal, limfadectomie i refacerea continuitii prin hepatico-jejunoanastomoza. Sunt utilizate 2 tipuri de rezecie de cale biliar i anume rezecie segmentar (rezecia tumorii la cel puin 2 cm limitele macroscopice ale tumorii) i rezecia segmentar nalt (proximal sunt secionate cele 2 canale hepatice comune drept i stng). Rezecia segmentar a CBP presupune ridicarea esutului fascial nconjurtor mpreun cu limfonodulii gsii pe faa posterioar a capului pancreatic decolat i n unghiul coledoco-duodenal. Timpul cel mai delicat al interveniei const n izolarea coledocului de elementele vasculare ale pediculului hepatic: artera hepatic proprie, care va fi suspendat pe un la i vena port. Separarea coledocului de vena port este mai uoar n partea de jos, retroduodenal, unde coledocul se deprteaz progresiv de trunchiul venos. Se secioneaz coledocul distal, iar traciunea sa, nlesnete separarea CBP de planul portal. Separaia tumorii de planul venos pn aproape de convergen se va face cu gesturi blnde fiind facilitat de utilizarea bisturiului cu ultrasunete. La acest nivel, canalul hepatic comun va fi secionat. Refacerea tranzitului se face prin anastomoza canalului hepatic comun restant cu duodenul sau cu jejunul.

Fig.3 Anastomoz hepatico-duodenal

Anastomoza hepatico-duodenal este indicat cnd calibrul hepatocoledocului supratumoral este mai mare de 10 mm i este facilitat de decolarea duodenopancreatic (manevra Kocher), care a fost fcut n timpul de explorare. Anastomoza se face ntr-un singur plan, total, pe canalul hepatic, extramucos sau total pe duoden, cu nodurile nuntru pentru planul posterior i n afar, pentru planul anterior, la distan de 3 mm, cu cu fire neresorbabile, separate (Fig. 3). Cea mai utilizat anastomoz este ns anastomoza hepatico-jejunal care se poate realiza n 2 variante: pe ans n Y (Roux) sau pe ans continu (n omega). Prezint avantajul c se opune refluxului alimentar i prezint o rat mai mic de fistul. Anastomoza hepatico-jejunal pe ans n , Y (Roux) este cea mai folosit n practica clinic, fiind recomandat cnd canalul hepatic este sub 10 mm diametru.

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Ansa anastomotic este trecut transmezocolic n etajul supramezocolic, iar anastomoza se efectueaz terminolateral, care este mai sigur avnd o rat de complicaii postoperatorii mai mic. Anastomozele precolice i terminoterminale nu sunt recomandate dect n cazuri selecionate. Lungimea ansei excluse din circuitul alimentar trebuie s fie de cel puin 50 cm pentru a mpiedica refluxul alimentar n cile biliare. Ansa trebuie suspendat deoparte i de alta a anastomozei, la capsula hepatic, patul colecistic i micul epiploon. Anastomoza n omega se poate efectua precolic sau transmezocolic cu anastomoz Braun la piciorul ansei. Totui acest montaj nu suprim ns, posibilitatea refluxului alimentar n calea biliar. Pentru evitarea acestui dezavantaj Juvara recomand striciunea ansei aferente iar ansa eferent trebuie s fie lung. n rezectia segmentara nalt a CBP, proximal sunt secionate cele dou canale hepatice, drept i stng. Este indicata n tumorile canalului hepatic comun aproape de convergen i n caz de convergen joas. Refacerea continuitii se face prin anastomoza hepatico-jejunal pe ans n Y (Roux) cu implantarea separat a celor 2 canale hepatice. Datorit calibrului mic al celor 2 canale hepatice se recomand protezarea anastomozelor fie cu tub pierdut, fie cu tub Kehr. Mortalitatea perioperatorie este de sub 5%, iar morbiditile pot ajunge i pn la 20% dup diferite studii. Principalele complicaii postoperatorii sunt fistulele biliare la nivelul anastomozei biliodigestive (dac fistula este mic, tratamentul este conservator cu aspiraie continu, i administrare de octreotide), dehiscena anastomozei cu instalarea unei fistule duble, biliare i digestive (oblig la reintervenie, cu drenaj biliar extern Kehr, transfistular, sutur, plombaj epiplooic sau fistul dirijat pe duoden), nefuncionalitatea anastomozei, peritonite localizate sau generalizate, supuraii parietale. Complicaiile generale sunt comune chirurgiei biliare i digestive [13,34]. n tumorile maligne ale coledocul distal, ca i n cancerele ampulare, intervenia curativ este reprezentat de duodenopancreatectomia cefalic care const n exereza blocului duodeno-pancreatic i rezecia CBP pn la convergen [37]. Mortalitatea postoperatorie variaz dup diferite studii ntre 5-15%, iar morbiditatea ntre 30-50%. Principala complicaie este fistula pancreatic. Prognosticul este mai bun dect n cazul celolalte tipuri de cancer de ci biliare, supravieuirea ajungnd pn la 54% la 5 ani, dac rezecia a fost R0 i nu exist invazie limfonodular [35]. Factorii de prognostic negativ sunt invazia limfonodular i gradul de difereniere al tumorii. Criteriile de nerezecabilitate dup Popescu I sunt: boli asociate ce contraindic intervenii chirurgicale de amploare, metastaze la distan, tumori multifocale i invazie extins a trunchiului venei porte [14,36]. Din nefericire, n majoritatea cazurilor, tumorile sunt diagnosticate deseori n stadii nerezecabile, interveniile paleative fiind indicate mai frecvent dect cele radicale. Scopul tratamentului paleativ este decompresia cilor biliare, cu remiterea icterului, evitarea insuficienei hepatice i scderea riscului unei colangite. Metodele de decompresiune biliar se mpart n: 1) metode nechirurgicale invazive prin drenaj transparietohepatic, de tipul drenajului extern, sau intern dup forajul tumoral i forajul transtumoral endoscopic; 2) metode chirurgicale de tipul derivaiilor biliodigestive, forajul transtumoral urmat de drenaj extern sau intern (tub pierdut) sau drenaj extern transhepatic. Metodele chirurgicale de rezolvare a icterului sunt superioare celorlalte metode radiologice sau endoscopice [5,14]. Alegerea tipului de drenaj depinde att de disponibiliti (tehnice i financiare) ct mai ales de tipul obstruciei, localizare, de posibilitile tehnice de a introduce sau nu un fir ghid i apoi un cateter prin zona de obstrucie tumoral.

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Drenajul biliar transparietohepatic este indicat n obstruciile maligne nalte, fiind totodat folosit i ca metod de decompresie a cilor biliare nainte de intervenia chirurgical cu viz curativ. Pentru obstruciile joase abordul endoscopic pare mai potrivit n special atunci cnd se intenioneaz plasarea unui stent. Procedurile endoscopice sunt utile mai ales pentru leziunile ampulei Vater i coledocului distal. Drenajul biliar transparietohepatic presupune introducerea unor stenturi metalice expandabile n cile biliare intrahepatice prin tehnici de radiologie intervenional . Primul drenaj extern a fost descris de Kaude et al la nceputul anilor '70. Hoevels et al n Europa i Nakayama n Japonia au realizat ulterior primele drenaje interne. n Romnia, primele drenaje biliare percutane transhepatice s-au efectuat la Clinica Radiologic a Spitalului Universitar Sf. Spiridon Iasi, de Prof. Daniil C et al n anul 1982 [38,39]. Contraindicaiile metodei sunt date n principal de tulburrile de coagulare, ascita voluminoas, caexia neoplazic cu stare general grav i un indice Karnovsky sub 40%. Se practic un foraj transtumoral i se plaseaz stentul trecut pe un fir ghid, sub ghidaj fluoroscopic subtumoral n coledoc sau n duoden. Vrful acestuia este auto-retentiv. Se obine astfel un drenaj bilar extern-intern, cu drenajul bilei iniial att la exterior ct i n intestin (pentru decompresia iniial) urmat de drenaj strict intern, calea extern fiind pstrat ca rezerv pentru eventuale manipulri ulterioare. n caz de nereuit a forajului transtumoral, stentul poate fi plasat deasupra tumorii realizndu-se un drenaj biliar extern. n general un stent are o durat de via de 6 luni, dup care n majoritatea cazurilor se colmateaz i trebuie nlocuit [40]. La cca. 80-90% din pacieni se poate realiza un drenaj intern iniial, la 5% nu se poate realiza dect un drenaj extern iar la 5%, fie nu se poate realiza drenajul, fie volumul hepatic decomprimat nu este suficient pentru a determina reducerea simptomatologiei. Complicaiile posibile sunt: hemoperitoneul, coleperitoneul, hemobilia, colangita, dar i posibilitatea nsmnrii celulelor tumorale cu apariia carcinomatozei peritoneale sau a metastazelor parietale. Complicaiile la distan se ntlnesc cu o frecven mai mare, 40-50%, fiind reprezentate de funcionarea defectuoas a cateterului, fie prin colmatare fie prin dislocare. Mortalitatea procedeului este de 1,5-3% [5,14,41]. Endoprotezarea cilor biliare este procedura prin care se plaseaz o protez din plastic sau metalic n interiorul cilor biliare prin abord percutan transhepatic prin radiologie intervenional, pe cale endoscopic sau prin tehnica rendez-vous (abord att endoscopic ct i percutan) [42]. Protezarea cilor biliare a fost realizat prima dat n 1978 de ctre Burchard i Pereiras, care au utilizat proteze de plastic, fr rezultate ncurajatoare datorit obstruciei precoce. Ulterior, folosirea unor proteze mai mari de 12-14 F au artat c acestea i pstreaz permeabilitatea pe o perioad de 19-26 de sptmni. Protezele metalice au intrat n practica clinic curent din 1989. Durata medie de pstrare a permeabilitii a acestora este de 24-39 sptmni. n Romnia, primele endoprotezri percutane transhepatice a cilor biliare s-au efectuat n Clinica Radiologica a Spitalului Universitar Sf. Spiridon Iai, de Prof. Daniil C. et al n anul 1984. Dup ce firul ghid trece de zona tumoral pn n duoden, se fac dilataii cu balona a stricturii tumorale i se introduce stentul metalic care se expandeaz. Proteza trebuie s depeasc cu 2 cm nivelul proximal al obstruciei. Dac nu, se introduce nc o protez care s se suprapun parial cu prima, pe o lungime de 2 cm. Plasarea stentului se verific printr-o colangiografie de control [41,43].

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n tehnica rendez-vous, pe ghidul trecut n duoden sub control fluoroscopic se introduce endoscopic proteza retrograd. Principalul avantaj al endoprotezrii este o mai bun calitate a vieii, dezavantajul lor fiind c nu pot fi nlocuite, de cele mai multe ori fiind nglobate n tumor. Legat de supravieuirea pacienilor, rezultatele nu sunt ncurajatoare n ciuda tehnicii n permanent mbuntire. Astfel, scopul tratamentelor paliative rmne ndeprtarea simptomatologiei determinate de obstrucia biliar n ncercarea de a diminua mobiditatea asociat i a prelungi supravieuirea n condiiile unei caliti a vieii ct mai bune . La bolnavii cu risc chirurgical crescut i mai ales la vrstnici forajul transtumoral endoscopic evit complicaiile radiologiei intervenionale, indicaiile fiind tumorile hepatocoledocului pedicular i coledoc distal nerezecabile. n ultimii ani, plasarea endoscopic de stenturi a devenit o alternativ la operaiile tradiionale de bypass biliodigestiv n tratamentul paliativ al pacienilor cu obstrucii biliare maligne. Ultimile studii efectuate n acest sens au demonstrat c tratamentul endoscopic este tratamentul de prim intenie, chirurgia rmnnd indicat doar atunci cnd apare obstrucia duodenal (doar la 13% dintre supravieuitori). Mortalitatea combinat intraoperatorie i n primele 30 de zile postoperatorii este de 15-30% fa de mortalitatea dup abordul endoscopic care este de 0-2%, cu o rat de succes de 90% [44-46]. Sonnenfield et al a relatat ntr-un studiu nerandomizat de comparare a endoprotezelor versus bypass-ul chirurgical c nu exist diferene semnificative n supravieuire dar cu o durat a spitalizrii i complicaii majore mai mari n grupul chirurgical. De asemenea inseria stentului endoscopic prezint o rat mai mic a complicaiilor i mortalitii postprocedur fa de inseria de stent percutan [44]. Andersen et al au efectuat un studiu pe 50 de pacieni cu tumori maligne ale cilor biliare, din care la 25 s-a protezat endoscopic CBP, iar la 19 pacieni s-a putut practica o anastomoz biliodigestiv. Nu a gsit diferene semnificative statistic n ceea ce privete supravieuirea (84 de zile n lotul endoscopic versus 108 zile), spitalizare sau calitatea vieii. Durata de funcionare a protezelor a fost de pn la 450 de zile pentru protezele de 7 F i ntre 68-234 de zile n cazul protezelor de 10 F. Andersen recomand ca n spitalele cu dotare tehnic pentru introducerea unui stent pe cale endoscopic, acesta s fie prima opiune terapeutic [45]. Liu et al prin aplicarea mai multor stenturi endoscopic descrie o rata de succes pentru tumorile Klatskin de 73% [47]. Van den Bosch et al recomand tratamentul endoscopic paliativ al obstruciilor biliare maligne pentru pacienii care au o speran de via sub 6 luni i tratamentul chirurgical de bypass biliodigestiv pentru pacienii care au o speran de via mai mare de 6 luni. [43] Tehnica protezrii endoscopice a cii biliare const n introducerea unui fir ghid pn cel puin 5 cm supratumoral, dup care se practic sfincterotomie cu ansa diatermic. Se introduce proteza expandabil pe firul ghid pn n poziia dorit. Se expandeaz proteza injectnd substan de contrast pn la 5 atmosfere i se efectueaz o radiografie de control. Majoritatea stenturilor se expandeaz pn la 75% din diametrul lor maxim. Complicaiile care pot apare sunt: hemoragia, pneumotoraxul, septicemia, hemobilia, iar la distan: migrarea stentului, hemoragie digestiv superioar (prin eroziuni duodenale) i colmatarea protezei datorit formrii aderenelor bacteriene sau creterii tumorale. Durata pn la colmatare este n medie de 4-5 luni pentru protezele de polietilen i de 8 luni pentru stenturile metalice, demonstrnd superioritatea acestora. La ora actual drenajul endoscopic este recomandat n leziunile Bismuth II, III, iar drenajul percutan in leziunile de tip IV [48]. n tumorile Klatskin, n absena colangitei este suficient drenajul ficatului dominant.

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Protezarea bilateral, dei se nsoete de o supravieuire mai lung are un procent de reuit de 65% din cazuri [49]. Dintre tehnicile chirurgicale, cel mai utilizat procedeu este forajul transtumoral. Se disec coledocul supraduodenal, se practic coledocotomie, se trece o sond metalic dincolo de tumor, dup care stenoza tumoral este dilatat progresiv (n jur de 5 mm) prin creterea calibrului instrumentului explorator. Ulterior se plaseaz o protez siliconat (tub pierdut) (fig. 5) sau un tub n T al crui ram proximal traverseaz masa tumoral ajungnd ntr-un canal biliar de deasupra tumorii i drennd astfel bila extern sau intern, n duoden atunci cnd tubul este pensat.

Fig. 5 Tumor Klatskin foraj transtumoral (stnga) i protezare transtumoral cu tub pierdut (dreapta)

Alt variant este cea a drenajul bipolar cu tub n U (Terblanche) sau cu tub pierdut Huguet (ramul distal al tubului este scos prin incizia de coledocotomie sau trecut transpapiloduodenal i exteriorizat printr-o incizie n peretele duodenal dup tehnica Witzel) [1]. Principalele complicaii sunt reprezentate de perforaia tumorii, a cii biliare sau a unui ram portal, iar la distan, colmatarea tubului de dren. Alte tipuri de drenaje externe n care coala romneasc are o important contribuie sunt drenajele biliare axiale. n 1965 Burlui face primul drenaj axial. Prin brea de coledocotomie se ptrunde cu un explorator metalic gen benique, se depete zona tumoral, ajungndu-se n canalele biliare intrahepatice, pn n vecintatea suprafeei exterioare a ficatului unde este exteriorizat i se ataeaz un tub de dren, care este tras transhepatic, trece transtumoral, ajungnd n coledocul subtumoral. Peste 2 ani n 1967, Burlui i Raiu aduc o ameliorare tehnic a drenajului axial, crend un instrumentar (compus dintr-o serie de dilatatoare drepte i 5 mandrene de diametre i curburi diferite care se pot fixa la un mner universal) ce permite exteriorizarea drenului coledocian prin vena ombilical repermeabilizat sau transligamentar. Metoda a fost brevetat n 1976. Drenajul biliar axial cu toate variantele lui, nu este superior celorlalte tehnici de drenaj, dar, pe de alt parte, ofer o alt posibilitate terapeutic paleativ de dezobstrucie biliar [50]. Derivaiile interne bilio-digestive au ca scop drenarea retrograd a bilei i sunt de fapt derivaii interne intrahepatice supratumorale. Dac convergena nu este invadat, cea mai bun soluie este efectuarea unei anastomoze ntre canalul hepatic stng i o ansa jejunal n Y. n cazul invaziei tumorale a convergenei, se poate practica n funcie de canalul hepatic invadat: anastomoz intrahepatic stng, dreapt i bilateral.

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n cancerele nerezecabile ale hepatocoledocului pedicular, de multe ori, forajul tumoral este imposibil. n aceste cazuri se prefer o anastomoz paleativ supratumoral sau la nivelul convergenei. [13] n cancerele coledocului distal nerezecabile sunt utilizate diferite tipuri de derivaii bilare: colecistodigestive- stomac, duoden, jejeun, sau coledocodigestiveduoden-jejun.[51] Pentru anastomozele intrahepatice stngi, cele mai utilizate procedee la ora actual sunt colangiojejunostomiile. Colangiojejunostomia Hepp-Couinaud, presupune seciunea ligamentului rotund i disecarea captului su hepatic, n interiorul anului ombilical, pn la nivelul unde ligamentul ptrunde n parenchim, prin cele dou prelungiri laterale, stng i dreapt. Incizia parenchimantoas este facilitat de utilizarea unui disector cu ultrasunete. Canalul biliar al segmentului III este situat deasupra i n faa ramului portal al segmentului III fiind elementul superior i anterior al pediculului segmentar, identificarea sa fiind facilitat de ecografia intraoperatorie. Dup ce este reperat, canalul dilatat este incizat longitudinal pe 1-2 cm. Se scoate din circuitul digestiv o ans n Y de 80 cm i se practic anastomoz colangiojejunal, laterolateral n plan total pe canalul hepatic i extramucos pe jejun cu fire lent resorbabile 5-0. Acest tip de anastomoz se poate practica i cu canalul segmentului IV; calea de abord este paralel, dar situat la dreapta ligamentului rotund. n acest caz este necesar drenajul transanastomotic. O alt anastomoz biliodigestiv care se poate utiliza este colangiojejunostomia intrahepatic stng (Longmire), care const n rezecia hepatic segmentar lateral stng (lobectomie stng), ntr-un plan care trece la 1 cm de ligamentul falciform. La nivelul tranei de hepatectomie se evidenia canalul biliar lobar stng, acesta urmnd s fie anastomozat la o ans jejunal n Y. Colangiogastrostomia Couinaud este asemntoare celei precedente, dar anastomoza se efectueaz cu stomacul. Fgranu descrie hepatogastroanastomoza, n care trana de rezecie a segmentului III hepatic se anastomozeaz cu stomacul i se asigur cu o plastie cu ligament rotund [1]. Colangiojejunostomia intrahepatic dreapt, se practic de obicei cu canalul segmentului VI. Dup ce acesta este reperat prin puncie ghidat ecografic se practic o incizie cuneifom centrat de acul de puncie i se evideniaz canalul la nivelul tranei de hepatotomie, se trece la realizarea anastomozei colangiojejunale. Anastomozele intrahepatice drepte sunt indicate n cadrul anastomozelor bilaterale, n tumorile Bismuth II i III cnd nu exist comunicare ntre cele 2 teritorii hepatice. Exist 2 tipuri de anastomoz dreapt utilizate: cu i fr rezecie hepatic. Anastomoza intrahepatic dreapt cu rezecie const n hepatectomie atipic a vrfului anteroinferior drept al ficatului, trana hepatic fiind suturat n ansamblul su cu o ans n Y, iar canalele biliare sunt intubate cu un dren Vlker care traverseaz ansa n Y [14]. Dintre anastomozele intrahepatice dreapte fr rezecie cea mai utilizat este colangiojejunostomia terminolateral Bismuth-Lechaux cu canalul segmentului V prin incizia marginii anterioare a ficatului la 3 cm, la dreapta veziculei biliare. Prioton recomand abordul transcizural anterior al segmentului V printr-o incizie transversal la dreapta hilului, iar Launois, abordul transcizural posterior al canalelor biliare drepte, cu o rat mai mic de fistule biliare [13]. Anastomoza intrahepatic bilateral este utilizat cnd invazia tumoral prinde convergena i n cazul eecului dublei protezri transtumorale, chirurgicale sau endoscopice, dar i pentru c reduce riscul sepsisului, ce poate apare prin dezvoltarea colangitei n teritoriul hepatic nedrenat. Colangiojejunostomia bilateral

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transparenchimatoas, tehnic propus de Bismuth, presupune rezecia parial a segmentului IVb. Deseori aceste anastomoze, nu pot fi executate tehnic, datorit invaziei tumorale sau sunt rapid invadate de extensia procesului tumoral. De aceea este preferat colangiojejunostomia cu canalele biliare ale segmentelor III i VI. Alte derivaii biliodigestive care pot fi folosite sunt colangiocolecistoanastomoza Kolsky, n care se anastomozeaz vezicula biliar cu un canal biliar dilatat, evideniat prin dezinseria poriunii mediale a colecistului i disecia n patul hepatic, dup care vezicula biliar este reinserat cu fire separate i hepatico-colecisto-enteroanastomoz, recomandat n condiiile n care canalul cistic este obstruat de tumoare [5]. Dac anastomozele biliodigestive sunt bine executate, ofer cea mai bun soluie de paliaie a icterului cu o bun calitate a vieii. Totui rata morbiditilor i mortalitii postoperatorii se menine mare, datorit fistulelor anastomotice i proceselor inflamatorii de colangit n segmentele hepatice nedrenate. Pe aceste considerente se poate afirma c drenajul transtumoral poate fi mai eficient dect o anastomoz biliodigestiv periferic, dar pe de alt parte existena unei anastomoze paliative permite completarea unui tratament paliativ cu radioterapie intraluminal utiliznd Iridiu 192 [13,22,52]. Dei s-au fcut progrese remarcabile n ultimii ani, tratamentul adjuvant n tumorile maligne ale cilor biliare principale nu amelioreaz semnificativ supravieuirea acestor pacieni. Pentru c majoritatea cancerelor cilor biliare sunt nerezecabile, cel mai utilizat tratament este forajul transtumoral cu plasarea unui stent, chirurgical, radiologic sau endoscopic. Scopul radioterapiei este de a prelungi supravieuirea, a menine permeabilitatea ct mai lung a stentului i de a ameliora durerile. Deoarece, durata de via a pacienilor depete durata de permeabilitate a stenturilor, radioterapia extern i intraluminal devine obligatorie n managementul postoperator al acestor pacieni. Radioterapia extern trebuie s depeasc 50 Gy pentru a fi eficient n adenocarcinoamele de ci biliare [53]. Dac n cancerele de vezicul biliar i n ampuloamele vateriene, studiile au demonstrat ineficiena radioterapiei externe, n cancerele nerezecabile de ci biliare, aceasta reprezint cel mai bun tratament adjuvant cu ameliorare semnificativ a calitii vieii [54,55]. Dar utilizarea unei doze de peste 50 Gy afecteaz organele aflate n cmpul de radiaie: ficatul, rinichiul i tractul digestiv. Din aceast cauz, dac doza necesar depete 80Gy, atunci radioterapia extern trebuie asociat cu brahiterapia. Asocierea radioterapiei externe cu brahiterapia au un efect benefic n principal n cazul rezeciilor R1, i mai ales n tumorile mici, prelungind supravieuirea i timpul de apariie al recidivei locale [56,57]. De asemenea radioterapia intraluminal, aplicat prin proteze biliare plasate percutanat sau endoscopic, folosind Ir192 controleaz proliferarea tumoral, prelungind astfel permeabilitatea stentului transtumoral. Alte avantaje ale asocierii brahiterapiei cu radioterapia extern constau n ameliorarea durerii, controlul hemoragiei tractului digestiv i n tratamentul fistulelor biliare [58,59]. Chimioterapia este indicat la pacienii cu cancere nerezecabile (avansate local), cu metastaze la distan i n recidivele dup rezecie [60]. Poate fi practicat sub forma chimioterapiei sistemice sau sub forma chimioterapiei locale intraarteriale. Cancerul de ci biliare este foarte puin sensibil la chimioterapie. Monochimioterapia cu 5 FU, Mitomicin C sau Doxorubicin se nsoete de o rat de rspuns de 10-20%. Regimul FAM (5 FU, Doxorubicin i Mitomicin), repetat la 8 sptmni a determinat o rat de rspuns de 29% [61], iar asocierea 5 FU (oral) cu Streptozotocin sau metil-CCNU

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(MeCCNU) s-a nsoit de rspuns la 3 pacieni din 34. Rezultatele au nceput s se mbunteasc dup 1999 cnd, a nceput s fie folosit gemcitabina. Aceasta poate fi folosit singur sau n asociere cu 5 FU, oxaliplatin sau irinotecan. Asocierea gemcitabinei cu cisplatin obine cea mai mare rat de rspuns 35-38%, cu o supravieuire care poate ajunge i la 11 luni [62]. Gemcitabina este la ora actual n Japonia, chimioterapicul, recomandat a fi utilizat n tratamentul cancerului de ci biliare nerezecabil. Rezultate promitoare s-au obinut i dup tratamentul cu anticorpi monoclonali de tipul erlotinibului (anti-EGFR) [63]. Chimioterapia regional cu 5 FU, Fluorodeoxyuridine sau Doxorubicin n administrare intraarterial (n artera hepatic) a avut o rat de rspuns mai crescut (4050%) n raport cu cea a chimioterapiei sistemice [14]. Lygidakis, public rezultate bune folosind imunochimioterapia loco-regional, administrat pe calea arterei hepatice [52]. n ceea ce privete chimioterapia adjuvant postoperatorie dup rezecia curativ, aceasta nu mbuntete semnificativ statistic supravieuirea. Rezultatele dup tratamentul cu gemcitabin ncep s fie promitoare, dar numrul prea mic de studii i loturi prea mici de pacieni nu au impus-o nc. Asocierea radioterapiei externe cu brahiterapia i regimurile de chimioterapie cu gemcitabin mresc rata supravieuirii pe termen lung dup rezecia radical. O alt metod de tratament adjuvant este terapia fotodinamic (TFD) pe stent introdus endoscopic sau percutan, cu o rat de supravieuire n tumorile nerezecabile comparabil cu rezecia R1 . n condiiile n care rata median de supravieuire este de 3 luni fr tratament i de doar 4-6 luni cu protezarea cii biliare, terapia fotodinamic este o opiune de luat n considerare [64]. Aceast metod paliativ este nc la nceput i pn la ora actual exist puine studii i cu un numr mic de pacieni pentru a se putea impune, dar rezultatele fiind ncurajatoare: Zoepf et al. pe un lot de 39 de pacieni, raporteaz prelungirea supravieuirii mediane fa de plasarea unui stent transtumoral de la 7 luni la 21 de luni [65]. Shim et al raporteaz o rat de supravieuire la 1 an de 59.6% i o rat de supravieuire median de 18 luni, dar obine totodat i o scdere a dimensiunilor tumorale, msurat ecografic de aproape 3 cm la 4 luni dup tratament [66]. CONCLUZII Cea mai frecvent localizare a cancerului cii biliare principale este cea proximal, ce cuprinde canalele hepatice drept i stng, convergena i canalul hepatic comun (tumori Klatskin). Colangiografia prin rezona magnetic (colangioIRM) este superioar celorlalte metode de explorare preoperatorie, permind diagnosticul i stadializarea tumorilor. Rezeciile complexe, ce presupun asocierea rezeciei de ci biliare cu rezecii hepatice, iar uneori i rezecii vasculare, dei sunt asociate cu o mortalitate i o morbiditate mai mare, prezint o supravieuire mai lung i o mai bun calitate a vieii. Tratamentul paleativ const n asigurarea drenajului biliar prin derivaii biliodigestive sau prin stenturi introduse chirurgical, radiologic, percutan sau endoscopic. Dei mult timp radiochimioterapia nu a prezintat rezultate ncurajatoare n ameliorarea prognosticului, asocierea radioterapiei externe cu brahiterapia i regimurile de chimioterapie cu gemcitabin cresc rata supravieuirii.

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CONDUITA N RUPTURILE DE ISTM AORTIC


C. Moroanu, C. Roat, S. Lunc Clinica de Urgene Chirurgicale, Spitalul Clinic de Urgene Sf. Ioan Iai Universitatea de Medicin i Farmacie "Gr. T. Popa" Iai
MANAGEMENT OF TRAUMATIC RUPTURE OF THE AORTIC ISTHMUS (Abstract): Traumatic rupture of the aortic isthmus is a rare lesions occurring usually in patients subjected to sudden deceleration in cars accidents. This lesion is a potentially fatal injury that leads to death in 75-90% of cases at the time of injury. However, patients who survive to reach the hospital have the chance to overpass this dramatic situation. Computer tomography and transesophageal echocardiography are of great value in making the diagnosis. Open surgery with conventional repair is still considered the gold standard technique for cases of isolated rupture. Delayed management approach with controlled hypotension and radiological monitoring is a safe and recommended option for patients with severe multiple injuries or co-morbidities that put surgery at high risk. Urgent endovascular stenting offers a minimally invasive method that has been shown to be a feasible, safe and efficient technique which may be proposed as a therapeutic alternative for patients with multiple trauma instead of delayed surgical repair after stabilization. In Romania few patients with traumatic aortic rupture arrive alive at the hospital. However, with the progresses in the first aid and transportation of the trauma patients, in our hospitals such cases will appear more frequently and surgeons working in emergency hospitals should be prepared to manage such dramatic cases. KEY WORDS: AORTIC ISTHMIC RUPTURE, TRAUMA, SURGERY. Coresponden: Dr. Corneliu Moroanu, Spitalul Clinic de Urgen Sf. Ioan Iai, Clinica de Urgene Chirurgicale, Str. Gen. Berthelot nr. 2, Iai, tel: 0232 216586; e-mail: corneliumorosanu@gmail.com*

INTRODUCERE Leziunile de istm aortic au loc n urma unor traumatisme nchise, cel mai frecvent secundar unor traumatisme prin deceleraie brusc, urmare a unor accidente rutiere. Gravitatea lor este deosebit, de aceea ncercarea de a stabili o conduit corect poate oferi pacienilor ce ajung vii la spital, anse mai mari de supravieuire. Vitezele din ce n ce mai mari de deplasare ale autovehiculelor au dus i la o cretere important a numrului de accidente rutiere i la o gravitate i complexitate din ce n ce mai mare a acestora. n cadrul leziunilor produse prin accidente rutiere se difereniaz ca o entitate bine conturat ruptura traumatic de aort [1-3]. Studii necropsice [1] arat c doar 7-13% din pacienii cu ruptur traumatic de aort supravieuiesc att de mult nct s ajung la spital n via. Un studiu arat c aproximativ 38% dintre pacieni supravieuiesc mai mult de 30 de minute, dar numai 8%, mai mult de 4 ore [1]. CONDUITA TERAPEUTIC Conduita este difereniat n funcie de starea pacientului, tipul leziunii si prezena leziunilor asociate [4-7]. Uneori, importana hemoragiei impune controlul chirurgical imediat al acesteia, de maxim urgen, limitnd la strictul necesar examinrile sau explorrile. Alteori, relativa benignitate a leziunii permite o examinare
received date: 15.11.2008 accepted date: 23.12.2008
*

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mai complex a pacientului. Examinarea clinic i paraclinic a pacientului trebuie adaptate gravitii cazului. Rezolvarea unei leziuni traumatice aortice presupune implicarea unei echipe medico-chirurgicale complexe. Ca pentru orice traumatizat grav se ncepe cu asigurarea funciilor vitale, n paralel cu aceasta efectundu-se i examenul clinic, apreciindu-se totodat necesitile i posibilitile efecturii investigaiilor paraclinice [1,2,8]. Dac situaia permite, se fac investigaiile necesare pentru diagnosticul leziunii aortice: radiografie toracic, computer tomografie (CT), rezonan magnetic nuclear (RMN), echocardiografie transesofagian (ETE), iar pentru aprecierea leziunilor asociate n cazul politraumatismelor: radiografii de coloan vertebral, bazin, membre, investigarea traumatismelor cerebrale. Ierarhizarea rezolvrii leziunilor [1,2,9,10] n situaia n care pacientul prezint leziuni asociate abdominale hemoragice sau leziuni expansive intracraniene, acestea se rezolv naintea celei aortice. Pacientul se poziioneaz n decubit lateral drept i este intubat cu o sond traheal cu dublu lumen cu posibilitatea ventilrii selective a plmnilor, condiii ce permit la nevoie toracotomia de urgen dac apar probleme n timpul desfurrii interveniei abdominale sau cranio-cerebrale. Pe toat durata interveniei abdominale sau cranio-cerebrale se monitorizeaz leziunea aortic prin echografie transesofagian i tensiunea arterial (TA) care trebuie meninut ntre 100-120 mmHg cu betablocante dac debitul cardiac este suficient pentru a reduce riscul de ruptur nainte de repararea leziunii. Dac situaia impune, n cazul hemoragiilor masive pacientul este transportat de urgen n sala de operaie unde se instituie msurile mai sus menionate i se poate efectua ca investigaie paraclinic echocardiografia transesofagian sau toracoscopia diagnostic, n cazul n care exist timpul necesar pentru a le efectua. S-a ncercat stabilirea unor protocoale de conduit n cazul rupturii traumatice de aort [1,2,5,11]: 1. trebuie suspicionat o leziune aortic la toi pacienii cu accidente prin deceleraie violent; 2. se evalueaz pacientul concomitent cu resuscitarea pn la obinerea unei presiuni arterial la ambele brae i la membrele inferioare; 3. radiografia toracic examinarea radiografiei pentru lrgirea mediastinului (peste 8 cm la nivelul coastei C3) sau dispariia butonului aortic. Urmtoarele semne sunt sugestive pentru o posibil leziune aortic: - hematom apical pulmonar stng; - depresiunea bronhiei principale stngi; - traheea i esofagul deviate la dreapta; - fracturi costale C1, C2; - dispariia ferestrei aortopulmonare; 4. examinarea pacientului pentru evidenierea diferenelor de tensiune arterial ntre cele dou membre superioare sau superioare i inferioare; sugestive sunt diferena mai mare de 10 mmHg (pseudocoarctaie) sau murmur infrascapular stng; 5. dac se consider probabil leziunea aortic, se va evita hipertensiunea arterial n orice moment al resuscitrii prin administrarea de betablocante cu aciune scurt [1,5,12];

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6. dac este descoperit un mediastin lrgit i pacientul poate sta vertical se face radiografie n aceast poziie; dac mediastinul nu mai este lrgit, dar nu se observ butonul aortic se face computer tomografie cu seciuni la nivelul arcului aortic; 7. dac mediastinul este tot lrgit sau radiografia n poziie vertical nu se poate efectua, se va face CT sau ETE: dac la CT nu se evideniaz snge periaortic se exclude leziunea aortic, iar dac la ETE nu se evideniaz ruptura aortic atunci se exclude de asemenea, leziunea aortic; 8. angiografia aortic trebuie obinut n urmtoarele circumstane: - radiografia toracic arat mediastin lrgit iar CT-ul i ETE nu se pot efectua; - CT-ul arat snge n mediastin sau ruptur de aort (necesitatea angiografiei se va stabili de ctre chirurg); - ETE arat ruptura de aort sau rezultatul e ndoielnic. Dac ETE arat ruptur de aort intervenia chirurgical poate fi realizat numai pe baza ETE; - diferena marcat a pulsurilor ntre braul drept i stng; diferena marcat a pulsului ntre membrele superioare i inferioare. TRATAMENT CHIRURGICAL Tratamentul chirurgical trebuie s respecte cteva principii de baz pentru a se bucura de succes [1,2,5]: - monitorizarea atent a pacientului; - anestezie adecvat interveniei; - abordul trebuie s confere vizibilitate bun i confort n plag; - controlul rapid al hemostazei; - asigurarea unei protecii cerebrale adecvate; - asigurarea unei perfuzii adecvate a poriunii corpului de sub clampaj; - tratamentul chirurgical efectuat de urgen n condiii de monitorizare atent a pacientului (Tabelul I).
Tabelul I Monitorizarea pacientului Electrocardiograma; TA sngernd la artera radial i, de preferat, i la artera femural; Presiunea venoasa central (PVC); Saturaia n oxigen a sngelui arterial SaO2; Sond urinar pentru monitorizarea debitului urinar; Cateter Swan-Gantz; Temperatura central rectal sau urinar.

Anestezia trebuie s evite variaiile tensionale importante, n perioada clamprii i declamprii aortei, mai ales atunci cnd nu se folosete o metod pentru perfuzia jumtii inferioare a corpului [1,8]. Cu pacientul n decubit dorsal se practic intubaie oro-traheal cu o sond cu dublu lumen i cu posibilitatea ventilrii separate a plmnilor, pentru a opri ventilaiile plmnului stng n timpul toracotomiei. Poziia pacientului i abordul trebuie s confere o bun vizibilitate i posibilitatea de a controla hemostaza la distan i de a lucra n condiii bune, de aceasta depinznd viteza i calitatea interveniei i implicit viaa pacientului [1-3]. Cnd leziunea se afl la nivelul crosei distale sau istmului aortic cum se ntmpl cel mai

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frecvent n rupturile de aort toracic, poziia este n decubit lateral drept, iar abordul prin toracotomie postero-lateral stng prin spaiul IV i.c. sau cu rezecia coastei a V-a. Controlul hemostazei prin compresiune digital, posibil doar n cazul plgilor punctiforme cu sutura leziunii sau prin clamparea venelor cave (inflow occlusion) ofer chirurgului un interval de timp de 1-2 minute pentru rezolvarea leziunii sau cel mai frecvent prin clamparea aortei proximal i distal de leziune, apoi abordul leziunii aortice i repararea ei [1,2,13,14]. Msuri de protecie a prii inferioare a corpului (cea situat sub nivelul clampajului) n timpul ischemiilor prelungite, pentru a evita complicaiile secundare acesteia; rapoartele recente recomand, ca i consens general, folosirea unei metode pentru a asigura fluxul vascular aortic distal, ca fiind mai sigur dect metoda simplului clampaj. Pentru rupturile de aort, n care se ntlnesc de obicei asocieri lezionale ce contraindic folosirea heparinei se aplic alte metode pentru a asigura vascularizaia prii inferioare a corpului. Clampajul simplu i rezolvarea leziunii (Clamp-Sew Technique) [1,11,14] are cteva avantaje care fac din aceasta o metod preferat de unii chirurgi. Este cea mai uoar metod i poate fi folosit de orice chirurg cu experien. Metoda este util la pacienii instabili care sngereaz activ din leziunea aortic, la aceti pacieni nefiind timp pentru a instala un sistem de perfuzie distal. Metoda clamp-sew poate fi folosit de chirurgii generaliti, chirurgii vasculari sau cei traumatologi care nu au experien n instituirea circulaiei extracorporeale. Dac timpul de clampaj aortic rmne sub 25-30 min frecvena paraplegiei este mic. Timpul mediu de clampaj raportat n literatur pentru repararea rupturilor de aort este de 41 min. Multe cazuri de ruptur de aorta necesit mai mult de 30 min de clampaj datorit hematomului existent, friabilitii aortei i dificultilor n identificarea anatomiei locale. Aceasta, mai ales dac ruptura se extinde spre orificiul arterei subclaviculare stngi, cnd este necesar clampajul ntre artera carotid comun stng i subclavicular stng, asociat cu clampajul separat al arterei subclaviculare stngi. Ocluzia arterei subclaviculare stngi crete incidena paraplegiei. Tehnici pentru perfuzia parii inferioare a corpului [1,11,13]; perfuzia prii inferioare a corpului trebuie monitorizat i meninut peste 60 mmHg. Sistemul trebuie s fie simplu de aplicat, disponibil i sigur. Metodele de circulaie extracorporeal, care necesit heparinizare crescut sunt contraindicate la pacienii cu leziuni multiple i potenial hemoragic, sunt asociate cu o cretere a mortalitii i problemelor pulmonare i nu mai sunt folosite pentru leziunile de aort istmic. Pacienii traumatizai sunt frecvent hipotermici i de aceea schimbtorul termic este foarte util la pacienii la care temperatura central este sub 35. Exist mai multe tehnici pentru a realiza perfuzia prii inferioare a corpului: 1. By-pass-ul parial stng [1]. Este o metod foarte folosit n repararea transeciilor de aort i implic plasarea unei canule n atriul stng fie direct, fie prin intermediul unei vene pulmonare stngi. Canula arterial este plasat n artera femural stng, sau preferabil n aorta distal. Absena canulei aortice permite ca ntreaga operaie s fie efectuat prin intermediul toracotomiei i este convenabil i rapid. Bypass-ul parial stng mai are avantajul c descarc cordul stng i faciliteaz controlul hipertensiunii proximale n timpul clampajului. Canula atrial reduce apariia aritmiilor ventriculare i circuitele de perfuzie extracorporeal faciliteaz controlul volumelor intravasculare i constituie o metod prin care se poate administra rapid la nevoie cantitatea necesar. Partea inferioar a corpului este bine perfuzat iar debitul poate fi

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monitorizat i ajustat n funcie de necesiti. Dezavantajele sunt: heparinizarea, dar cu circuitele tapetate cu heparin, heparinizarea sistemic poate fi omis, cu creterea foarte mic a riscului de tromboz sau embolie. Suprafaa mic a circuitului de perfuzie reduce substanial stimulul trombotic i de aceea nu se recomand droguri antifibrinolitice; riscul major este fibrilaia venticular. Deoarece, cel mai frecvent, acest sistem este folosit fr schimbtor termic trebuie avut grij la pierderile de cldur i la meninerea temperaturii ct mai aproape de normal. 2. By-pass-ul atriu drept-artera femural [1,6]. Recent a nceput s fie folosit o tehnic nou care folosete ca linie venoas un cateter lung introdus prin vena femural dreapt pn n atriul drept i ca linie arterial un cateter introdus prin artera femural dreapt. Aceasta folosete o pomp centrifugal i poate, sau nu, folosi oxigenator. Avantajul acestei tehnici fa de by-pass-ul parial stng este c se efectueaz canularea periferic nainte de toracotomie i astfel, atriul stng i venele pulmonare de lng hematomul mediastinal nu mai trebuie disecate. Cnd se folosete oxigenator nu se administreaz heparin sistemic dar se folosete un circuit tapetat cu heparin i ntregul circuit se menine nchis. Tot sngele din cmpul operator este aspirat n cell-saver i splat nainte de a se ntoarce n perfuzat. Dac sistemul este folosit fr oxigenator, heparina nu se administreaz deloc, sau n cantitate mic ca i pentru by-passul parial stng. Partea inferioar a corpului este perfuzat la un debit normal (2-3 L/min), dar presiunea arterial a oxigenului este de 40 mmHg, iar saturaia de 45-60%. Aceasta saturaie este suficient pentru necesitile esuturilor dac hemoglobina este peste 10 g/100mL. Sngele intens desaturat din vena cava inferioar se amestec cu cel mai puin desaturat din vena cav superior. Dei existau temeri c reducerea saturaiei arteriale a oxigenului poate produce leziuni la nivelul mduvei spinrii, acestea nu a aprut. 3. untul aortic pasiv proximal distal (Gott shunt) [1,13]. untul Gott este un unt ascuit tapetat cu heparin (heparin-coated), confecionat din polivinil astfel nct ambele capete pot fi folosite ca i canule. Captul proximal este plasat de obicei n aorta ascendent sau n arc. Canularea ventricular este rar folosit datorit fluxului sczut, aritmiilor produse, sngerrilor i incidenei crescute a paraplegiei. Datorit presiunii sczute atriul stng nu poate fi folosit pentru canula de intrare. Captul distal este plasat n aorta descendent toracic sau artera femural stng sau iliac extern stng. Diametrul untului este fix, de aceea fluxul este pasiv, nemonitorizat i dependent strict de diferena de presiune. Nu exist o garanie a unui flux anumit spre diferite organe, presiunea n artera femural trebuind monitorizat. Tehnica necesit expunerea i canularea arcului aortei sau aortei ascendente i poate necesita extensia anterioar a inciziei. untul Gott este o metod simpl i uor de folosit i probabil cea mai folosit metod pentru a asigura fluxul n partea inferioar a corpului pentru c se poate gsi n fiecare spital i nu necesit by-pass cardio-pulmonar. Rezolvarea leziunii aortice. Odat efectuat incizia i expunerea adecvat se finalizeaz decizia de asigurare a circulaiei n partea inferioar a corpului. Aceast decizie poate fi luat i nainte de incizie dac se preconizeaz folosirea canulrilor femurale, ca n cazul by-passului atriu drept artera femural. Dac este destul de simplu de obinut controlul distal, cel proximal este ns, mai dificil de obinut. Este indicat ca locul pentru clampajul proximal s fie disecat primul deoarece exist riscul ruperii hematomului mediastinal n timpul manevrelor de disecie la nivelul atriului sau venelor pulmonare stngi. Pleura mediastinal este incizat de-a lungul suprafeei anterioare a arterei subclaviculare stngi, iar nervul vag e identificat i protejat. Disecia continu medial sau lng arcul aortic pn la nivelul arterei carotide comune stngi.

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Faa anterioar a arcului aortic ntre aceste dou vase este disecat napoia traheei i superior pn la bronhia principal stng. Faa posterioar este disecat iniial cu foarfecele, apoi digital pn cnd un clamp i un nur de traciune pot fi trecute n jurul aortei. Se plaseaz un buldog pe artera subclavie stng la 2-3 cm de la originea sa. Dup ce se obine controlul proximal i distal al aortei i se instituie circuitul de perfuzie se clampeaz aorta i se deschide hematomul mediastinal. Dac hematomul mediastimal este deja rupt i exist sngerare masiv n cavitatea pleural, n timp ce ajutorul efectueaz compresiunea manual la nivelul sngerrii, chirurgul disec rapid arcul aortic deasupra hematomului, ntre artera carotida i subclavia stng i clampeaz aorta. Aorta descendent este clampat la mijlocul toracelui i apoi se ptrunde n hematom. Nu se tenteaz nici un procedeu de perfuzie a prii inferioare a corpului, dar trebuie avut grij ca tensiunea arterial s fie meninut normal sau chiar uor crescut pentru a reduce posibilitatea ischemiei medulare. Repararea aortei prin sutur direct sau interpoziie de grefon se efectueaz ct mai repede posibil. Se recomand folosirea unor proteze de dacron impregnate cu colagen sau gelatin, pentru a se reduce tensiunea i a evita disecia i sacrificiul arterelor intercostale. Sutura se face cu fir monofilament 3-0 sau 4-0 surjet continuu, prinznd bine din adventice i esuturile mediastinale. Dup terminarea anastomozelor se declampeaz proximal, apoi distal i se restabilete astfel fluxul. Se suprim canulele dac au fost montate, iar toracele se nchide n planuri anatomice, plasndu-se un dren pleural de obicei.
Tabelul II Complicaii postoperatorii Autor Numr pacieni Procente Paraplegie Insuficien renal Sepsis Pneumonie/ARDS Paralizie de corzi vocale stngi Paralizie de nerv frenic stng Accident vascular cerebral Reexplorare pentru sngerare Embolism pulmonar Tromboza venoasa profund Pericardit Ameeli Infecii ale plgii Chilotorax Decese (pacieni) Schmidt 73 pacieni % 5,4 9,6 13,7 21,9 4,1 1,4 2,7 1,4 1,4 2,7 1,4 1,4 7/77 (9,6%) Cowley 51 pacieni % 19,6 9,8 9,8 17,7 13,7 5,9 9,8 3,9 3,9 3,9 3,9 22/51 (43,1%) Kodali 50 pacieni % 10,0 4,0 34,0 14,0 4,0 4,0 14/50 (28%)

Cnd ruptura se extinde proximal la baza arterei subclavii stngi, clampajul proximal trebuie plasat astfel nct va obstrua originea arterei carotide stngi. Ocluzia arterei carotide stngi este bine tolerat fr a se produce suferin cerebral pentru o perioad de 10-15 minute. Artera subclavie stng va fi complet detaat i reanastomozat la proteza aortic prin interpoziia unui grefon. Protezarea endolumenal. Aplicabil la pacieni stabili cu rupturi de istm aortic, necesit aparatur specializat i o echip antrenat cu manevrele endovasculare, condiii ce nu pot fi ntrunite des ntr-un spital de urgene.

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Tratamentul leziunilor asociate. Leziunile abdominale sngernde sau leziunile expansive intracraniene se repar de obicei naintea rupturii de aort dac aceasta nu sngereaz. Aceasta este ns riscant, deoarece n timpul rezolvrii acestor leziuni s-au raportat decese ale pacienilor datorit rupturii hematomului mediastinal, de aceea trebuie avut grij ca TA s fie meninut ntre 100-120 mmHg. Leziunile osoase i maxilo-faciale sunt rezolvate dup tratarea leziunii aortice ca parte a aceleai anestezii fr ca aceast cretere a duratei anesteziei s determine i o cretere a morbiditii, dar mbuntind semnificativ rezultatele.
Tabelul III Incidena paraplegiei postoperatorii n relaie cu conduita chirurgical Conduita Fr unt unt pasiv By-pass Pacieni (numr) 443 424 490 Paraplegia (%) 19,2 11,1 2,4 Timpul de clampaj aortic (minute) 31,8 46,8 47,8

REZULTATE Aproximativ 41% din pacienii operai pentru leziuni de aort sufer complicaii postoperatorii majore (Tabelul II) [1,2,10,15-20]. Paraplegia i parapareza apar cu o medie de 9,9% dup o statistic a lui von Opell [10] care include 1492 de pacieni operai pentru leziuni aortice. Limitele sunt ntre 2,4% cnd sunt folosite mijloace de perfuzie active pentru jumtatea inferioar a corpului i 11,1% cnd sunt folosite unturile pasive, mergnd i pn la 19,2% cnd nu s-a folosit nici o metod pentru perfuzia jumtii inferioare a corpului (Tabelul III) [15,18-20]. ntr-un lot recent de 32 pacieni cu timpul mediu de clampaj de 16 min (limite 645 min) Schmidt [19] raporteaz un singur caz de paraplegie postoperatorie. Datele din literatura arat clar c incidena paraplegiei postoperatorii crete cu durata clampajului i n condiiile neutilizrii mijloacelor de perfuzie a prii inferioare a corpului. Odat cu mbuntirea acordrii primului ajutor la locul accidentului i a transportului rapid al pacienilor i n spitalele din Romnia vor aprea astfel de cazuri ce pot fi salvate dac exist echipe antrenate capabile sa acioneze rapid.
1. 2. 3. 4. 5. 6. BIBLIOGRAFIE Edmunds LH. Cardiac Surgery in the adult. McGraw-Hill, Health Profesional Division; 1997. p. 1245-1301. Popa IPD. Sistemul arterial aortic. Bucureti: Editura Medical; 1982. p. 124-197, 477-486. Ben-Menachen Y. Rupture of the thoracic aorta by broad side impacts in road traffic and other collisions: further angiographic observations and preliminary autopsy findings. J Trauma. 1993; 35: 363-367. Saletta S, Lederman E, Fein S, Singh A, Kuehler DH, Fortune JB. Transesophageal echocardiography for initial evaluation of the widened mediastinum in trauma patients. J Trauma. 1995; 39: 137-142. Nagy K, Fabian T, Rodman G, Fulda G, Rodriguez A, Mirvis S. Guidelines for the diagnosis and management of blunt aortic injury: An EAST practice management guideline workgroup. J Trauma. 2000; 48: 1128-1143. Galli R, Pacini D, Di Bartolomeo R, Fattori R, Turinetto B, Grillone G, Pierangeli A. Surgical indications and timing of repair of traumatic ruptures of the thoracic aorta. Ann Thoracic Surg. 1998; 65(2): 461-464.

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7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.

Hunt JP, Baker CC, Lentz CW, Rutledge RR, Oller DW, Flowe KM, Nayduch DA, Smith C, Clancy TV, Thomason MH, Meredith JW. Thoracic aorta injuries: management and outcome of 144 patients. J Trauma. 1996; 40(4): 547-555. Devitt JH. Blunt thoracic trauma: anaesthesia, assessment and management. Can J Anaesth. 1993; 40: 29-39. Fisher JP, Kent RB. Combined blunt thoracic aortic and abdominal trauma: diagnostic and treatment priorities. South Med J. 2000; 93: 865-867. von Oppell UO, Dunne TT,. De Groot MK, Zilla P. Traumatic aorta rupture: twenty-year metaanalysis of mortality and risk of paraplegia. Ann Thoracic Surg. 1994; 58: 585-593. Maggisano R, Nathens A, Alexandrova NA, Cina C, Boulanger B, McKenzie R, Harrison AW. Traumatic rupture of the aorta: shoud one always operate immediately. Ann Vasc Surg. 1995; 9(1): 44-52. Fabian TC, Davis KA, Gavant ML, Croce MA, Melton SM, Patton JH Jr, Haan CK, Weiman DS, Pate JW. Prospective study of blunt aortic injury: helical ct is diagnostic and antihypertensive therapy reduces rupture. Ann Surgery. 1998; 227(5); 666-676. Hilgenberg AD, Logan DL, Akins CW, Buckley MJ, Daggett WM, Vlahakes GJ, Torchiana DF. Blunt injuries of the thoracic aorta. Ann Thorac Surg. 1992; 53(2): 233-238. Sweeney MS, Young DJ, Frazier H, Adams PR. Traumatic aortic transection: eight-year experience with the clamp sew tehnique. Ann Thorac Surg. 1997; 64: 384-389. Cowley RA, Turney SZ, Hankins JR, Rodriguez A, Attar S, Shankar BS. Rupture of the thoracic aorta caused by blunt trauma a fifteen years experience. J Thorac Cardiovasc Surg. 1990; 100: 652-660. Komar AR, Fogler R. Abdominal vascular injuries. E-Medicine February 2002. Rosenthal MA, Ellis JI. Cardiac and mediastinal trauma. Emerg Med Clin North Am. 1995; 13: 887-902. Schmidt CA, Jacobson JG. Thoracic aortic injury. A ten-year experience. Arch Surg. 1984; 119: 1244-1246. Schmidt CA, Wood MN, Razzouk AJ, Killeen JD, Gan KA. Primary repair of traumatic aortic rupture: a preferred approach. J Trauma. 1992; 32: 588-592. Kodali S, Jamieson WR, Leia-Stephens M, Miyagishima RT, Janusz MT, Tyers GF. Traumatic rupture of the thoracic aorta. A 20-year review: 1969-1989. Circulation. 1991; 84: III40-46.

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MECHANICAL ESOPHAGEAL ANASTOMOSIS: RETROSPECTIVE STUDY OF 56 PATIENTS


J. Herve, Ch. Simoens, D. Smets, V. Thill, P. Mendes Da Costa Department of Digestive, Thoracic and Laparoscopic Surgery CHU Brugmann, ULB, Brussels, Belgium
MECHANICAL ESOPHAGEAL ANASTOMOSIS: RETROSPECTIVE STUDY OF 56 PATIENTS (Abstract): Aim: To analyze outcomes of intrathoracic esophageal anastomosis performed using mechanical stapling devices . Methodology: We retrospectively analyzed the records of 56 consecutive patients who underwent esophagectomy, total gastrectomy, or degastro-gastrectomy with mechanical intrathoracic esophageal anastomosis between 1995 and 2006. The mean age of patients according to procedure were 62.5, 67.4, and 69.6 years, respectively. Results: We observed only one anastomotic leak (1.6%), which we treated medically. Postoperative mortality was 12.5%; no deaths were related to the presence of an anastomotic leak or to surgical complications. Four of the 45 satisfactorily-followed patients (8.8%) presented with anastomotic stenosis; all patients were treated successfully by endoscopic dilatation. Conclusion: Intra-thoracic esophageal anastomoses can be performed more efficiently using mechanical stapling devices. The risk of stenosis is reduced when the anastomoses are termino-lateral and when their diameter is as wide as possible. Strictures can be treated efficiently by endoscopic dilatation. KEY WORDS: ESOPHAGEAL ANASTOMOSIS, MECHANICAL STAPLING DEVICES POSTOPERATIVE COMPLICATIONS,

Correspondence to: Pierre Mendes da Costa, MD, PhD, Professor of Surgery, Department of Digestive, Thoracic and Laparoscopic Surgery, CHU Brugmann, Place A. Van Gehuchten, 4, B 1020 Brussels, Belgium; e-mail: pierre.mdc@chu-brugmann.be*

INTRODUCTION Mechanical stapling devices came into widespread use near the end of the 1970s, making digestive anastomosis procedures safer and quicker. Esophageal anastomoses are delicate procedures because of the distinct vascularization and longitudinal disposition of muscular fibers in the esophagus. The aim of this retrospective study was to analyze the results obtained using mechanical stapling devices for intrathoracic esophageal anastomosis.

PATIENTS AND METHODS We retrospectively analyzed the medical records of 56 consecutive patients who underwent esophagectomy with gastric pull-up (n=28), total gastrectomy (n=22), or degastro-gastrectomy (n=6) in our department from May 1995 to December 2006 (Table I), in order to estimate short- and long-term local and general complications due to mechanical anastomosis. When follow-up was considered to be insufficient, the patients physician contacted the patient by email or telephone.

* received date: 3.01.2009 accepted date: 31.01.2009

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During esophagectomy, esophageal resection was carried out either via double access (abdominal and right thoracic, n=18) or by a left thoracotomy and phrenotomy (n=10). Abdominal access, which allowed preparation of the stomach and the exploration of the abdominal cavity, was achieved by coelioscopy in 7 of 28 patients (25%). Surgical procedure The patient was placed in the left lateral decubitus position, which allowed abdominal and thoracic access. First, the abdominal cavity was explored by median laparotomy. The duodenum was mobilized by Kochers maneuver and pyloroplasty was performed. Stomach preparation consisted of gastrolysis of the great curvature, taking care to preserve the gastroepiploic vessels. The spleen was preserved except in the event of tumoral invasion or incontrollable hemorrhagic lesion. The lower esophagus was released at the level of the diaphragmatic hiatus once the stomach had been completely mobilized.
Table I. Patient characteristics and diagnoses Esophagectomy Number of patients Sex ratio (m/f) Mean age, years (range) 28 24/4 62.5 (44-89) Diagnosis Squamous cell carcinoma Adenocarcinoma 12 15 Stage I and II Stage III and IV Stage 12 15 0 19 Stage I and II Stage III and IV Lesser curvature Fundus Antrum Linitis plastica 3 0 1 2 0 4 15 1 3 Stage I and II Stage III and IV 0 4 Total Gastrectomy 22 14/8 67.4 (29-93) Degastrogastrectomy 6 6/0 69.6 (60-81)

Localization Middle third Lower third 5 23 5 3 6 5

Lymphoma and other tumors Benign lesions Pre-operative chemo- or radiotherapy

0 1 9

Next, right thoracotomy was performed in the fifth intercostal space. Exploration of the thoracic cavity was possible after depression of the right lung. The esophagus was completely dissected from its mediastinal adherences; then, the stomach was pulled up and placed on the posterior mediastinum and polar gastrectomy was performed by linear stapling. The esophagus was resected above the tumor with a margin of 3 to 5 cm. The resected piece was sent for pathological evaluation to determine whether the margins were free of tumoral invasion. The anvil of the circular stapling device was introduced

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into the esophagus and secured by a purse-string suture. The stapler was passed through a separate gastrotomy, advanced through the proximal greater curvature of the stomach, locked into the anvil, and tightened. The doughnuts from the circular stapler were always checked for completeness and sent for pathological analysis to rule out tumoral invasion. The gastrotomy was closed by linear stapling. The thoracic cavity was closed after installing a thoracic drain and a Penrose drain near the anastomosis. Left thoracotomy access was achieved by opening the eighth left intercostal space. Abdominal cavity access was possible after left phrenotomy. All total gastrectomies were carried out by bilateral abdominal subcostal incision. After exploration of the abdominal cavity, the lesser sac was exposed and the right gastroepiploic and the pyloric arteries were ligated. The lesser curvature was released by dissection of the pars flaccida, and the left gastric artery was ligated. The abdominal esophagus was dissected and put on lakes. A distal section of the stomach was performed 2 centimeters after the pylorus by linear stapling. The anvil of the circular stapler was introduced after dissection of the distal esophagus and was fixed by a purse-string suture. The resected piece was sent for pathological analysis. Reconstruction of digestive continuity was realized by a trans-mesocolic Rouxen-Y esojejunostomy. At the end of the procedure, the abdominal cavity was closed after Penrose drain installation and a nasogastric tube was placed beyond the anastomosis.
Table II Characteristics of surgery Esophagectomy Operation time in min, mean (range) Bleeding in ml, mean (range) Mean number of lymph nodes resected (range) Clean resected margins / Total resected margins Associated procedures 240 (150-450) 760 (150-3500) 7 (0-22) 27/27 11 in 7 patients Total Gastrectomy 190 (130-330) 750 (1004120) 13 (5-48) 21/22 5 in 4 patients Degastrogastrectomy 220 (120-250) 1400 (6003500) 9 (0-14) 4/4 6 in 5 patients Total 225 (130-450) 900 (100-4120) 10 (0-48) 52/53 (98%) 22 in 16 patients

Postoperative procedures All patients were followed in the intensive care unit (ICU) during the immediate post-operative period. A gastrographine swallow examination was carried out between the fourth and seventh days, before starting oral feeding and mobilization of the drains. The patients were followed in consultation (surgery and gastroenterology) after 1, 3, 6, and 12 months, and after the first year, every 6 months. Forty-five of 49 patients (92%) were well followed, with an average follow-up duration of 28 months. RESULTS The median operation time for the entire study sample was 225 minutes (range, 130-450). For esophagectomy, the median operation time was 240 minutes (range, 150450); for total gastrectomy, the median time was 190 minutes (range, 130-330); and for degastro-gastrectomy, the median time was 220 minutes (range, 120-250). The median

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bleeding volume was 900 mL (range, 100-4120); 760 mL (range, 150-3500) for esophagectomy, 750 mL (range, 100-4120) for total gastrectomy, and 1400 mL (6003500) for degastro-gastrectomy. The resected margins were free of disease in 98% of cases. For one patient who suffered from gastric lymphoma, we chose not to restart anastomosis event though intraoperative histopathologic assessment indicated tumoral invasion of the resected margins. This patient received adjuvant chemotherapy and was free of disease free at 49 months follow-up (Table II). During the interventions, 22 additional procedures were necessary among 16 patients. The types of interventions are detailed in Table III. In total, we performed 8 splenectomies for uncontrollable hemorrhage. Tumoral invasion necessitated 3 splenectomies, 3 caudal pancreatectomies, and 1 transverse colectomy. A partial hepatectomy was performed for suspicion of metastasis, and radio-frequency ablation was performed on a tumor in the upper lobe of the right lung of one patient. Two anastomosis were repeated: one after an unsatisfactory leak test and one after examination of the resected margins indicated tumoral invasion. Two bronchopulmonary breaches were sutured (Table III).
Table III Associated procedures Esophagectomy Splenectomy for hemorrhage Splenectomy for tumoral invasion Caudal pancreatectomy for tumoral invasion Transverse colectomy for tumoral invasion Segmental resection of the liver Radioablation of pulmonary tumor Re-anastomosis Suture of broncho-pulmonary injury Total 4 0 1 0 0 1 3 2 11 Total Gastrectomy 2 1 1 0 1 0 0 0 5 Degastrogastrectomy 2 2 1 1 0 0 0 0 6 Total 8 3 3 1 1 1 3 2 22

The median stay of the entire study group was 14 days (range, 10-60; see Table IV for breakdown according to the type of surgery). The median duration of stay in the ICU was 3 days (range, 1-74). Oral feeding was authorized after a median of 6 days (range, 4-21), following swallow radiography on the fifth day. Local and general complications are detailed in Table V. Among the local complications, we observed only 1 anastomotic leakage (1.6%). The leakage was diagnosed 5 days after the surgical procedure by contrast swallow radiography. The patient was treated with naso-gastric suction and total parenteral nutrition for 20 days. The patient did not develop any anastomotic stenosis thereafter. Seven of 56 patients (12.5%) died during their hospital stay. The details concerning in-hospital mortality are listed in Table VI. After excluding patients who received neoadjuvant therapy, in-hospital mortality was 6.5%: 5.2% in patients who

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underwent esophagectomy, 4.7% in patients who underwent total gastrectomy, and 17% in patients who underwent degastro-gastrectomy. No deaths were related to the presence of an anastomotic leak (Table VII).
Table IV Hospitalization Esophagectomy Radiological control in days, median (range) Delay of re-alimentation in days, median (range) Number of complications Number of deaths during hospitalization, n/N (%) Delay of death in days Duration of stay in the ICU in days, median (range) Duration of postoperative hospitalization in days, median (range) 5 (4-11) 7 (5-21) 27 4/28 (14%) 1,5,5 and 60 5 (2-74) Total Gastrectomy 5 (4-6) 6 (4-7) 14 2/22 (9%) 27 and 28 2.5 (1-7) Degastrogastrectomy 4.5 (4-7) 6.5 (4-7) 6 1/6 (17%) 21 3 (2-6) 3 (1-74) 7/56 (12.5%) Total 5 (4-11) 6 (4-21)

14 (10-60)

14 (10-42)

10 (10-38)

14 (10-60)

Table V Local and general complications Oesophagectomy Total Gastrectomy General Complications Cardio-vascular Complications Cardiac Failure Atrial Fibrillation Transient Ischemic Attack Pulmonary Complications Pulmonary Infection Multi Organ Failure Pleural Effusion Other Acute Kidney Failure Hepatic decompensation Mental Confusion Urinary Infection Septicemia Fever of Undetermined Origin Pancreatic Fistula Anastomotic Leakage Parietal Abcess Total 1 3 1 5 2 3 0 0 2 5 0 0 Degastro-gastrectomy Total

0 1 0 0 0 1 0 0 0 0 2 0 1 0 1 6

1 4 3 10 2 4 2 1 2 3 4 4 1 1 5 47

0 2 1 0 2 0 2 1 1 1 1 3 Local Complications 0 0 1 0 4 0 27 14

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Forty-nine patients left the hospital and 45 patients were followed satisfactorily. Eight patients (18%) suffered from dysphagia. Stenosis was observed by endoscopy or contrast swallow assessment in 4 of these patients; all were treated by endoscopic dilation 2 to 4 months after the initial intervention. Four patients had dysphagia without stenosis. Nine patients (20%) suffered from bile reflux, observed by endoscopy. Two patients suffered from a dumping syndrome. The rate of loco-regional recurrence was 12%. The mortality rate during follow-up was 62% and the average time to death was 9 months (Table VIII).

Table VI In-hospital mortality - diagnosis Pt 1 2 3 4 5 6 7 Operation Esophagectomy Esophagectomy Esophagectomy Esophagectomy Total Gastrectomy Total Gastrectomy Degastrogastrectomy Delay Day 5 Day 5 Day 1 Day 60 Day 28 Day 27 Day 21 Cause Multi-organ failure Multi-organ failure Hemorrhage Pulmonary failure Pulmonary embolism Multi-organ failure Cardiocirculat ory arrest ASA 3 3 1 3 4 2 4 Diagnosis Squamous cell carcinoma Squamous cell carcinoma Adenocarcinoma Adenocarcinoma Adenocarcinoma Adenocarcinoma Adenocarcinoma Stage III III I III IV II IV Neoadjuvant Therapy Radiochemotherapy Radiochemotherapy None Radiochemotherapy Radiochemotherapy None None

Table VII In-hospital mortality - global mortality Esophagectomy 4/28 (14%) Total Gastrectomy 2/22 (9%) Degastro-gastrectomy 1/6 (17%) Total 7/56 (12.5%)

Mortality after excluding patients treated with neoadjuvant radiochemotherapy Esophagectomy 1/19 (5.2%) Total Gastrectomy 1/21 (4.7%) Degastro-gastrectomy 1/6 (17%) Total 3/46 (6.5%)

DISCUSSION Surgery of the esophagus is challenging. The patients often suffer from a malignant disease accompanied by weight loss or other deficiencies, or suffer from cardio-respiratory problems. In addition, the cervical, thoracic, and abdominal situation of the esophagus and its distinct vascularization and histological structure make the esophagus a difficult tissue to suture. The development of technical improvements that would make esophageal suturing safer has long been a goal of surgeons [1].

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Manual or mechanical sutures? With the development of mechanical stapling devices, digestive anastomosis has become far more efficient. These instruments are simple to use and have contributed to making anastomosis more routine, reproducible, and faster, decreasing the time of intervention [2]. As well, these devices are invaluable for performing anastomosis in restricted spaces. Some series have compared mechanical esogastric anastomoses with manual anastomoses. Beitler and Urschel [3] compared manual anastomoses with mechanical anastomoses in a meta-analysis and found that the risks for anastomotic leakage were comparable, but that mechanical esogastric anastomosis caused more stenoses than did manual anastomosis. Takeyoshi et al [4] retrospectively analyzed the records of 390 patients who underwent gastrectomy and compared manual esojejunal anastomoses with circular mechanical anastomoses. They concluded that the rate of leakage was significantly lower with mechanical anastomoses. Stenoses appeared to be more important in patients who received mechanical sutures than manual sutures, but this difference was not statistically significant. Lee and his collaborators [5] retrospectively analyzed 352 esophagectomies and confirmed that the risk of anastomotic leakage was more important when the anastomosis was manual. However, the type of anastomosis, whether manual or mechanical, does not seem to influence the quality of life after esophagectomy [6].
Table VIII Follow-up Esophagectomy Percentage of patients followed Mean time follow-up - months (range) Dysphagia (%) Stenosis (%) Fistula (%) Reflux (%) Loco-regional recurrences Dumping syndrome (%) Mortality (%) Mean delay of death (months) 96% (23/24) 27.3 (3-95) 6/23 (26%) 4/23 (17%) 1/28 (4%) 2/23 (9%) 4/22 (18%) 0/23 15/23 (65%) 12.2 (3-36) Total Gastrectomy 85% (17/20) 24.3 (1-93) 2/17 (12%) 0/17 0/22 4/17 (24%) 1/17 (6%) 1/17 (6%) 10/17 (59%) 11.1 (1-48) Degastrogastrectomy 100% (5/5) 42.8 (1-100) 0/5 0/5 0/6 3/5 (60%) 0/4 1/5 (20%) 3/5 (60%) 5.3 (1-11) Total 92% (45/49) 27.9 (1100) 8/45 (18%) 4/45 (9%) 1/56 (1.7%) 9/45 (20%) 5/43 (12%) 2/45 (4%) 28/45 (62%) 8.9 (1148)

Which type of mechanical suture? Mechanical anastomosis can be performed linearly or circularly. Blackmon and colleagues [7] retrospectively compared outcomes of 214 patients who received either linear or circular manual sutures and found that dysphagia and stenoses were more frequent when anastomosis was performed manually. This series also showed that among the mechanical anastomoses, there were less stenoses when a linear stapler was

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used. This conclusion is identical to that of Johansson and colleagues [8], who analyzed data of 206 patients who underwent esojejunal (n=149) or esogastric (n=57) mechanical anastomosis. In addition, this retrospective study concluded that stenoses were more frequent following esogastric anastomoses than esojejunal anastomoses, as observed in our series. Lastly, the authors observed that the risk of stenosis was decreased by increasing the diameter of circular anastomosis. Lee and collaborators [5] also concluded that in circular mechanical anastomosis, the risk of stenosis is decreased by carrying out a termino-lateral anastomosis rather than a termino-terminal anastomosis. All of our anastomoses were termino-lateral. Cervical or thoracic anastomosis? In our experience, thoracic mechanical anastomosis is the preferred technique. Defenders of cervical anastomosis claim that complications that occur at the cervical level are less serious than those that occur at the thoracic level. Walther and colleagues [9] reported the results of a randomized study comparing 41 cervical manual anastomoses with 42 intrathoracic circular mechanical anastomoses. This study detected a significant difference in the time of operation and time necessary to execute the anastomosis, in favor of thoracic anastomosis. However, they did not observe any significant differences in mortality, morbidity, survival, or tumor resection. Pyloric drainage procedures? A variety of pyloric drainage procedures can be used: pyloroplasty, pyloromyotomy, or pyloric dilation with the finger [10]. In our center, we perform pyloroplasty during esophagectomy with stomach reconstruction in order to limit the risk of chronic dysmotility of the gastric remnant following bilateral vagotomy after esophagectomy. On one hand, pylorus drainage may facilitate gastric emptying and reduce gastroesophageal reflux. On the other hand, it may promote bile reflux into the esophagus. In our series, bile reflux occurred in 8% of patients. Palms and collaborators [11] retrospectively compared 198 patients divided into 3 groups: without pyloric drainage, with pylorotomy, and with pyloroplasty. They found that neither pyloromyotomy nor pyloroplasty improved gastric emptying nor reduced pulmonary complications and anastomosis healing disorders, but did significantly promote reflux esophagitis and bile reflux in the long term. Lanuti and colleagues [12], who retrospectively compared 83 patients without pyloric drainage with 159 patients with pyloric drainage, came to the same conclusions concerning gastric emptying. Reflux was not studied. In addition, they observed no significant difference in pulmonary or anastomotic complications between the two groups. These observations are in contrast to the conclusions of a meta-analysis by Urschel [13], which noted a reduction in gastric emptying disorders in the immediate post-operative period when pyloric drainage was used. On the other hand, all studies agree that local and general complications, in the short or long term, are not influenced by the use of pyloric drainage. Outcomes after splenectomy In a retrospective analysis of 738 esophagectomies, Black et al [14] reported that 6.5% of splenectomies were performed for bleeding (as compared to 14% in our series). The authors reported that significantly more lesions of the spleen required a splenectomy during the Ivor-Lewis procedure that survival rates were identical whether

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or not the patient had undergone splenectomy. than after left thoracotomy and phrenotomy. This study also concluded that splenectomy did not influence the incidence of pulmonary, parietal, or anastomotic complications and Left thoracotomy: is it still a valid approach? In our series, 10 of 28 esophagectomies were carried out by left thoracotomy and phrenotomy. We find that this access, achievable without changing the position of the patient, offers excellent visibility of the esophageal hiatus and the stomach. Other studies have confirmed these observations [15-18]. Contrast swallow testing before refeeding? In our center, contrast swallow testing is routine before restarting oral feeding. Tonouchi and colleagues [19] studied 17 cases of anastomotic leakage that occurred in a series of 331 gastrectomies (5%). In this series, only 2 of 17 leakages were diagnosed after the first radiological swallow analysis. The authors reported that 100% of the patients who suffered an anastomotic leakage presented a biological inflammatory syndrome and fever. They recommended a computed tomography-scan in cases of doubt. Other authors [20] have asserted that radiological analyses before refeeding are useless and need not be routine after total gastrectomies with mechanical esojejunal anastomosis.
Table IX Literature review N Forschaw* [15] Palmes* [11] Walther* [9] Johansson* [8] Hofstetter [7] Takeyoshi [4] Our series* 38 198 42 206 147 324 46 Follow-up NC 12 months 60 months 12 months 25 months NC 28 months In-hospital mortality (%) 3 2.5 2.4 2 4 NC 6.5 (5.2)** Fistula (%) 7.9 15.1 0 4 7.5 3.1 1.7 Stenosis (%) 23.7 4.4 28.6 26 21.1 4.9 9 Mean number of dilatations per patient NC NC 2 1 NC NC 2

* 30 days mortality without neo-adjuvant treatment; ** Esophagectomy; NC, not communicated

In-hospital mortality In our series, overall in-hospital mortality was 12.5%. After excluding patients who had preoperative radiochemotherapy, in-hospital mortality was 6.5%, including 5.2% after esophagectomy (Table IX). Among the 7 patients in our series who died, 4 received neoadjuvant therapy. Of these, 3 died of respiratory insufficiency or acute respiratory distress syndrome (ARDS); the fourth died of pulmonary embolism. In a prospective study of 200 patients, Reynolds and collaborators observed that patients were at greater risk for developing respiratory insufficiency or ARDS if they had esophagectomy after radiochemotherapy [21]. Hagry et al found that in-hospital mortality was increased among patients with high-grade esophageal cancer who had received neoadjuvant radiochemotherapy [22].

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However, some recent meta-analyses concluded that neoadjuvant radiochemotherapy improved the survival rate and tumoral resectability without significantly increasing postoperative morbidity and mortality [23-25]. CONCLUSION Intra-thoracic esophageal anastomoses can be performed more quickly and more easily with the aid of mechanical stapling devices. The risk of stenosis is reduced when the anastomosis is termino-lateral and when the diameter is as wide as possible. Strictures can be treated efficiently by endoscopic dilatation.
1. 2. REFERENCES Primo G. Observations experimentales sur la suture oesophagienne. Essai de suture en un plan. Acta Chirurgica Belgica. 1955; 8: 772-780. Hori S, Ochiai T, Gunji Y, Hayashi H, Suzuki T. A prospective randomized trial of hand-sutured versus mechanically stapled anastomoses for gastroduodenostomy after distal gastrectomy. Gastric Cancer. 2004; 7(1): 24-30. Beitler AL, Urschel JD. Comparison of stapled and hand-sewn esophagogastric anastomoses. Am J Surg. 1998; 175(4): 337-340. Takeyoshi I, Ohwada S, Ogawa T, Kawashima Y, Ohya T, Kawate S, Arai K, Nakasone Y, Morishita Y. Esophageal anastomosis following gastrectomy for gastric cancer: comparison of hand-sewn and stapling technique. Hepatogastroenterology. 2000; 47(34): 1026-1029. Lee Y, Fujita H, Yamana H, Kakegawa T. Factors affecting leakage following esophageal anastomosis. Surg Today. 1994; 24(1): 24-29. Scurtu R, Groza N, Otel O, Goia A, Funariu G. Quality of life in patients with esophagojejunal anastomosis after total gastrectomy for cancer. Rom J Gastroenterol. 2005; 14(4): 367-372. Hofstetter WL, Martin LW, Mehran RJ, Rice DC, Swisher SG, Walsh GL, Roth JA, Vaporciyan AA. Propensity-matched analysis of three techniques for intrathoracic esophagogastric anastomosis. Ann Thorac Surg. 2007; 83(5): 1805-1813. Johansson J, Zilling T, von Holstein CS, Johnsson F, Oberg S, Walther B. Anastomotic diameters and strictures following esophagectomy and total gastrectomy in 256 patients. World J Surg. 2000; 24(1): 78-84. Walther B, Johansson J, Johnsson F, Von Holstein CS, Zilling T. Cervical or thoracic anastomosis after esophageal resection and gastric tube reconstruction: a prospective randomized trial comparing sutured neck anastomosis with stapled intrathoracic anastomosis. Ann Surg. 2003; 238(6): 803-812. Yamashita Y, Hirai T, Mukaida H, Yoshimoto A, Kuwahara M, Inoue H, Toge T. Finger bougie method compared with pyloroplasty in the gastric replacement of the esophagus. Surg Today. 1999; 29(2): 107-110. Palmes D, Weilinghoff M, Colombo-Benkmann M, Senninger N, Bruewer M. Effect of pyloric drainage procedures on gastric passage and bile reflux after esophagectomy with gastric conduit reconstruction. Langenbecks Arch Surg. 2007; 392(2): 135-141. Lanuti M, de Delva PE, Wright CD, Gaissert HA, Wain JC, Donahue DM, Allan JS, Mathisen DJ. Post-esophagectomy gastric outlet obstruction: role of pyloromyotomy and management with endoscopic pyloric dilatation. Eur J Cardiothorac Surg. 2007; 31(2): 149-153. Urschel JD, Blewett CJ, Young JE, Miller JD, Bennett WF. Pyloric drainage (pyloroplasty) or no drainage in gastric reconstruction after esophagectomy: a meta-analysis of randomized controlled trials. Dig Surg. 2002; 19(3): 160-164. Black E, Niamat J, Boddu S, Martin-Ucar A, Duffy JP, Morgan WE, Beggs FD. Unplanned splenectomy during oesophagectomy does not affect survival. Eur J Cardiothorac Surg. 2006; 29(2): 244-247. Forshaw MJ, Gossage JA, Ockrim J, Atkinson SW, Mason RC. Left thoracoabdominal esophagogastrectomy: still a valid operation for carcinoma of the distal esophagus and esophagogastric junction. Dis Esophagus. 2006; 19(5): 340-345. Linden PA, Sugarbaker DJ. Section V: techniques of esophageal resection. Semin Thorac Cardiovasc Surg. 2003; 15(2): 197-209.

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17. Heitmiller RF. Results of standard left thoracoabdominal esophagogastrectomy. Semin Thorac Cardiovasc Surg. 1992; 4(4): 314-319. 18. Anikin VA, McManus KG, Graham AN, McGuigan JA. Total thoracic esophagectomy for esophageal cancer. J Am Coll Surg. 1997; 185(6): 525-529. 19. Tonouchi H, Mohri Y, Tanaka K, Ohi M, Kobayashi M, Yamakado K, Kusunoki M. Diagnostic sensitivity of contrast swallow for leakage after gastric resection. World J Surg. 2007; 31(1): 128-131. 20. Lamb PJ, Griffin SM, Chandrashekar MV, Richardson DL, Karat D, Hayes N. Prospective study of routine contrast radiology after total gastrectomy. Br J Surg. 2004; 91(8): 1015-1019. 21. Reynolds JV, Ravi N, Hollywood D, Kennedy MJ, Rowley S, Ryan A, Hughes N, Carey M, Byrne P. Neoadjuvant chemoradiation may increase the risk of respiratory complications and sepsis after transthoracic esophagectomy. J Thorac Cardiovasc Surg. 2006; 132(3): 549-555. 22. Hagry O, Coosemans W, De Leyn P, Nafteux P, Van Raemdonck D, Van Cutsem E, Hausterman K, Lerut T. Effects of preoperative chemoradiotherapy on postsurgical morbidity and mortality in cT3-4 +/- cM1lymph cancer of the oesophagus and gastro-oesophageal junction. Eur J Cardiothorac Surg. 2003; 24(2): 179-186. 23. Urschel JD, Vasan H. A meta-analysis of randomized controlled trials that compared neoadjuvant chemoradiation and surgery to surgery alone for resectable esophageal cancer. Am J Surg. 2003; 185(6): 538-543. 24. Gebski V, Burmeister B, Smithers BM, Foo K, Zalcberg J, Simes J. Survival benefits from neoadjuvant chemoradiotherapy or chemotherapy in oesophageal carcinoma: a meta-analysis. Lancet Oncol. 2007; 8(3): 226-234. 25. Liao Z, Cox JD, Komaki R. Radiochemotherapy of esophageal cancer. J Thorac Oncol. 2007; 2(6): 553-568.

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THYROGLOSSAL DUCT CYST


E. Trcoveanu, D. Niculescu, Elena Cotea, A. Vasilescu, Felicia Crumpei, D. Ferariu, Mdalina Palaghia, D. Dorob First Surgical Clinic, St. Spiridon Hospital Iai Gr.T. Popa University of Medicine and Pharmacy Iai, Romania
THYROGLOSSAL DUCT CYST (Abstract): The thyroglossal duct cyst (TDC) results from a failure in obliterating the embryogenic duct produced during thyroid migration and it represents the most common type of developmental cyst encountered in the neck region. Ectopic thyroid tissue neoplasias are rare, and even rarer when associated with the TDC. Methods: During the period 1998-2008, in the First Surgical Clinic, University Hospital St. Spiridon Iasi, 14 patients with thyroglossal duct cyst were diagnosed and treated. All records were reviewed for age and sex, diagnostic methods, sizes, surgical management and recurrences. Results: All patients with thyroglossal duct cysts are described as midline cysts of the neck. The ratio females/males was 6/1 with mean age 37.6 years (13-60 years). One case was with an external fistula. The treatment performed was a variant of Sistrunks procedure in which the thyroglossal tract was excised to a variable extent, but in all cases with central hyoidectomy. The size of the cyst ranged from 1.2 to 4 cm (mean 2.6 cm). Postoperative course was unventful in all cases. No recurrence was recorded in this series. We describe a case, a 19 years old female with thyroid papillary carcinoma evolving from a TDC. The literature is reviewed. Conclusion: The standard surgical approach to TDC is Sistrunk's operation with low recurrence rates. Malignancy within a thyroglossal duct cyst is very rare but should be included in the differential diagnosis of a neck mass. In such cases total thyroidectomy with removal of the tumour of thyroglossal duct and the body of the hyoid bone are recommended because the carcinoma may be multifocal and because a lymphatic invasion of the thyroid may take place in order to ensure a correct follow-up. KEY WORDS: THYROGLOSSAL PAPILLARY CARCINOMA DUCT CYST, SISTRUNK'S OPERATION, THYROID

Correspondence to: Eugen Trcoveanu, MD, PhD, Professor of Surgery, First Surgical Clinic, St. Spiridon Hospital Iai, 700111, Independenei Street No 1, Iai, Romania; e-mail: etarco@iasi.mednet.ro*

INTRODUCTION The thyroglossal duct cyst (TDC) is a well recognized developmental abnormality which arises in some 7% of the population. Consequently, it represents the most common type of developmental cyst encountered in the neck region. TDC results from a failure in obliterating the embryogenic duct produced during thyroid migration. TDCs are most often diagnosed in the pediatric age group and a minority of patients with TDCs are over 20 years of age at the time of diagnosis. A cyst may develop from the secretory residual epithelium. Ectopic thyroid tissue neoplasias are rare, and even rarer when associated with the TDC. It has been reported that over 62% of them may have some ectopic thyroid tissue. It typically presents itself as a mobile, painless mass in the anterior midline of the neck, usually in close proximity to the hyoid bone.

received date: 16.09.2008 accepted date: 30.11.2008

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METHODS During the period 1998-2008, in First Surgical Clinic, St. Spiridon Hospital of Iai, 14 patients with thyroglossal duct cyst were diagnosed and treated. 1902 thyroidectomies for thyroid disease were performed during this period. All records were reviewed for age and sex, diagnostic methods, sizes, surgical management and recurrences. All patients underwent clinical examination and screening laboratory tests, cervical and chest radiography, ultrasound scan, scintigraphy with 131I and thyroid function tests. RESULTS This TDC group consisted of 11 females (78.6%) and 3 males (21.4%) with mean age 37.6 years (13-60 years). The mean age of onset of symptoms was 24 years. The history of the disease varied from 1 month to 35 years. 13 patients with thyroglossal duct cysts are described as midline cysts of the neck. In this series 1 cyst was situated laterally. The level of the cysts in the neck was as follows: two in the suprahyoid region, 9 in the prehyoid region, three at the level of the thyroid cartilage. In this series no cysts were seen in the chest. A case with an external fistula with recurrence of 10 years after cyst removal by a variant of Sistrunk procedure is reported.

Fig.1 Thyroglossal duct cyst in the midline of neck

The commonest reason for seeking treatment was the discovery of an asymptomatic lump in the anterior part of the neck in 10 cases. Thyroid pathology (goiter) was associated in two cases. A tender inflamed lump and external fistula were noticed in another case. The clinical diagnosis was suggested by the presence of a cystic mass situated towards the front of the midline neck, which moved with protrusion of the tongue and could be transilluminated. In this series all patients were operated on. One case was initially treated with antibiotics for infected thyroglossal cysts. The treatment performed was a variant of Sistrunks procedure in which the thyroglossal tract was excised to a variable extent, but in all cases with central hyoidectomy. The original 1920 monograph by an american surgeon, Walter Ellis Sistrunk from the Mayo Clinic, described the surgical management of this congenital abnormality and remains the classic basic reference. The Sistrunk operation consists

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en bloc cystectomy and central hyoidectomy, with tract excision up to the foramen cecum. The size of the cyst ranged from 1.5 to 6 cm (mean 2.8 cm). Postoperative course was unventful in all cases. In this series no recurrence was recorded. Three of the patients were not followed up. In one case the histopathologic diagnosis was a papillary carcinoma evolving from a TDC. We describe this case in view of its extreme rarity and in order to highlight the therapeutic options in the management of malignancies arising in thyroglossal cysts. A 19 years old female noticed a painless mass in the midline of her neck, one month prior to her first visit to our clinic (Fig. 1).

Fig.2 Ultrasound scan revealed a cystic mass, with a thick content

Fig. 3 Excision of thyroglossal duct cyst with a well defined smooth surface accompanied by the suprahyoid tract.

She had no past history of neckinjury. She did not complain of dysphagia or odynophagia, or of phlogistic signs. During the clinical examination, we noticed a deep nodular lesion, of about 3x2 cm. It was fibroelastic, mobile during swallowing and at tongue protrusion. There were no clinically significant nodes. The thyroid gland was

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normal at palpation. Ultrasound scan showed a cystic mass, with a thick content; the thyroid was within normal limits (Fig. 2). The thyroid scintigraphy was normal. We performed a Sistrunk's procedure (removal of the mid-portion of the hyoid bone in continuity with the TDC and excision at the core of tissue between the hyoid bone and the foramen cecum (Fig. 3). The histopathologic exam revealed a papillary carcinoma in situ evolving from a TDC (Fig. 4). We didnt performed any other thyroidian procedure because the clinical exam as well as thyroidian ultrasonography and scintigraphy didnt revealed any lession. The patient has been followed for seven years. No metastasis occurred. DISCUSSION Embryologically, by the seventh or eighth week of development, the thyroid reaches its normal position, the area below the thyroid cartilage, descending through the thyroglossal duct (TDC). During the 10th week of fetal life, the TDC is usually obliterated. Failure of obliteration may result in the development of a cystic dilatation at any time in life. The body of the hyoid bone subsequently develops in the mesoderm joining the ventral ends of the second and third branchial arches and may incorporate the thyroglossal tract into its substance. TDCs are localized towards the midline, between the base of the tongue and the pyramidal lobe of the thyroid gland.

Fig.4 Histopathologic exam papillary carcinoma in TDC (hematoxilin-eosine ob. 10x)

TDCs are present in approximately 7% of the general population; up to 62% of these may contain ectopic and functional thyroid tissue, thereby enabling the development of thyroid-related tumours. 70% are diagnosed in childhood and 7% are diagnosed in adulthood. Malignant neoplasms rarely arise in thyroglossal cysts, in less than 1% of cases [1]. They usually take the form of either papillary carcinoma of thyroid origin (arising from thyroembrionic remnants in the duct or a cyst: 85-95% of cases), squamous carcinoma (arising from metaplastic columnar cells that line the duct: 5% of cases), or anaplastic, and Hurthle cell carcinoma. Criteria for the diagnosis of primary papillary carcinoma arising in a TDC after Widstrom are: 1) histologic identification of TDC demonstrating that the cyst or duct has an epithelial lining with normal thyroid follicles in the cyst wall; 2) there is normal thyroid tissue adjacent to the tumor; and 3) histopathologic examination of the thyroid gland reveals no signs of

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primary carcinoma [2]. In this paper we describe a case with primary papillary carcinoma. As TDCs are most often diagnosed in the pediatric age group, only a minority of cases with TDCs, are operated on at an adult age. The most common clinical sign was a non-tender, mobile neck mass, which was painful at swallowing in the anterior midline of the neck, usually in close proximity to the hyoid bone. Less often, TDCs may show signs and symptoms of secondary infection or present evidence of a fistula. The cystic mass is situated anteriorly towards the midline of the neck, which moved with tongue protrusion and could be transilluminated. In rare cases the cysts are situated laterally [3]. Hatada T et al report a case with intrathyroid thyroglossal duct cyst [4]. Preoperative evaluation of thyroglossal duct cyst includes: cervical and chest radiography, ultrasound scan, scintigraphy with 131I and thyroid function tests. An ultrasound exam is useful in malignancy by demonstrating a mural nodule, calcification or lymph node metastases. Computerized tomography has also been used in case of malignancy and ectopic cysts. Clinical confirmation of aberrant thyroid tissue is proved by a radioactive iodine scan. The ultrasound-guided fine-needle aspiration (FNA) is only moderately sensitive for a preoperative evaluation of TDCs. Cytomorphologic features are not always specific, but associated with clinical and radiological signs, they may be helpful for an accurate diagnosis. Thyroid epithelium is rarely identified [5].

Fig. 5 Autoportret Piero della Francesca in Polyptych of the Misericordia

The differential diagnosis involves: dermoid cyst, epidermoid cyst, branchial cleft cyst, lymph nodes, lymphangioma, thyroid pathology. The thyroglossal duct cyst raised many differential diagnostic problems obvious even in the Renaissance paintings (Fig. 5). Thus H.E. Emson contradicts L. Bondenson stating that Piero della Francescas self portrait from the Polyptych of the Misericordia betrays a thyroglossal duct cyst and not goiter [6]. The standard surgical approach to TDCs dating back to early 20th century is Sistrunk's operation encompassing removal of the mid-portion of the hyoid bone in continuity with the TDC and excision of a core of tissue between the hyoid bone and the

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foramen cecum [7]. The Sistrunk procedure is recommended as the main operation of choice, especially in adults in whom a more extended tract resection should be performed [8]. The risk of recurrence is high in case of inadequate tissue resection from the tongue base with such multiple tracts. In our series we performed a complete thyreoglossal tract in one case with recurrence, 10 years after the simple cyst removal. The alternative solution for surgical treatment is percutaneous ethanol injection. If the presence of a malignant lesion can be excluded, percutaneous ethanol injection may be considered a secondary treatment in patients with thyroglossal duct cysts in selected cases [9]. Primary carcinoma is rare and is seen in less than 1% of cases [10,11]. Carcinoma arises slightly more often in females in the fourth decade of life. The malignancy should be suspected by rapid increase in size, dysphagia, hoarseness of voice and pain . The thyroglossal duct cyst is hard, fixed and irregular. The diagnosis is usually based on pathological examination of the cyst. Approximately 200 cases have been reported in the literature worldwide, diagnosed with papillary carcinoma arising from the thyroglossal duct. The tall cell variant is a rare papillary carcinoma and has a poor prognosis [12]. Following the Sistrunk's procedure, when a histopthological examination reveals a malignancy, the thyroid gland must be studied radiologically and scintigraphically. Sistrunks procedure would suffice if the thyroid gland was found to be normal. Total thyroidectomy is recommended in selected cases, as a papillary carcinoma, may be present [13]. Cervical bilateral node dissection is not necessary in all cases, only in 8% of cases a significant involvement of regional lymph nodes was present [14]. In our case, we used a radical surgical method with total tyroidectomy. For all patients with papillary carcinoma of thyroglossal cyst, radioactive iodine and thyroid suppression are recommended, if the the patient had or not a thyroidectomy or the thyroid scan is normal [1,15]. Patel et al made a retrospective study and analysed the prognostic factors predictive of overall survival in patients with TDCs, and revealed that the only significant predictor of outcome was the extent of surgery for TDCs. Patients who had simple excision have had a 10-year overall survival rates of 75%, in comparison with 100% in the patient who suffered Sistrunks procedure [16]. The patients with squamous carcinoma arising in a thyroglossal cyst have a poorer prognosis and should be treated with postoperative external beam radiotherapy [10]. CONCLUSION TDC results from a failure in obliterating the embryogenic duct produced during thyroid migration. The cyst usually appears as an asymptomatic swelling in the prehyoid region of the neck. The standard surgical approach to TDC is Sistrunk's operation with low recurrence rates. Malignancy within a thyroglossal duct cyst is very rare but should be included in the differential diagnosis of a neck mass. The therapy includes surgery, radioactive iodine and thyroid suppression, as is the case with differentiated thyroid cancers. In such cases total thyroidectomy with removal of the tumour of thyroglossal duct and the body of the hyoid bone are recommended because the carcinoma may be multifocal and because a lymphatic invasion of the thyroid may take place in order to ensure a correct follow-up.

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1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.

14. 15. 16.

REFERENCES Kandogan T, Erkan N, Vardar E. Papillary carcinoma arising in a thyroglossal duct cyst with associated microcarcinoma of the thyroid and without cervical lymph node metastasis: a case report. J Med Case Reports. 2008; 2: 42. Widstrom A, Magnusson P, Hallberg O, Hellqvist H, Riiber H. Adenocarcinoma originating in the thyroglossal duct. Ann Otol. 1976; 85: 286290. Mohan PS, Chokshi RA, Moser RL, Razvi SA Thyroglossal duct cysts: a consideration in adults. Am Surg. 2005; 71(6): 508-511. Hatada T, Ichii S, Sagayama K, Ishii H, Sugihara A, Terada N, Yamamura T.Intrathyroid thyroglossal duct cyst simulating a thyroid nodule. Tumori. 2000; 86(3): 250-252. Cignarelli M, Ambrosi A, Marino A, Lamacchia O, Cincione R, Neri V. Three cases of papillary carcinoma and three of adenoma in thyroglossal duct cysts: clinical diagnostic comparison with benign thyroglossal duct cysts. J Endocrinol Invest. 2002; 25: 947-954. Emson HE. Thyroid swellings in Renaissance art. J R Soc Med. 2004; 97: 311. Sistrunk WE. The surgical treatment of cysts of the thyroglossal tract. Ann Surg. 1920; 71: 121124. Lin ST, Tseng FY, Hsu CJ, Yeh TH, Chen YS. Thyroglossal duct cyst: a comparison between children and adults. Am J Otolaryngol. 2008; 29(2): 83-87. Baskin HJ. Percutaneous ethanol injection of thyroglossal duct cysts. Endocr Pract. 2006; 12(4): 355-357. Vijay R, Rajan KK, Feroze M. Inapparent twin malignancy in thyroglossal cyst: case report. World J Surg Oncol. 2003; 1(1): 15. Yang YJ, Haghir S, Wanamaker JR, Powers CN Diagnosis of papillary carcinoma in a thyroglossal duct cyst by fine-needle aspiration biopsy. Arch Pathol Lab Med. 2000; 124(1): 139-142. Kybaiolu F, Simek GG, Onal BU. Tall cell variant of papillary carcinoma arising from a thyroglossal cyst: report of a case with diagnosis by fine needle aspiration cytology. Acta Cytol. 2006; 50(2): 221-224. Plaza CP, Lpez ME, Carrasco CE, Meseguer LM, Perucho Ade L. Management of welldifferentiated thyroglossal remnant thyroid carcinoma: time to close the debate? Report of five new cases and proposal of a definitive algorithm for treatment. Ann Surg Oncol. 2006; 13(5): 745-752. Renard TH, Choucair RJ, Stevenson WD, Brooks WC and Poulos E: Carcinoma of the thyroglossal duct. Surg Gynecol Obstet. 1990; 171: 305-308. Maziak D, Borowy ZJ, Deitel M, Jaksic T and Ralph-Edwards A. Management of papillary carcinoma arising in thyroglossal duct anlage. Can J Surg. 1992, 35: 522-525. Patel SG, Escrig M, Shaha AR, Singh B, Shah JP. Management of well-differentiated thyroid carcinoma presenting within a thyroglossal duct cyst. J Surg Oncol 2002; 79: 134139.

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TRATAMENTUL CHIRURGICAL LAPAROSCOPIC AL HERNIEI HIATALE - STUDIU ASUPRA UNUI LOT DE 40 CAZURI
Lcrmioara Perianu1, N. Dnil2, C. Bradea2 1 Departamentul de Anatomie; 2 Clinica I Chirurgie Spitalul Sf. Spiridon Iai Universitatea de Medicin i Farmacie Gr.T.Popa Iai,
LAPAROSCOPIC TREATMENT OF HIATAL HERNIA STUDY OF 40 CASES (Abstract): Minimally invasive surgery has changed the therapeutic approach in the most frequent eso-gastric diseases. With the excellent results in the control of symptoms and low associated morbidity, laparoscopic surgery is indicated in hiatal hernia, as a superior alternative to the classical surgical treatment. Aim: The authors performed a retrospective study analyzing the functional results and the long term outcome of laparoscopic repair of hiatal hernias. Material and methods: From 1994 to 2006, 40 patients underwent a laparoscopic procedure for a symptomatic hiatal hernia, 7 of them being converted into open surgery. Results: mean operating time was 15437 minutes, mean hospital time was 6.16 days for successful laparoscopic surgery and 14.8 days in case of conversions. The associated morbidity was related with conversion (19.44%), splenic rupture (4.84%) and respiratory diseases (4.65%). Mortality rate was 0.5%. Discussions: the obtained results were compared with the published data allowing us to discuss about indications of laparoscopic surgery, technical difficulties and clinical outcome. For hiatus hernia and gastroesophageal reflux, Nissen fundoplication by laparoscopy is the technique of choice. Conclusions: Objective anatomical studies are required in order to determine the indications and contraindications of laparoscopic surgery.

KEY WORDS: HIATAL HERNIA, LAPAROSCOPY, NISSEN OPERATION Coresponden: Dr. Lcrmioara Perianu, Departamentul de Anatomie, Universitatea de Medicin i Farmacie Gr.T. Popa Iai, Bd. Independenei, nr. 1, 700111, Iai;* INTRODUCERE Laparoscopia constituie o metod modern de diagnostic i tratament care prezint avantajul minimizrii impactului i a incidenei poteniale a complicaiilor. Abordul laparoscopic permite analiza integritii diafragmului, evaluarea i reconstrucia direct a defectelor congenitale i a leziunilor organelor abdominale aprute secundar herniilor dobndite [1]. Pn n ultimile 3 decade, interveniile chirurgicale pentru herniei hiatal sau reflux gastroesofagian erau abordate n dou maniere clasice: transtoracic i transabdominal. Din 1991, cnd se aplic pentru prima dat fundoplicatura Nissen prin abord laparoscopic, aceast metod chirurgical reprezint o alternativ de elecie a chirurgiei clasice, prin avantajele incontestabile pe care le aduce n ceea ce privete rezultatul imediat i eficacitatea pe termen lung privind mbuntirea calitii vieii pacientului [2,3]. MATERIAL I METOD ntre 1994 i 2006, pe o perioad de 12 ani, se realizeaz un studiu retroprospectiv pe un lot format din 40 de pacieni internai, evaluai i tratai laparoscopic n Clinica I
received date: 10.01.2008 accepted date: 22.10.2008
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Chirurgie a Spitalului de Urgen Sf. Spiridon. Din cei 40 de pacieni, 33 au fost tratai exclusiv laparoscopic, iar n 7 cazuri s-a impus conversia n chirurgie clasic (17,5%). Datele preoperatorii, intraoperatorii i postoperatorii au fost analizate prospectiv i exprimate n termeni de valori medii, exprimri procentuale i deviaie standard. Prelucrarea statistic a fost realizat prin intermediul programului Statistica 6.0. REZULTATE Simptomele tipice ale herniei hiatale au fost prezente la toi pacienii: pirozis (93,55%), disfagie (59,68%), regurgitaie acid (72,58%), senzaie de grea i vrsturi (51,61%). Pacienii au fost tratai laparoscopic prin abord transabdominal, prin unul din procedeele chirurgicale standard utilizate n chirurgia clasic, uor modificate datorit particularitilor legate de tipul de abord.
Tabelul I Tipuri de intervenii chirurgicale laparoscopice efectuate Tip intervenie NISSEN NISSENROSSETTI TOUPET DOR Nr. cazuri 15 13 3 9 % 37,5 32,5 7,5 22,5 Intervenii asociate recalibrarea hiatusului la 5 pacieni (ntr-un caz a fost necesar utilizarea unei proteze de polipropilen); colecistectomie la 4 pacieni; recalibrarea hiatusului la 1 pacient; colecistectomie la 2 pacieni; colecistectomie laparoscopic la 1 pacient;

Prin analiza datelor statistice s-a constatat c durata medie a interveniei chirurgicale laparoscopice a fost de 15437 minute, iar spitalizarea medie a fost de 6,16 zile, prelungindu-se la 14,8 zile n cazul conversiilor. O mrturie a complexitii interveniilor laparoscopice o reprezint rata crescut a conversiilor - 19,44% (7 cazuri). Cauzele conversiei au fost: leziuni esofagiene (1 caz), gastrice (2 cazuri), splenice (3 cazuri), dificulti tehnice (3 cazuri). Ulterior s-au practicat fundoplicatura Nissen (5 cazuri) i respectiv procedeul Dor (2 cazuri). n postoperator s-a efectuat controlul radiologic prin tranzit baritat esogastroduodenal la toi cei 40 de pacieni, iar la 8 pacieni s-a efectuat i examen endoscopic. S-a constatat o rat nalt a morbiditii postoperatorii (16,67%) care a impus reintervenia: abces intraabdominal (2 cazuri), fistul esofagian (1 caz), fistul gastric (2 cazuri), abces mediastinal (1 caz). Disfagia precoce a fost ntlnit la 91,94% dintre pacieni i nu a fost influenat de conversie (p>0,5), iar disfagia tardiv a aprut la un interval mediu de 3,6 luni i a fost constatat la 12,9% dintre pacieni. Mortalitatea postoperatorie a fost de 0,5%. DISCUII Abordul laparoscopic este considerat actualmente, tehnica standard de tratament a herniilor hiatale. Abordul laparoscopic permite vizibilitatea zonei de lucru (spaiul subfrenic fiind mai greu accesibil chirurgiei deschise dect laparoscopiei), avnd

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rezultate anatomice i funcionale mai bune, prin pstrarea integritii structurilor jonciunii eso-gastrice i refacerea facil a anatomiei regiunii. Incidena recidivelor herniilor hiatale este minim (0-5%), laparoscopia conferind avantajele minitraumatismului parietal, mai ales pentru pacienii cu tare importante asociate (obezitate, patologie cardiac i pulmonar). Alte argumente care pledeaz n favoarea abordului laparoscopic n tratamentul herniilor hiatale sunt reprezentate de rata mai sczut a complicaiilor intra- i postoperatorii (leziuni splenice, eventraii), reducerea semnificativ a hemoragiei intraoperatorii, durerea sczut postoperator, confort postoperator mai bun, rezultat estetic mai bun comparativ cu cel din chirurgia clasic, durat de spitalizare mai redus cu reluarea mai rapid a activitilor cotidiene [4]. n literatura de specialitate sunt discutate n special dou aspecte: reducerea ratei complicaiilor precoce severe, care impun reintervenii i respectiv, alegerea tipului de procedeu antireflux. Elementele de risc tehnic din cursul chirurgiei laparoscopice sunt reprezentate de disecia pilierilor diafragmatici, reducerea complet a sacului herniar localizat n torace, mobilizarea esofagului distal cu identificarea traiectului nervilor vagi anterior i posterior, mobilizarea complet a fundusului gastric cu seciunea vaselor gastrice scurte, sutura pilierilor diafragmatici, confecionarea unei fundoplicaturi complete i eficiente [4]. Complicaiile severe care impun reintervenii imediate, dei pe statistica prezentat au o inciden nalt, de peste 15%, sunt raportate n literatur cu o rat de sub 1% [4]; n general sunt reprezentate de perforaii esofagiene, gastrice, migrri ale fundoplicaturii n torace sau hemoragii. Reinterveniile deschise dup intervenii chirurgicale pentru herniile hiatale sunt asociate cu o morbiditate de 20-40% i o mortalitate de 2% [2,4]. Minimizarea morbiditii i mortalitii cu remisia simptomatologiei, mbuntirea calitii vieii i durabilitatea rezultatelor interveniei rmn obiectivele oricrui tratament chirurgical [3,5]. Abordul laparoscopic are un impact major asupra fiecruia dintre aceti factori, eficacitatea ei depinznd de acurateea actului chirurgical propriu-zis care la rndul su depinde de trainingul chirurgului [1,5]. n cazul identificrii perforaiilor intraoperatorii este indicat conversia imediat a laparoscopiei n chirurgie clasic. Reintervenia laparoscopic este tehnic laborioas i presupune disecia i secionarea aderenelor, desfacerea suturilor, expunerea complet a hiatusului, pregtirea extremitii distale i poziionarea intratoracic a esofagului, desfacerea suturilor pilierilor, nlturarea esutului fibros excesiv parahiatal, refacerea hiatusului diafragmatic normal i reconstrucia unei noi valve. Cu toate aceste dificulti, mortalitatea dup refundoplicatura laparoscopic este comparabil cu cea din procedeele primare [6]. Alegerea tipului de procedeu antireflux se realizeaz n funcie de caracteristicile anatomo-clinice ale herniei hiatale i mai ales de preferina i trainingul chirurgului [5]. Rezultatele imediate i la distan a diferitelor tipuri de procedee antireflux par a fi similare [7]. Totui, studii recente consider c operaia Toupet pare a avea rezultate mai bune, avnd o rat mai sczut dect operaia Nissen a disfagiei postoperatorii i controlnd, cu o eficien similar, refluxul [8]. CONCLUZII Tratamentul laparoscopic trebuie s urmreasc reducerea herniei, disecia esofagului n mediastin n momentul coborrii sfincterului esofagian inferior n cavitatea abdominal, reconstrucia unghiului lui Hiss, refacerea anatomiei structurilor

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regiunii esogastrice i diafragmatice corespunztoare, refacerea anatomiei regiunilor interesate pentru tot restul vieii pacientului, obinerea celei mai reduse rate de complicaii posibile. Intervenia laparoscopic, dei se asociaz uneori cu o rat crescut a morbiditii postoperatorii, este abordul standard pentru tratamentul herniilor hiatale. Rata morbiditii postoperatorii este influenat de trainingul chirurgului. Tehnicile antireflux au rezultate la distan similare, att din punct de vedere al recidivei, ct i al disfagiei tardive i controlului refluxului gastro-esofagian.
1. 2. 3. 4. 5. BIBLIOGRAFIE Trcoveanu E. Training in laparoscopic surgery. The problem of competence and responsibility. Chirurgia. 1995; 44(2): 17-27. Ackermann C, Bally H, Rothenbuehler JM, Herder F. The surgery of paraesophageal hernias: technique and results. Schweiz Med Wochenschr. 1989; 119: 723-725. Gmez Crdenas X, Flores Armenta JH, Elizalde Di Martino A, Guarneros Zrate JE, Cervera Servn A, Ochoa Gmez R, Quijano Orvaanos F. Antireflux surgery, comperative study of three laparascopic techniques. Rev Gastroenterol Mex. 2005; 70(4): 402-410. Nilsson G, Wenner J, Larsson S. Randomized clinical trial of laparoscopic versus open fundoplication for gastroesophageal reflux. Br J Surg. 2004; 91: 552-559. Priego P, Lobo E, Sanjuanbenito A, Martnez Molina E, Prez de Oteyza J, Ruiz Tovar J, Rodrguez Velasco G, Fresneda V. Causes of conversion in laparoscopic surgery for gastroesophageal reflux disease: an analysis of our experience. Rev Esp Enferm Dig. 2008; 100(5): 263-267. Spaventa-Ibarrola AG, Decanini-Tern C, Becerril-Martnez G, Gonzlez-Lazzeri S. Refundoplication for failed antireflux surgery. Experience in sixteen cases. Cir Cir. 2006; 74(2): 89-94. Pessaux P, Arnaud JP, Ghavami B, Flament JB, Trebuchet G, Meyer C, Huten N, Champault G. Laparoscopic antireflux surgery: comparative study of Nissen, Nissen-Rossetti, and Toupet fundoplication. Socit Franaise de Chirurgie Laparoscopique. Surg Endosc. 2000; 14(11): 1024-1027. Strate U, Emmermann A, Fibbe C, Layer P, Zornig C. Laparoscopic fundoplication: Nissen versus Toupet two-year outcome of a prospective randomized study of 200 patients regarding preoperative esophageal motility. Surg Endosc. 2008; 22(1): 21-30.

6. 7.

8.

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AVANTAJELE TRATAMENTULUI CHIRURGICAL LAPAROSCOPIC N TUMORILE OVARIENE CHISTICE


Cristina David1, Ivona Lupacu1, E. Trcoveanu2 1. Clinica a II-a Obstetric Ginecologie, Spitalul Cuza Vod Iai 2. Clinica I Chirurgie, Spitalul Sf. Spiridon, Iasi Universitatea de Medicin i Farmacie Gr.T. Popa Iai
LAPAROSCOPIC ADVANTAGE IN MANAGEMENT OF CYSTIC OVARIAN MASSES (Abstract): The aim of the study was to spotlight the advantages of using laparoscopic surgery in the treatment of ovarian cysts, by comparing the results obtained on two groups of patients: the first group of 165 patients treated by conventional surgery (laparotomy) and the second group of 44 patients laparoscopicaly treated. The patients were hospitalized, diagnosed and treated in the 2-nd Clinic of Obstetrics and Gynecology and in the 1-st Clinic of General Surgery in Iassy. More conservative surgical techniques were performed by laparoscopic surgery than by conventional surgery. We found a lower incidence of intra- and postlaparoscopic surgery complications than intra- and postlaparotomy. The postoperative hospitalization was shorter after laparoscopy than after laparotomy. The functional prognosis (menstrual function and fertility) was favorable in the laparoscopicaly treated patients. In conclusions, laparoscopic surgery has unchallenged advantages in the treatment of ovarian cysts, especially in young women. KEY WORDS: OVARIAN CYST, LAPAROSCOPY, LAPAROTOMY Coresponden: Dr. Cristina David, Clinica a II-a Obstetric Ginecologie, Spitalul Cuza Vod Iai, str. Cuza Vod, nr. 34, Iai, Romnia; tel. 0232 215468, fax 0232 215468*

INTRODUCERE Laparoscopia a cunoscut n ultimii ani o evoluie remarcabil, att n domeniul chirurgiei generale, ct i n chirurgia ginecologic. Acest tip de chirurgie prezint avantaje incontestabile n comparaie cu chirurgia convenional: cicatrici abdominale estetice, durere postoperatorie redus, recuperare postoperatorie rapid, durat redus de spitalizare, medicaie minim, risc redus de aderene postoperatorii, posibilitatea efecturii unor tehnici chirurgicale miniminvazive conservatoare, cu pstrarea funciei menstruale i reproductive a femeii. Interveniile chirurgicale laparoscopice constituie, de cele mai multe ori, un succes, cu condiia selectrii corecte i riguroase a cazurilor care se preteaz acestui tip de chirurgie. Patologia tumoral ovarian benign (chistul de ovar) este una dintre patologiile care beneficiaz n cel mai nalt grad de avantajele chirurgiei laparoscopice. MATERIAL I METOD Lotul de studiu a cuprins 44 de cazuri de tumori ovariene chistice, tratate laparoscopic, iar lotul martor a inclus 165 de cazuri cu tumori ovariene chistice tratate convenional. Aceste cazuri au fost spitalizate, diagnosticate i tratate n Clinica a II-a Obstetric Ginecologie i n Clinica I Chirurgie Iai, n perioada 2001-2008. Studiul realizat a respectat metodologia studiilor clinice comparative. Analiza celor dou loturi s-a realizat prin compararea tehnicilor chirurgicale practicate, a
received date: 10.10.2008 accepted date: 22.11.2008
*

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intensitii durerii postoperatorii, a ratei complicaiilor intra- i postoperatorii, a duratei medii de spitalizare postoperatorie i a prognosticului menstrual i de fertilitate al pacientelor. Au fost folosite testele de semnificaie statistic Mann-Whitney i 2 Pearson. Au fost utilizate instrumentarul i aparatura STORZ i OLYMPUS pentru chirurgie endoscopic. REZULTATE Vrsta pacientelor a fost cuprins ntre 16 i 41 ani n lot de studiu, tratat laparoscopic i ntre 24 i 75 ani n lotul martor. Vrsta medie a pacientelor tratate laparoscopic a fost 24,27 ani, iar a celor tratate convenional a fost de 40,56 ani. Majoritatea pacientelor din lotul martor au fcut parte din grupa de vrst 25-29 ani, deci o grup de vrst apropiat de cea n care s-au situat pacientele lotului de studiu (25-29 ani i 30-34 ani). Se observ c tratamentul chirurgical laparoscopic a fost aplicat, n special, pacientelor de vrst tnr, la care suspiciunea de tumor ovarian malign a fost minim sau absent i la care s-a dorit obinerea unui prognostic funcional menstrual i de fertilitate favorabil (Fig. 1).

Fig. 1 Structura pe grupe de vrst a loturilor investigate

n lotul martor au existat i paciente aflate n perioada menopauzal i postmenopauzal, n cazul crora s-a considerat mai sigur intervenia chirurgical convenional, chiar dac nu au existat elemente de suspiciune de malignitate. De asemenea, prezena unor afeciuni generale asociate a mpiedicat intervenia laparoscopic (contraindicaii pentru pneumoperitoneu). Din punct de vedere al diagnosticului anatomo-clinic, loturile studiate au cuprins cazuri de tumori chistice ovariene benigne, suspecte i maligne. n lotul martor au existat 155 cazuri (93,90%) de tumori ovariene chistice benigne, 8 cazuri (4,80%) de tumori ovariene chistice borderline i 2 cazuri (1,20%) de tumori ovariene maligne. n lotul de studiu toate tumorile ovariene chistice au fost benigne (Fig. 2).

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Din punct de vedere al diagnosticului anatomo-patologic, loturile studiate au cuprins cazuri de: chist seros, chist hematic, chist mucinos, chist dermoid, endometriom, tumor borderline i adenocarcinom.

1 lot chir.laparoscopica 140 120 100 80 60 40 20 0 conservator radical 2 lot chir.conventionala

126

35

39 9

Fig. 2 Rezultatele anatomo-patologice analizate comparativ pe cele dou loturi

1 lot chir.laparoscopica 140 120 100 80 60 40 20 0 conservator radical 2 lot chir.conventionala

126

35

39 9

Fig. 3 Analiza comparativ a tehnicii chirurgicale pe cele dou loturi

n lotul de studiu au predominat cazurile de chist seros hematic, mucinos, dermoid i endometriozic. Toate cazurile de tumori ovariene chistice au fost de natur benign, ceea ce demonstreaz o bun selectare a cazurilor prin metodele diagnostice actuale. Aplicarea testelor de semnificaie statistic pentru diagnosticul anatomopatologic pe cele dou loturi studiate a artat frecvena mai crescut a chisturilor seroase simple att n lotul martor (59,40%), ct i n lotul de studiu (34,10%), acestea fiind urmate ca frecven, de chistul hematic i endometriom. Rezult, deci, c tumorile ovariene chistice benigne au predominat n ambele loturi studiate, permind astfel evaluarea comparativ a metodelor clasice i moderne de tratament. Analiza tipului de tehnic chirurgical practicat (conservatoare sau radical) a demonstrat predominana tehnicilor chirurgicale conservatoare (chistectomie) n lotul de

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studiu, tratat laparoscopic (Fig. 3), n comparaie cu lotul martor, tratat convenional, la care au predominat tehnicile chirurgicale radicale (ovariectomie, anexectomie). Interveniile radicale practicate la pacientele lotului martor au fost decise i de vrsta mai naintat a unora dintre paciente, la care nu a fost important pstrarea funciei menstruale i reproductive. Interveniile laparoscopice ofer posibilitatea unor tehnici chirurgicale miniminvazive, conservatoare, care asigur prognostic menstrual i reproductiv favorabil (Fig. 4).

B
Fig. 4 Aspecte intraoperatorii A Puncionarea chistului seros; B Fenestrarea chistului seros

nr.cazuri 120 100 80 60 40 20 0 minima

114

1 lotchir.laparoscopica 2 lotchir.conventionala

37 40 7
moderata

0
severa

11

Fig. 5 Analiza comparativ a intensitii durerii postoperatorii

Analiza statistic comparativ i aplicarea testelor de semnificaie statistic au artat o diferen statistic semnificativ ntre cele dou loturi, din perspectiva interveniilor conservatoare: n lotul de studiu, acest tip de intervenii a predominat. Analiza comparativ a intensitii durerii postoperatorii n cele dou loturi a artat o intensitate redus a durerii postoperatorii la toate cazurile tratate laparoscopic i la doar 18% dintre cazurile tratate convenional, restul pacientelor din lotul martor resimind durerea postoperatorie cu intensitate moderat sau sever. De menionat c toate pacientele au beneficiat de anestezie general prin IOT.

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Intensitatea durerii posoperatorii resimite a fost stabilit prin chestionarea pacientelor, acestea fiind rugate s situeze senzaia dureroas pe o scar de la 0 la 10 (13 durere minim, 4-7 durere moderat, 8-10 durere sever) (Fig. 5). Aplicarea testelor de semnificaie statistic a artat c exist diferene semnificative statistic privind intensitatea durerii postoperatorii pentru cele dou tipuri de intervenii chirurgicale (Tabel I).
Tabel I Rezultatele aplicrii testelor de semnificaie statistic pentru compararea intensitii durerii postoperatorii Test de semnificaie statistic Pearson Chi-ptrat Raportul de probabilitate N (Nr. cazuri) Valoare calculat 53,675 55,012 209 Df (grade libertate) 2 2 Semnificaie statistic 0,0001 0,0001 SS*
*SS-semnificativ statistic

Durerea postoperatorie minim n cazul interveniilor laparoscopice se explic prin faptul c n cursul acestor intervenii nu se deschide larg peretele abdominal, manevrele chirurgicale sunt blnde i efectuate cu instrumente atraumatice i complicaiile intraoperatorii i postoperatorii imediate sunt rare. Durerea postoperatorie cu localizare abdominal i iradiere n umr sau n hipocondrul drept poate fi cauzat, n cazul interveniilor laparoscopice, de persistena intraperitoneal a CO2. Aceast durere poate fi redus sau chiar evitat prin exsuflarea atent i complet a gazului, la sfritul interveniei laparoscopice.
Tabel II Complicaiile intraoperatorii comparativ pe cele dou loturi Tip chirurgie Chirurgie convenional Chirurgie laparoscopic Total
N % N % N %

Complicatii intraoperatorii absente


158 95,80 44 100 202 96,70

Total
165 44 209

prezente
7 4,20 0 0 7 3,30

n ceea ce privete aspectul complicaiilor intra- i postoperatorii, analiza comparativ a frecvenei acestora pentru cele dou tipuri de intervenii chirurgicale arat o prevalen semnificativ mai sczut a complicaiilor intra- i postoperatorii la lotul de studiu, tratat laparoscopic, comparativ cu lotul martor, tratat convenional (Fig. 6). Complicaiile intraoperatorii survenite n cazurile de tumori chistice ovariene tratate convenional au constat n depolisri accidentale ale anselor intestinale, n timpul unor adeziolize dificile. n cazurile tratate laparoscopic nu s-au nregistrat complicaii intraoperatorii (Tabel II).

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Complicaiile postoperatorii au predominat n cazurile tratate convenional, majoritatea fiind complicaii infecioase (la nivelul plgii operatorii) i vasculare (tromboflebite pelvine i ale membrelor inferioare) (Fig.6).

158
160 140 120 100 80 60 40 20 0

146

conventional laparoscopic

44 7 0

43 19 1

0nu

1da li ii

0nu

1da li ii

Fig. 6 Complicaii intra- i postoperatorii- comparativ pe cele dou loturi Tabel III Complicaiile postoperatorii comparativ pe cele dou loturi Tip chirurgie Chirurgie convenional Chirurgie laparoscopic Total N % N % N % Complicatii postoperatorii absente 146 88,50 43 97,70 189 90,40 prezente 19 11,50 1 2,30 20 9,60 165 100,00 44 100,00 209 100,00 Total

Tabel IV Rezultatele aplicrii testelor de semnificaie statistic pentru compararea complicaiilor postoperatorii Test de semnificaie statistic Pearson Chi-ptrat Raportul anselor Testul exact Fisher N (Nr. cazuri) Valoare calculat 3,429 4,480 209 Df (grade libertate) 1 1 Semnif. asimpt. (2-sided) 0,064 0,034 Semnif. exacta (1-sided)

0,048 SS*
*SS-semnificativ statistic

n cazurile tratate laparoscopic s-a nregistrat doar un caz de tromboflebit postoperatorie a membrelor inferioare (Tabel III). Aplicarea testelor de semnificaie statistic pentru complicaiile postoperatorii a artat o diferen semnificativ statistic ntre cele dou loturi (Tabel IV).

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Durata de spitalizare postoperatorie a fost o alt variabil analizat comparativ n cele dou loturi. Durata medie de spitalizare postoperatorie a lotului de studiu (lotul laparoscopic) a fost de 3,23 zile, fiind semnificativ mai redus, fa de cea a lotului martor, care a fost de 9,19 zile. Durata cea mai redus de spitalizare postoperatorie a fost ntlnit n cazuri tratate laparoscopic (2 zile), iar durata cea mai lung de spitalizare postoperatorie a fost ntlnit n cazuri tratate chirurgical convenional (18 zile) (Tabel V).
Tabel V Indicatorii statistici de tendin central- pentru durata de spitalizare Durata de spitalizare Nr. cazuri (N) Valoarea medie Limita inferioar CI 95% Limita superioar Mediana Variana Eroarea standard Minimum Maximum Percentila 25 Percentila 50 Percentila 75 Asimetria Boltirea Lot de studiu Valoare Eroarea calculat standard 44 3,23 0,121 2,98 3,47 3,00 0,645 0,803 2 5 3,00 3,00 4,00 0,686 0,383 Lot martor Valoare Eroarea calculat standard 165 9,19 0,157 8,88 9,50 9,00 4,093 2,023 5 18 8,00 9,00 10,00 1,570 4,538

0,357 0,702

0,189 0,376

Aplicarea testelor de semnificaie statistic pentru durata de spitalizare postoperatorie arat diferena semnificativ statistic ntre cele dou loturi (Tabel VI).
Tabel VI Rezultatele aplicrii testului neparametric Mann-Whitney pentru durata spitalizrii postoperatorii
Variabila Loturi comparate Lotul de studiu Lotul martor Total Nr.cazuri 44 165 209 Rangul mediu 2,55 26,99 Suma rangurilo r 92,00 0953,00 Testul aplicat Mann-Whitney U Wilcoxon W Z Semnificaie statistic Valoarea calculat 2,000 992,000 10,303 0,0001 SS*

Durata spitalizrii postoperatori i

*SS-semnificativ statistic

Durata de spitalizare postoperatorie este semnificativ mai redus n cazul interveniilor laparoscopice dect n cazul interveniilor convenionale, deoarece recuperarea cazurilor tratate laparoscopic se face mai rapid: pacientele nu acuz dureri postoperatorii intense, frecvena complicaiilor intra- i postoperatorii este redus,

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medicaia necesar este minim, mobilizarea pacientei se face precoce i reluarea tranzitului intestinal este, de asemenea, mai rapid. Funcia menstrual postoperatorie a fost analizat comparativ la pacientele cu vrste sub 45 de ani din cele dou loturi. Analiza comparativ a acestei variabile a artat o proporie mai crescut a pacientelor cu funcie menstrual normal la 6 luni postoperator n lotul de studiu, n comparaie cu pacientele lotului martor (Fig. 7).
1l otchi r.la pa ros copi ca

50 40 30 20 10 0 amenoree

44 35

2l otchi r.conventi ona l a

35 38

9 0
hipomenoree normala

Fig. 7 Funcia menstrual analizat comparativ pe cele dou loturi.

105
120 100 80 60 40 20 0 NU

1lotchir.laparoscopica 2lotchir.conventionala

29 15 12

DA

Fig. 8 Fertilitatea postoperatorie analizat comparativ pe cele dou loturi

Aplicarea testelor de semnificaie statistic a artat c exist diferene semnificative statistic privind funcia menstrual postoperatorie pentru cele dou tipuri de intervenii chirurgicale practicate (p = 0,0001). Prognosticul menstrual mai bun la pacientele tratate laparoscopic este determinat de proporia mai mare de intervenii laparoscopice conservatoare, care permit pstrarea unor zone mai mici sau mai mari de parenchim ovarian normal, funcional. La pacientele lotului martor, la care interveniile radicale au fost mai frecvente, rata tulburrilor ciclului menstrual a fost mai mare, nregistrndu-se amenoree, hipomenoree sau oligomenoree.

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Fertilitatea postoperatorie, exprimat prin obinerea unei sarcini n primul an postoperator, a fost analizat comparativ la pacientele cu vrste sub 45 de ani din cele dou loturi. Doar 12 paciente (7,30%) din lotul martor au obinut o sarcin n primele 9 luni postoperator, n timp ce 15 paciente (34,10%) din lotul de studiu au obinut o sarcin n acelai interval de timp postoperator (Fig. 8). Analiza comparativ i aplicarea testelor de semnificaie statistic pentru fertilitatea postoperatorie la cele dou loturi investigate a artat diferene semnificative statistic (p = 0,0001). DISCUII Managementul maselor anexiale chistice de origine ovarian este n ultima vreme bine codificat i depinde de vrsta pacientei i de necesitatea pstrrii funciei menstruale i/sau a fertilitii, precum i de caracteristicile imagistice (scor ecografic, examinare n modul Doppler) ale tumorilor chistice ovariene sau, n unele circumstane (menopauz, postmenopauz), de valoarea CA125. Riscul general de apariie a unei tumori ovariene maligne este de 13% pentru femeile aflate n perioada premenopauzal i de 45% pentru cele aflate n perioada postmenopauzal [1,2]. n faa unui caz cu mas anexial ovarian chistic, se pun dou probleme: 1) necesitatea interveniei chirurgicale conservatoare sau radicale, convenional sau laparoscopic sau posibilitatea monitorizrii clinice; 2) care este probabilitatea ca masa anexial s fie malign. Controversele majore n ceea ce privete conduita n cazurile de mase anexiale, sunt legate de momentul i modul n care acestea trebuie tratate. n perioada peripubertar majoritatea maselor anexiale ovariene chistice au caracter funcional i pot fi tratate expectativ sau medicamentos; ele regreseaz de cele mai multe ori spontan [3] Tumorile chistice complexe ntlnite n aceast etap de via sunt teratomul matur, tumori de sinus endodermal sau coriocarcinomul. n cazul tumorilor ovariene chistice simple, cu caracter organic, ct i n cazul teratoamelor mature se indic o atitudine terapeutic minim invaziv - tratament chirurgical laparoscopic conservator (chistectomie sau cel mult ovariectomie parial). Aceast atitudine terapeutic este dictat de necesitatea pstrrii funciei menstruale i reproductive la aceste paciente tinere. n cazul tumorilor chistice suspecte, laparoscopia se poate practica n scop diagnostic fiind urmat imediat, n cazurile confirmate ca fiind maligne, de tratament chirurgical convenional, cu respectarea protocolului oncologic complet. n perioada reproductiv predomin chisturile ovariene funcionale, chistadenoamele seroase, mucinoase i endometrioamele. Atitudinea terapeutic este similar celei din perioada peripubertar, n vederea obinerii unui prognostic funcional (menstrual i reproductiv) favorabil. Dac se decide intervenia chirurgical, aceasta trebuie s fie minim invaziv, conservatoare, n cazul tumorilor chistice sigur benigne. Perioada meno- i postmenopauzal este caracterizat de frecvena crescut a tumorilor ovariene chistice maligne. Evaluarea ecografic i dozarea CA125 sunt foarte importante. Atitudinea expectativ poate fi adoptat n cazul tumorilor ovariene chistice simple, cu diametrul sub 3-5 cm [1,4]. Dac se decide intervenia chirurgical, de obicei ea este practicat convenional radical (anexectomie uni- sau bilateral, asociat sau nu cu histerectomie total) [5].

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n cazul tumorilor ovariene chistice fr elemente diagnostice care s sugereze malignitatea, se poate practica laparoscopia operatorie, cu o prim etap diagnostic. Dac apar elemente de suspiciune de malignitate, atunci cazul se convertete la chirurgie convenional [1,4]. Majoritatea autorilor proscriu intervenia laparoscopic n perioada menopauzal, din cauza riscului ridicat de malignitate i de diseminare a celulelor maligne n timpul interveniei laparoscopice [1,2,4]. Laparoscopia diagnostic care pune n eviden o tumor ovarian malign, trebuie s fie urmat imediat de intervenie chirurgical convenional, cu respectarea protocolului oncologic [4,6]. Cu siguran ns, la pacientele adolescente sau la cele de vrst reproductiv, laparoscopia reprezint metoda terapeutic adecvat n cazurile de mase anexiale, avnd n vedere riscul redus de malignitate la vrstele tinere [3]. Orice intervenie chirurgical laparoscopic este precedat de pregtirea preoperatorie a pacientei (evacuarea tubului digestiv, cateterizarea vezicii urinare), precum i de consimmntul informat al pacientei, privind intervenia chirurgical. Pentru evitarea accidentelor intra-operatorii se vor practica testele de securitate la efectuarea pneumoperitoneului, se va crea o presiune intraperitoneal adecvat (14-15 mm Hg), iar introducerea trocarelor se va face conform regulilor de securitate [3,7-10]. Evaluarea intraabdominal const n inspecia ntregii caviti peritoneale. Descoperirea unei tumori maligne impune laparotomia imediat sau direcionarea pacientei ctre un serviciu de oncologie, dup prelevarea unei biopsii i lavajul atent i abundent al cavitii peritoneale i al traiectelor trocarelor [8-11]. Dup confirmarea originii ovariene a masei anexiale, se preleveaz lichid peritoneal pentru examen citologic i bacteriologic. Urmtorul timp este evaluarea masei anexiale ovariene: localizare, dimensiuni, aspectul peretelui chistic, vegetaii extrachistice, coninut, aderene peritumorale [8,11]. n cazul unui chist seros funcional sau organic, se practic fenestrarea peretelui chistic, aspirarea coninutului acestuia, cu examen citologic, chistoscopie (examinarea feei interne a peretelui chistic pentru excluderea unor vegetaii sau septuri intrachistice) i chistectomie, prin stripping-ul peretelui chistic de pe parenchimul ovarian. Peretele chistic decolat se va extrage n endobag, iar la nivelul parenchimului ovarian restant se va efectua hemostaza cu electrocauterul bipolar. Se efectueaz astfel o intervenie conservatoare, minim invaziv, cu pstrarea structurii i funciei ovarului afectat. Acest tip de intervenie este posibil doar la pacientele tinere, la care nu exist niciun element de suspiciune de malignitate a tumorii chistice ovariene [8,12]. Cazuri particulare de tumori ovariene chistice sunt chistul dermoid i endometriomul. n cazul chistului dermoid se va ncerca decolarea i extragerea chistului intact, pentru a evita diseminarea coninutului muco-gelatinos n cavitatea peritoneal i evoluia spre peritonit chimic sau boal gelatinoas a peritoneului [13,14]. n cazul endometriomului ovarian decolarea peretelui chistic este mai dificil din cauza aderenelor existente ntre acesta i parenchimul ovarian. Din acest motiv, dup aspirarea coninutului chistic (cu aspect ciocolatiu) i decolarea parial a peretelui chistic, patul chistic va fi cauterizat cu electrodul bipolar, pentru a distruge fragmentele de perete chistic restante i pentru a efectua hemostaza. Aceast manevr are i efect profilactic evitnd o eventual malignizare ulterioar, deoarece este cunoscut faptul c endometriomul are potenial malign. i ntr-un caz i n cellalt, toaleta cavitii peritoneale i pelvine trebuie s fie riguroas i efectuat cu soluie salin din abunden pentru evitarea diseminrii celulelor endometriale [15,16].

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n cazul n cazul n care nu se dorete pstrarea funciei ovariene (paciente aflate n perioada perimenopauzal sau postmenopauzal) se poate practica percelioscopic ovariectomie sau anexectomie uni- sau bilateral, cu extragerea ovarului sau anexei n endobag [15,16]. Conform Ghidului Practic n Cazul Maselor Anexiale elaborat de Societatea Elveian de Ginecologie i Obstetric (SSGO), o mas anexial benign sau probabil benign poate fi tratat laparoscopic prin chistectomie, n perioada premenopauzal i prin anexectomie n postmenopauz, cnd se poate propune chiar anexectomia bilateral [1,5]. O mas anexial probabil malign trebuie tratat prin anexectomie. Extragerea unei mase anexiale tratat chirurgical laparoscopic trebuie fcut n endobag. O mas anexial malign impune laparotomie median i intervenia trebuie s cuprind lavaj peritoneal, anexectomie bilateral, histerectomie total, omentectomie, biopsii peritoneale, limfadenectomie pelvin i paraaortic (mai ales n stadiile incipiente) i apendicectomie. Puncionarea i/sau morcelarea unei mase anexiale nu sunt indicate pentru c expun la risc de recidiv, de diseminare malign sau de diseminare a coninutului unui chist dermoid. Perioada de timp ntre ruperea capsulei unui carcinom ovarian stadiul I i laparotomie nu trebuie s depeasc 8-14 zile [1,5,9,10]. Tratamentul laparoscopic permite obinerea unui prognostic funcional (menstrual i de fertilitate) favorabil la pacientele tinere. CONCLUZII Chirurgia laparoscopic prezint avantaje incontestabile pentru tratamentul maselor anexiale de natur ovarian, cu caracter benign. Avantajele chirurgiei laparoscopice sunt: tehnici chirurgicale miniminvazive, conservatoare, risc infecios redus, durere postoperatorie minim, medicaie minim, durat redus de spitalizare, recuperare rapid, cicatrici abdominale estetice, complicaii intra- i post-operatorii reduse. Pacientele tinere beneficiaz n cel mai nalt grad de aportul chirurgiei laparoscopice deoarece prin interveniile chirurgicale laparoscopice se obine un prognostic funcional ovarian optim. Succesul interveniilor laparoscopice depinde de selectarea corect i riguroas a cazurilor (vrsta pacientei, caracteristicile ecografice ale masei anexiale). Abordul laparoscopic al tumorilor chistice ovariene este benefic i sigur pentru paciente, dar dac intraoperator se deceleaz elemente de suspiciune de malignitate i dac aceasta se confirm, atunci cazul trebuie imediat convertit la chirurgie convenional, cu respectarea protocolului oncologic.
1. 2. 3. 4. 5. 6. BIBLIOGRAFIE Management of Adnexal Mass, AHRQ Publications No. 06-E004, 2006. Ovarian Cysts in Postmenopausal Women. RCOG Guideline No 34, 2003. Pfeifer SM, Gosman GG. Evaluation of adnexal masses in adolescents. Pediatr Clin North Am. 1999; 46(3): 573-592. Parker W, Levine R, Howred F, Sansone B, Berek J. Laparoscopic management of cystic adnexal masses in postmenopausal women: a multicenter study. J Am Cl Surgery. 1999; 179: 733-737. Yuen PM, Yu KM, Yip SK, Lau WC, Rogers MS, Chang A. A randomized prospective study of laparoscopy and laparotomy in the management of benign ovarian masses. Am J Obstet Gynecol. 1997; 177: 109-114. Ovarian cancer new perspectives in treatment. Oncology Review. 1997; 12: 11-15.

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7. 8. 9. 10. 11. 12. 13. 14. 15. 16.

Lupacu Ivona, David Cristina, Rusu Elena, Pnzaru C. Criterii de securitate n chirurgia laparoscopic. Obstetrica i Ginecologia. 2000; 3: 197-200. Mettler L, Semm K, Shive K. Endoscopic management of adnexal masses. J Soc Laparoendosc Surg, 1997; 1: 103-112 David Cristina. Actualiti n diagnosticul i tratamentul maselor anexiale. Tez de doctorat. UMF Iai, 2008. Trcoveanu E. Elemente de chirurgie laparoscopic. Vol II. Iai: Editura Polirom; 1998. Mettler L. Manual of Lapascopic and Hysteroscopic Gynecological Surgery, Jaypee Brothers, New Delhi, 2006. Bruhat MA, Mage G, Pouly JL, Manhes H, Canis M, Wattiez A. Operative laparoscopy. McGraw-Hill; 1992. p. 9-215. Lin P, Falcone T, Tulandi T. Excision of ovarian dermoid by laparoscopy and by laparotomy. Am J Obstet Gynecol. 1995; 173: 769-771. Lupacu Ivona, David Cristina, Gemnaru Liliana, Solomichi Valeria, Vasiliu Veronica, Veghe Simina Laparoscopia n tratamentul maselor anexiale. British Medical Journal, ediia n limba romn, 2003; 9: 416-419. Mencaglia L, Wattiez A. Manual of Gynaecological Laparoscopic Surgery. Tuttlingen: EndoPress, 2003; p. 120-123. Tutunaru D, Vrtej P, Badea I, Boldea Georgeta, tefnescu Claudia. Concepte moderne privind diagnosticul i tratamentul endometriozei: abordul laparoscopic. Obstetrica i Ginecologia, 1999; 1: 6.

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LEIOMIOM AL COLONULUI TRANSVERS SURS NEOBINUIT DE PERITONIT


Gh. Ghidirim, I. Miin, Gh. Zastavnichi Catedra Chirurgie nr. 1 N. Anestiadi Laboratorul de Chirurgie Hepato-Bilio-Pancreatic Universitatea de Medicin i Farmacie N. Testemitsanu Chiinu Spitalul Clinic Municipal de Urgen, Chiinu, Republica Moldova
LEIOMYOMA OF THE TRANSVERSE COLON UNCOMMON SOURCE OF PERITONITIS (Abstract): Leiomyoma of the transverse colon is uncommon. The majorities of these lesions are clinically insignificant, being diagnosed incidentally. Symptomatic leiomyomas of the colon are less common; sporadic case reports have been described in the relevant literature. We describe an additional case of extraluminal transverse colon leiomyoma with necrosis and perforation. A 22-year old female patient complaining abdominal pain was admitted with the diagnosis of peritonitis. The intraoperative findings were: a transverse colon mass on the mesenteric wall, purulent fluid on the left flank and Douglas pouch. A transverse colon resection with primary anastomosis has been performed. The histological findings were consistent with extraluminal leiomyoma with necrosis. The postoperative period was uneventful and the patient discharged on the 9th postoperative day. During a 9 month followup the patient is free of disease recurrence. Although benign, colon leiomyoma may cause life-threatening complications, requiring emergency surgery. KEY WORDS: LEIOMYOMA, COLON, PERITONITIS. Coresponden: Conf. Dr. Igor Mishin, str. Munceti nr. 52, ap. 60, 2001, Chiinu, Republica Moldova; e-mail: mishin_igor@mail.ru*

INTRODUCERE Leiomiomul colonului este o entitate nozologic rar [1], primul caz de leiomiom al colonului complicat cu perforaie i peritonit fiind descris n literatura de specialitate de ctre Swerdlow et al n 1975 [2]. Leiomiomul colonului se prezint frecvent, ca o formaiune voluminoas lipsit de semne de ocluzie intestinal, manifestarea clinic de peritonit fiind extrem de rar. Descriem un caz clinic de leiomiom extraluminal al colonului transvers complicat cu peritonit, precum i revista literaturii referitor la acest subiect. PREZENTAREA CAZULUI Pacienta R.R., 22 ani, a fost spitalizat n urgen, acuznd dureri abdominale, greuri, vrsturi, xerostomie, astenie fizic. Bolnava relateaz debutul relativ brusc al afeciunii, n urm cu cca 12 ore, prin dureri n epigastru, care apoi, s-au generalizat n tot abdomenul. Examenul obiectiv deceleaz un abdomen simetric, ce nu particip la micrile respiratorii, contractat. Semnele de iritaie peritoneal erau pozitive pe toat suprafaa abdomenului. Explorrile biologice: Hb = 140 g/L, globule roii = 4,3x1012/L, Ht = 41%, leucocite = 22,4x109/L.
received date: 19.11.2008 accepted date: 20.12.2008
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La ecografia abdominal se constat tumor solid neomogen, cu localizare n mezogastru, lichid liber n cavitatea peritoneal, iar la radiografia abdominal simpl nu se constat pneumoperitoneu. Se intervine chirurgical n urgen, prin laparotomie median; explorarea intraoperatorie evideniaz: 1) formaiune tumoral de cca 150x100 mm extraluminal, localizat la nivelul peretelui mezenteric a colonului transvers, cu necroz i perforaie; 2) cca 200 ml lichid seros-purulent n cavitatea peritoneal. S-a practicat rezecie de colon transvers cu anastomoz termino-terminal. Examenul anatomopatologic: Macroscopic, formaiune tumoral dezvoltat pe faa mezenteric a colonului transvers de 150x100mm, cu necroz central, care nu intereseaz mucoasa (Fig. 1). Microscopic: examenul histologic demonstreaz fibre musculare cu aspect de leiomiom cu focare de necroz i infiltraie limfoleucocitar (Fig. 2). Perioada postoperatorie a decurs fr complicaii. Pacienta a fost externat n a 9 a zi postoperator. Pe durata supravegherii timp de 9 luni nu au fost semne obiective de recidiv a tumorii.

Fig. 1 Piesa operatorie Formaiune tumoral dezvoltat la nivelul peretelui mezocolic al colonului transvers (stnga); aspect endoluminal (mucoasa secionat) se remarc aspectul necrozat al tumorii.

DISCUIE Leiomioamele pot fi localizate pe tot traiectul tubului digestiv, fiind mai frecvent localizate n stomac i intestinul subire [3]. Leiomioamele cu localizare n colon sunt extrem de rare, reprezentnd doar 3% din totalitatea leiomioamelor tubului digestiv [4]. Conform datelor Hatch KF et al, cele mai frecvente localizri ale leiomioamelor cu sediu n colon sunt ascendentul, descendentul i sigmoidul, fiind descrise doar 15 cazuri n colonul transvers (1960-1996); acestea sunt mai frecvent diagnosticate la femei [5]. Manifestrile clinice depind de dimensiuni i raportul tumorii cu lumenul intestinal; astfel, n raport cu lumenul intestinal distingem leiomioame cu cretere endocolic, exocolic sau mixt [1,5,6], dei pentru leiomioame este mai caracteristic creterea exocolic [5]. Leiomioamele intraluminale se prezint de obicei ca polipi cu sau fr pedicul, ocazional fiind surs de hemoragie [1]. Leiomioamele cu sediu exocolic devin simptomatice n virtutea dimensiunilor semnificative, tabloul clinic fiind dominat de durere abdominal sau formaiune abdominal palpabil [1]; totui majoritatea leiomioamelor cu sediu n colon sunt asimptomatice, fiind tipic reprezentate de formaiuni intraluminale polipoide care pot fi nlturate endoscopic [4,7,8]. La

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pacienii simptomatici, cea mai frecvent manifestare clinic este durerea abdominal, ca i n prezentul caz, mai rar pacienii acuznd formaiune abdominal palpabil sau hemoragie gastrointestinal [5]. Mai puin frecvent leiomioamele pot prezenta complicaii majore; astfel, Swerdlow DB et al au descris un caz de leiomiom intraluminal al cecului complicat cu perforaie i peritonit [2]. O alt posibil complicaie este invaginarea cu dezvoltarea tabloului clinic de ocluzie intestinal [9]. Aspectul imagistic al tumorilor leiomiomatoase este nespecific; astfel, examenul computer tomografic poate determina prezena calcificrilor precum i diverse grade de necroz intern sau schimbri de tip chistic [1]. Modificrile descrise sunt caracteristice att pentru leziunile benigne ct i pentru cele maligne [10].

Fig. 2 Leiomiom al colonului transvers hematoxilin-eozin; ob 40x

Diferenierea microscopic ntre tumorile benigne i maligne cu origine din musculatura neted este dificil, la momentul actual fiind utilizate criteriile de malignizare propuse de Evans RW: dimensiuni celulare sporite, celule mari cu form neregulat, lipsa diferenierii celulare, prezena celulelor scurte, rotunde cu nuclee ovale, precum i prezena celulelor cu nuclei multipli hipercromi cu coloraie variabil [11]. Diferenierea ntre leiomiom i leiomiosarcom este de obicei efectuat n baza prezenei necrozei, polimorfismului nuclear, dimensiunii tumorii i numrului de mitoze [12]. n literatura de specialitate sunt descrise o varietate de procedee operatorii pentru soluionarea acestei patologii, variind de la simpla excizie endoscopic a tumorii, la colectomia subtotal [5]. nlturarea chirurgical este singura modalitate de tratament pentru leiomioamele cu sediul n colon, prognosticul fiind favorabil, iar n literatura de specialitate nu sunt descrise cazuri de recidiv a tumorii [5]. Totui, decizia referitor la volumul interveniei chirurgicale depinde de aspectul histologic, dimensiunea, sediul tumorii, precum i de statutul nodulilor limfatici adiaceni [5]. CONCLUZII Dei leiomioamele colonului sunt tumori rare i preponderent asimptomatice, pot fi sursa unor complicaii potenial letale, impunnd intervenii chirurgicale de urgen, i deci necesit a fi incluse n protocolul de diagnostic diferenial al peritonitelor i al hemoragiilor digestive.

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BIBLIOGRAFIE Chen CW, Jao SW, Wu CC, Ou JJ, Hsiao CW, Chao PC. Massive lower gastrointestinal hemorrhage caused by a large extraluminal leiomyoma of the colon: report of a case. Dis Colon Rectum. 2008; 51(6): 975-978. 2. Swerdlow DB, Pecora C, Grandone F. Leyomioma of the cecum presenting as an acute surgical abdomen. Dis Colon Rectum. 1975; 18(5): 438-440. 3. Appelman H, Helwig EB. Cellular leiomyomas of the stomach in 49 patients. Arch Patol Lab Med. 1977; 101(7): 303-307. 4. Bjorsdottir H, Bjornsson J, Gudjosson H. Leiomyomatous colonic polyp. Dig Dis Sci. 1993; 38(10): 1945-1947. 5. Hatch KF, Blanchard DK, Hatch GF, Wertheimer-Hatch L, Davis GB, Foster RS, Skandalakis JE. Tumors of the appendix and colon. World J Surg. 2000; 24(4): 430-436. 6. Skandalakis JE, Gray SW. Smooth muscle tumors of the alimenatry tract. In: Charles IL, Thomas C, editors. Springfield; 1962. p. 112-151. 7. Kadakia SC, Kadakia AS, Seargent K. Endoscopic removal of colonic leiomyoma. J Clin Gastroenterol. 1992; 15(1): 59-62. 8. Lee IL, Tung SY, Lee KF, Chiu CT, Wu CS. Endoscopic resection of a large colonic leiomyoma. Chang Gung Med J. 2002; 25(1): 39-44. 9. Edna TH. Colo-rectal intussusception due to a leiomyoma. Acta Chir Scand. 1978; 144(6): 409410. 10. Lee SH, Ha HK, Byun JY, Kim AY, Cho KS, Lee YR, Park HW, Kim PN, Lee MG, Auh YH. Radiological features of leiomyomatous tumors of the colon and rectum. J Comput Assist Tomogr. 2000; 24(3): 407-412. 11. Evans RW. Hisological appearences of tumors with a consideration of their histogenesis and certain aspects of their clinical features and behaviour. Edinburgh, UK: Livingstone; 1956. p. 773. 12. Morgan BK, Compton C, Talbert M, Gallaghea WJ, Wood WC. Benign smooth muscle tumors of the gastrointestinal tract: a 24-year experience. Ann Surg. 1990; 211(1): 63-66. 1.

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DIVERTICULUL MECKEL CAUZ RAR DE HEMORAGIE DIGESTIV INFERIOAR LA ADULT


R. Neagoe1, Doina Milutin2, D. Georgescu3, Daniela Sala1, L. Salan4, M. Eianu1 1 Clinica Chirurgie II; 2 Clinica Anatomopatologie; 3 Clinica Medical I Spitalul Clinic Judeean de Urgene Mure 4 Spitalul Municipal Tg. Secuiesc
MECKELS DIVERTICULUM RARE CAUSE OF INFERIOR DIGESTIVE BLEEDING AT ADULT (Abstract): Meckels diverticulum is the most prevalent congenital abnormality of

the gastro-intestinal tract, with an autopsy incidence of 2%. Although in the majority of cases it remains completely asymptomatic, in some instances it may mimic other disorders such as appendicitis, Crohns disease or peptic ulcer. Major complications include bleeding, obstruction, intussusception, diverticulitis and perforation. We report a case of a pacient with multiple bleedings, where clinical preoperatory investigations didnt establish the origin of hemorrhage.
KEY WORDS: MECKELS DIVERTICULUM, DIGESTIVE BLEEDING, EXPLORATORY LAPAROTOMY

Coresponden: Dr. Neagoe Radu, Clinica Chirurgie II, Spitalul Clinic Judeean de Urgene Mure; e-mail: dr.neagoeradu@yahoo.com* INTRODUCERE Diverticulul Meckel este cea mai frecvent anomalie congenital a tractului gastro-intestinal avnd o inciden autopsic de aproximativ 2% [1]. Afeciunea este n general asimptomatic ns uneori pacienii relateaz simptome ce orienteaz diagnosticul ctre o apendicit, boala Crohn sau ulcer peptic [2]. Afeciunea nu este lipsit de complicaii, unele grave, ce pot impune intervenia chirurgical de urgen hemoragia digestiv inferioar, obstrucia, invaginarea, diverticulita, perforaia [2,3]. PREZENTARE DE CAZ Prezentm cazul unui pacient n vrst de 24 de ani, sex masculin, internat n clinic prin transfer de la un spital teritorial, pentru dureri abdominale periombilicale, greuri, rectoragie minim. Istoricul afeciunii relev c primul episod hemoragic a aprut la vrsta de 12 ani, cnd n plin stare de sntate aparent prezint o rectoragie importanta soldat cu anemie sever (Hb = 4 g/dL, Ht = 18%). Investigaiile efectuate la acea dat n spitalul teritorial (tranzit baritat, irigografie) nu au decelat sursa hemoragiei, pacientul fiind tratat conservator, simptomatic (reechilibrare, hemostatice, transfuzii cu snge izogrup, plasm). Urmtorul episod hemoragic sever survine dup aproximativ 12 ani; n intervalul liber anamneza insistent descoper episoade fruste de rectoragie, precum
received date: 20.11.2008 accepted date: 22.12.2008
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i simptomatologia unui sindrom anemic cronic, intermitent, ambele neglijate de copil i aparintori. Cu o lun naintea internrii pacientul repet episodul hemoragic acut, fiind internat de urgen n spitalul judeean teritorial i investigat paraclinic; endoscopia digestiv superioar efectuat pn la nivelul DI a duodenului i irigografia nu evideniaz modificri patologice. Pacientul se transfer n serviciul nostru n stare clinic ameliorat, n vederea elucidrii diagnosticului. Examenul obiectiv evideniaz o uoar paliditate muco-tegumentar iar tueul rectal este pozitiv (melena). Analizele de laborator evideniaz devieri patologice ale hematocritului (Ht = 32%) i hemoglobinei (Hb = 10,2 g/dL ), fr modificri ale frotiului periferic, testelor de coagulare, probelor hepatice. n colaborare cu laboratorul de investigaii gastroenterologice se efectueaz esogastroduodenoscopia i pancolonoscopia, fr a decela sursa hemoragiei.

Fig. 1 Diverticul Meckel aspect intraoperator

Cunoscnd c diverticulul Meckel este cea mai frecvent cauz de hemoragie digestiv inferioar la copil, ridicm suspiciunea acestei afeciuni i efectum explorarea scintigrafic cu Tc-99 pertechnetat, al crui rezultat este ns incert; din motive tehnice nu am beneficiat de aportul angiografiei selective. Pe parcursul internrii, pacientul prezint un nou episod de hemoragie digestiv inferioar, cu alterarea strii generale, deteriorare hemodinamic ce ne determin s intervenim chirurgical de urgen; s-a efectuat o laparotomie median iar la explorarea cavitii abdominale am decelat la aproximativ 60 de centimetri de valvula ileo-cecal un diverticul Meckel de 6 cm, cu o baz de implantare de 1,5 cm (Fig. 1)). Rezolvarea chirurgical a cazului a fost simpl, printr-o enterectomie segmentar cu anastomoza entero-enteral termino-terminal monoplan, pacientul evolund favorabil i externndu-se la 7 zile postoperator. Examenul macroscopic al piesei operatorii a constatat prezena unei zone de mucoas heterotopic la nivelul diverticulului (Fig. 2), sub forma unei pastile de aproximativ 2 cm situat la baza acestuia, aspect confirmat prin examenul histopatologic la parafin mucoas heterotopic gastric, corporeal (Fig. 3).

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DISCUII Diverticulul Meckel este descris pentru prima dat de Hildanus n 1598, ulterior definit n lucrrile lui Little i Meckel ca o anomalie de involuie a canalului omfalomezenteric, prin obliterarea parial a segmentului ombilical al acestuia [3,4]. Anatomic, este situat pe ileon, n zona ramurilor terminale ale arterei mezenterice superioare, antimezostenic, la 40-100 cm de valvula ileo-cecal i este format din aceleai straturi ca i peretele intestinal, singura deosebire constnd din formaiunile limfoide rare i de dimensiuni foarte mici [3]; n o treime din cazuri se pot gsi n structura peretelui diverticular insule de esut heterotopic: gastric (60-85%), jejunal, pancreatic, colic, biliar [2,3].

Fig. 2 Piesa de rezecie; se remarc mucoasa heterotopic prezent la nivelul diverticulului Meckel

Insulele heterotopice de mucoas gastric, ntlnite mai frecvent, ocup pe o ntindere variabil baza diverticulului; n aceast mucoas gastric s-au identificat glande de tip fundic, corporeal sau piloric cu activitate secretorie pstrat, fapt ce explic patologia i complicaiile diverticulare [3]; celelalte incluzii heterotopice nu par s aib consecine patologice cu expresie clinic. Dei n marea majoritate a cazurilor diverticulul Meckel rmne o descoperire operatorie sau necroptic lipsit de semnificaie clinic, n unele cazuri devine sediul unor procese patologice cu caracter acut sau cronic. Studiile recente arat c riscul de apariie al complicaiilor diverticulului Meckel este de 25% naintea vrstei de 16 ani, dup aceast vrst riscul scznd considerabil pn la 4,2% [2]. Cea mai frecvent complicaie este hemoragia digestiv inferioar (27%), care se ntlnete mai frecvent la indivizii de sex masculin, statisticile indicnd o aglomerare constant a cazurilor n copilrie i n adolescen [2,5]; unele hemoragii sunt importante, nsoite de anemie acut sever i semne de oc hemoragic, alteori sunt modeste i se exteriorizeaz prin mici scaune melenice repetate, ce determin o anemie cronic [2]. Diagnosticul preoperator al diverticulului Meckel este foarte dificil, Aarnion i Salonen susinnd ca este posibil doar n 4,7 % din cazuri [1]. Examenul clinic nu aduce date sugestive diagnosticului n faza necomplicat a bolii, prezena unor mici mase palpabile periombilicale sau a unor leziuni ombilicale asociate avnd cel mult o

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valoare didactic semiologic dac nu doar istoric; prezena hemoragiei digestive inferioare capricioase i repetitive la copil sau adultul tnr este ns un semn prezumptiv cu mare valoare diagnostic [5]. Dintre numeroasele tehnici de investigare doar scintigrafia cu Tc-99m pertechnectat i-a demonstrat valoarea n stabilirea sursei de hemoragie, sensibilitatea examinrii fiind crescut prin administrare prealabil de pentagastrin [3]; utilitatea metodei este limitat pe de o parte din considerente tehnice (aparatura, laborator specializat, radiotrasor), iar pe de alt parte, de faptul c uneori (i n special la tineri) metoda poate da rezultate incerte sau chiar fals negative [4]. O alt posibilitate diagnostic a hemoragiilor digestive inferioare ar fi angiografia selectiv de arter mezenteric superioar, singur sau asociat cu utilizarea radiotrasorului [3], investigaie de care nu am dispus n serviciul nostru.

Fig. 3 Diverticul Meckel aspecte histopatologice (hematoxilin-eozin) A invaginare a mucoasei n peretele intestinului subire cu resturi de fibre musculare din musculara mucoasei la baza invaginrii; B invaginarea este delimitat de mucoasa de tip intestin subire cu un focar de mucoas gastric ectopic (central); C formaiunea diverticular delimitat de mucoasa ectopic de tip corporeal gastric (seciune prelevat din zona distal a diverticulului); D mucoasa ectopic de tip gastric corporeal (Ob 10x)

Laparoscopia este o metod modern ce permite n ultim instan diagnosticul i sanciunea terapeutic, fiind net superioar laparotomiei sub aspectul morbiditii postoperatorii; este metoda pe care o agream i noi pentru elucidarea unor situaii clinice incerte, dar de care nu ne-am folosit n situaia de urgen descris.

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CONCLUZII Caracterul capricios i repetitiv al hemoragiei digestive inferioare survenit la un copil, adolescent sau adult tnr, fr alt cauz evident, este un semn prezumtiv de mare valoare n diagnosticul diverticulului Meckel. Rezolvarea chirurgical este de regul simpl rezecia sau enterectomia.
1. 2. 3. 4. 5. BIBLIOGRAFIE Evers BM. Small Intestine, In: Townsend CM, editor. Sabiston Textbook of Surgery, 17-th edition. Elsevier; 2004. p. 1366-1368. Mortensen NJ, Jones O. The Small and Large Intestines, In: Russel RCG, Williams NS, Bulstrode CJK, editors. Bayley & Loves Short Practice of Surgery, 24-th edition. Arnold; 2004. p. 1159-1160. Cucu A. Diverticulul Meckel, In: Angelescu N, editor. Tratat de Patologie Chirurgical, vol. I, Bucureti: Editura Medical; 2001. p. 1540-1541 Pollak R. Adjunctive Procedure in Intestinal Surgery, In: Fisher JE, editor. Master of Surgery, 5th edition; 2007. p. 1392-1393. Mircea PA. Diverticulii intestinului subire, In: Grigorescu M, Pascu O, editors. Tratat de Gastroenterologie Clinic, vol. I, Bucureti; Editura Tehnic; 1996. p. 598-601.

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METASTAZ SCAPULAR A CARCINOMULUI HEPATOCELULAR PREZENTARE DE CAZ


N. Vlad1, R. Moldovanu1, C. Lupacu1, G. Rileanu1, M. Borcea2, D. Ferariu3, Liliana Vlad4 1 Clinica I Chirurgie I. Tnsescu-Vl. Buureanu Spitalul Sf. Spiridon Iai 2 Clinica ATI Spitalul Sf. Spiridon Iai Universitatea de Medicin i Farmacie Gr.T. Popa Iai 3 Laboratorul de Anatomie Patologic, Spitalul Sf. Spiridon Iai 4 Secia Boli Infecioase, Spitalul Orenesc Hrlu
A SCAPULAR METASTASIS OF THE HEPATOCELLULAR CARCINOMA CASE REPORT (Abstract): Hepatocellular carcinoma (HCC) is a primary liver cancer frequently related with liver cirrhosis; the common way for metastasis spread is the blood stream. The bone metastasis from a HCC is uncommon. We present an unusual scapular metastasis from a HCC as a first sign of the liver tumor. A 76 year old man has been reffered to our surgical unit presenting a solid painful tumor located in the scapular region. The clinical and ultrasound examination established the diagnosis of a soft tissue tumor. Intraoperative exploration revealed a brown sponge mass, extremly soft and bleeding. The resection of the tumor has been performed. The pathologic exam revealed the diagnosis of a metastasis from a well differentiated HCC. The postoperative abdominal ultrasound exam was performed and revealed two tumors situated in V-th and VII-th segments. The patient refuse other imagistic exams and surgical procedures. KEY WORDS: HEPATOCELLULAR CARCINOMA, BONE METASTASIS Coresponden: Dr. Nuu Vlad, Clinica I Chirurgie, Spitalul Sf. Spiridon Iai, Bd. Independenei, nr. 1, 700111; e-mail: nutu.vlad@gmail.com*

INTRODUCERE Carcinomul hepatocelular reprezint 80% dintre maligne hepatice primare [1]. Are o inciden n cretere cca 1000000 cazuri noi anual [1]. Este mai frecvent la brbai, iar incidena crete cu vrsta. Diseminarea la distan se realizeaz preferenial pe cale hematogen, iar n momentul diagnosticului aproximativ 50% din cazuri prezint deja metastaze la distan [1]. Metastazele osoase de la HCC sunt relativ rare, incidena lor variind ntre 3-20%, dei studiile necropsice consider c reprezint a treia localizare ca frecven, dup plmn i glanda suprarenal [2]. PREZENTAREA CAZULUI Pacientul S.M. n vrst de 76 ani, din mediul rural, a fost spitalizat n Clinica I Chirurgie n perioada 25.03.-10.04.2008. La momentul internrii pacientul acuza prezena unei formaiuni tumorale la nivelul regiunii scapulare drepte i dureri moderate la acest nivel. Din istoricul bolii menionm debutul insidios al afeciunii, formaiunea tumoral fiind remarcat de pacient n urm cu aproximativ un an, ulterior tumora crete treptat n dimesniuni, iar de trei luni devine dureroas. Din antecedentele personale
received date: 20.10.2008 accepted date: 15.12.2008
*

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patologice reinem o patologie cardiac complex: hipertensiune arterial, cardiopatie ischemic dureroas, fibrilaie atrial, insuficien cardiac clasa II NYHA. La examenul local s-a constatat prezena unei formaiuni tumorale de 20x22 cm. situat la nivelul regiunii scapulare drepte, bine delimitat, ferm, cu zone elastice, dureroas, fix fa de planurile profunde i superficiale. Examenul clinic general n limite normale. Analizele de laborator au evideniat o anemie moderat (Hb=11,3 mg/dL; Ht=34,9%) i transaminazele uor crescute (TGP=45 UI/L, TGO=53 UI/L). Radiografia toracic a constatat scleroemfizem pulmonar, pachete bronectatice 1/3 inferioar, cord mrit de volum cu arc pulmonar voluminos i o opacitate de pri moi de cca 150 mm diametru, la nivelul regiunii scapulare drepte (Fig. 1).

Fig. 1 Radiografia toracic opacitate de pri moi localizat la nivelul regiunii scapulare drepte

Fig. 2 Examenul ecografic Formaiune solid, neomogen, intens vascularizat.

Examenul ecografic a evideniat o formaiune solid, neomogen, de 160x140 mm, intens vascularizat. Nu s-a efectuat o examinare ecografic abdominal. Dup o pregtire preoperatorie simpl se intervine chirurgical; avnd n vedere dimensiunile formaiunii i tarele pacientului se opteaz pentru anestezie general cu intubaie oro-traheal. Intraoperator se constat o formaiune tumoral de140x120 mm, parial ncapsulat, de culoare maroniu-verzuie, foarte friabil i care snger ur la atingere. Dup ce se reuete disecia formaiunii fa de esuturile moi adiacente se constat c posterior tumora invadeaz scapula. Se rezec tumora cu dificultate i cu preul unei hemoragii importante, predominant de la nivelul esutului osos scapular. La

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examenul lojei tumorale se constat o lips de mas osoas la nivelul spinei scapulei i un defect circumferenial neregulat la nivelul corpului scapular de aproxmativ 40 mm diametru, care snger activ, tentativele de coagulare nefiind eficiente. Hemostaza este n final obinut prin meaj. Evoluia postoperatorie a fost lent favorabil, pacientul necesitnd o reechilibrare volemic n secia ATI. Hemoglobina i hematocritul postoperator au sczut semnificativ (Hb=5,8 mg/dL; Ht=16%), ccea ce a necesitat transfuzie de snge. n a 5-a zi postoperator s-a reintervenit chirurgical sub anestezie local i s-au suprimat meele. Ulterior evoluia postoperatorie a fost simpl. Pacientul fiind externat dup 10 zile. Examenul histopatologic (Fig. 3) a artat c tumora prezint aspect de carcinom hepatocelular, difereniat, cu arhitectur pseudoglandular (acinar), cu secreie de pigment biliar; au fost de asemenea prezente arii de necroz, numeroase embolii n vase i infiltrarea parial a structurilor musculo-aponevrotice ce formeaz pseudocapsula nodulului tumoral.

Fig. 3 Examen histopatologic A hematoxilin-eozin, ob.x4, embolii de carcinom hepatocelular n vase; B hematoxilin-eozin, ob.x4, arhitectur acinar, secreie biliar; C coloraie van Gieson, ob.x4, fascia muscular n dreapta, tumora n stnga

Ecografia abdominal efectuat ulterior a evideniat n segmentul V hepatic o formaiune hipoecogen, neomogen de 28x24 mm, cu necroz central de 14 mm, iar n segmentul VII, o alt formaiune de 18 mm diametru. Pacientul refuz alte investigaii (explorare computer tomografic, recoltarea unor markeri biologici alfa feto-proteina) precum i intervenia chirurgical (hepatectomie). Controlul efectuat la o lun postoperator a evideniat absena recidivei scapulare i aspectul staionar al tumorilor hepatice. DISCUII Carcinomul hepatocelular (CHC) are o rspndire geografic neuniform, fiind mai frecvent n rile din Asia de sud-est i Africa de Sud [2-4]. n Europa incidena este de 6 cazuri/100000 de locuitori [4]. Incidena CHC crete progresiv cu vrsta i este mai mare la brbai dect la femei, raportul fiind de 3/1 [1,5]. Etiopatogenia CHC este strns legat de ciroza hepatic. ntre 60-90% din cazuri CHC este grefat pe o form de ciroz hepatic [2-4]. Un rol important n apariia CHC l au i ali factori: virusul hepatitei B i mai ales C, consumul cronic de alcool, aflotoxinele alimentare, diverse boli metabolice, nitrosaminele i alte substane toxice [1,4,5].

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n ceea ce privete anatomia patologic, CHC este o tumor de consisten moale, de culoare maronie, intens vascularizat. Frecvent tumora este ncapsulat avnd un prognostic mai favorabil [3,5]. Microscopic tumorile sunt alctuite din celule cu aspect asemntor hepatocitelor [7]. Manifestrile clinice la debut sunt nespecifice, iar n fazele avansate poate s apar mas palpabil n hipocondrul drept, ascit i icter [5]. Explorrile imagistice utile pentru diagnostic i stadializare sunt: ecografia, tomografia computerizat, rezonana magnetic nuclear, angiografia selectiv; n unele cazuri se poate recurge la laparoscopia diagnostic. Diagnosticul histopatologic preoperator paote fi precizat pe materialul biopsic recoltat laparoscopic sau prin puncie-biopsie transparietohepatic [6]. Un rol important n stabilirea diagnosticului i urmrirea evoluiei l are dozarea alfa-feto-proteinei [1]. Diseminarea metastatic a CHC se face pe cale limfatic sau, mai frecvent, pe cale hematogen, prin circulaia portal sau sistemic. Localizrile metastatice cele mai frecvente sunt: plmnul (35-70%), ganglionii limfatici (16-45%), glande suprarenale (15%), oase (1-20%), creier (1-5%) [1,2]. Sunt raportate i metastaze excepionale subcutanate [8]. De asemenea, metastazele se pot localiza la nivelul intestinului subire putnd determina complicaii ocluzive [9]. Localizrile osoase citate n literatur sunt: vertebrele, oasele bazinului, mandibula, maxilarul, oasele craniene, sternul, coastele [10-14]. Localizarea scapular a metastazelor de CHC a fost raportat doar ntr-un singur caz - Zeller JL i Ireland ML n 1986 [15]. Metastazele osoase sunt osteolitice, iar rezecia lor este asociat cu hemoragii importante, ca i n cazul prezentat [10-16]; n unele cazuri hemoragia poate apare spontan, n cursul evoluiei tumorii [produc osteoliz i hemoragie n esuturile sau cavitile adiacente [4,12,13,16]. Aproximativ 5-7% din cazurile de CHC, la momentul diagnosticului, au deja metastaze osoase [4,17]. Metastazele osoase de CHC pot fi prima manifestare a bolii, iar diagnosticul este o surpriz anatomopatologic, ca i cazul prezentat [4,11-15]. Diagnosticul metastazelor osoase poate fi precizat prin explorri imagistice computer tomografie, rezonan magnetic nuclear, scintigrafie osoas cu tehneiu 99. Tratamentul metastazelor osoase de CHC este paliativ i include: chimioterapia sistemic, alcoolizarea direct, radioterapia sau rezecia chirurgical [2,4,11]. Atunci cnd metastazele de hepatocarcinom sunt confundate cu tumori ale esuturilor moi, iar primul gest terapeutic este ablaia tumorii, frecvent apare hemoragie intraoperatorie important i hemostaz dificil. Rezecia chirurgical a metastazei nu prelungete supravieuirea, stadiul tumorii primare fiind factor predictiv al supravieuirii [14,18]. CONCLUZII Metastazele osoase avnd ca origine un CHC sunt rare. Pot fi prima manifestare clinic a bolii, iar starea general a pacientului poate fi bun, dei neoplazia este ntr-un stadiu avansat. Datorit caracteristicilor morfopatologice ale tumorii, rezecia acestora se poate asocia cu o hemoragie important i dificulti de hemostaz.
1. 2. 3. BIBLIOGRAFIE Trcoveanu E. Patologie chirurgical hepatic: Tumori hepatice, 2007, Iai, p.107-118 Attili VS, Babu KG, Lokanatha D, Bapsy PP, Ramachandra C, Rajshekar H. Bone metastasis in hepatocellular carcinoma: need for reappraisal of treatment. J Cancer Res Ther. 2008; 4(2): 9394. Vlad L. Chirurgie hepatic. Cluj-Napoca: Editura Dacia; 1993. p. 127-135.

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4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18.

Miquel M, Masnou H, Domnech E, Montoliu S, Planas R, Gassull M., Atypical presentation of distant metastases from hepatocarcinoma. Gastroenterol Hepatol. 2005; 28(10): 626-628. Funariu G. Chirurgie abdominal. Cluj-Napoca: Editura Dacia; 2002. p. 141-144. Popescu I., Ciurea S. Tumorile maligne primare ale ficatului. In: Popescu I, editor, Chirurgia ficatului, vol. I. Bucureti: Editura Medical; 2004. p. 385-410. Popescu I. Tumorile hepatice benigne i maligne. In: Angelescu N, editor, Tratat de patologie chirurgical, vol. II. Bucureti: Editura Medical; 2001. p. 1848-1869. Masannat YA, Achuthan R, Munot K, Merchant W, Meaney J, McMahon MJ, Horgan KJ., Solitary subcutaneous metastatic deposit from hepatocellular carcinoma. N Z Med J. 2007; 120(1266): U2837. Kim HS, Shin JW, Kim GY, Kim YM, Cha HJ, Jeong YK, Jeong ID, Bang SJ, Kim do H, Park NH. Metastasis of hepatocellular carcinoma to the small bowel manifested by intussusception, World J Gastroenterol. 2006; 12(12): 1969-1971. Maccauro G, Muratori E, Sgambato A, Liuzza F, Esposito M, Grieco A, Gosheger G., Bone metastasis in hepatocellular carcinoma. A report of five cases and a review of the literature. Chir Organi Mov. 2005; 90(3): 297-302. Hedri H, Mhibik S, Abderrahim E, Goucha R, Ben Taarit C, Kheder A, Ben Moussa F, Zermani R, Ben Jilani S, Ben Maz H. Sternal metastasis revealing hepatocarcinoma. Rev Med Interne. 2004; 25(3): 238-241. Van Migem D, Marion C, Franois D, Libotte B. Sternal metastasis from hepatocellular carcinoma. J Belge Radiol. 1993; 76(6): 414 Teshigawara K, Kakizaki S, Sohara N, Hashida T, Tomizawa Y, Sato K, Takagi H, Mori M, Hoshino K, Mogi K. Solitary mandibular metastasis as an initial manifestation of hepatocellular carcinoma. Acta Med Okayama. 2006; 60(4): 243-247. Shim YS, Ahn JY, Cho JH, Lee KS. Solitary skull metastasis as initial manifestation of hepatocellular carcinoma. World J Surg Oncol. 2008; 6: 66. Zeller JL, Ireland ML. Hepatocellular carcinoma presenting as a solitary metastasis to the scapula. Case report and review of the literature. Orthopedics. 1986; 9(7): 983-986. Chen SC, Lian SL, Chuang WL, Hsieh MY, Wang LY, Chang WY, Ho YH., Radiotherapy in the treatment of hepatocellular carcinoma and its metastases. Cancer Chemother Pharmacol. 1992; 31 Suppl: S103-105. Lucarini S, Fortier M, Leaker M, Chhem R. Hepatocellular carcinoma bone metastasis in an 11year-old boy. Pediatr Radiol. 2008; 38(1): 111-114. Imamura I. Prognostic efficacy of treatment for extrahepatic metastasis after surgical treatment of hepatocellular carcinoma. Kurume Med J. 2003; 50(1-2): 41-48.

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BOALA CROHN ILEO-CECAL MALIGNIZAT, CU FISTUL ILEO-RECTAL PREZENTARE DE CAZ


Elena Gologan, A. Pantazescu, Iuliana Eva , Doinia Rdulescu4, Doina Butcovan4 1 Institutul de Gastroenterologie i Hepatologie, Iai 2 Clinica Chirurgical, Spitalul Clinic de Urgene Sf. Ioan, Iai 3 Laboratorul de Imagistic Medical, Spitalul Militar, Iai 4 Disciplina de Morfopatologie Universitatea de Medicin i Farmacie, Gr.T. Popa, Iai
ILEORECTAL FISTULA FROM CROHN ILEOCOLITIS WITH MALIGNANT CHANGE CASE REPORT (Abstract): Crohns disease is an inflammatory bowel disease with a total wall involvement which leads to the possibility of extramural complications as fistula. We present a 28 years old patient admitted for pain in the lower right quadrant of the abdomen, fever, chills, weight loss and anorexia. Clinical examination revealed a tumor in the lower right quadrant and moderate fever. Biochemical and hematological investigations identified a nonspecific inflammatory syndrome. Carcinoembrionar antigen was negative. All the imagistic (barium enema and computer tomography) and endoscopic (left colonoscopy there was no possibility to reach the right colon) investigations could not established the diagnostic, but these investigations identified the intestinal tumor involving cecum and terminal ileon, with mostly benign characters and loco-regional enlarged limph nodes. The surgical exploration showed an inflammatory tumor of the terminal ileon and cecum with ileo-rectal fistula; extended enterectomy, right colectomy, excision of the ileo-rectal fistula and ileo-colic anastomosis were performed The pathological exam revealed Crohn`s disease but with three nests of malignant cells. The postoperative course was uneventful and the patient was discharged in 7 days. KEY WORDS: CROHNS DISEASE, ILEO-COLIC FISTULA, CANCER, RIGHT COLECTOMY Coresponden: Dr. Elena Gologan, Institutul de Gastroenterologie i Hepatologie Iai, str. Independentei, nr. 1, 700111, Iai.

INTRODUCERE Boala Crohn este o afeciune inflamatorie cronic a tubului digestiv i care se localizeaz cel mai frecvent la nivelul ileonului terminal i colonului proximal. Inflamaia prinde tot peretele intestinal de la mucoas pn la seroas. Vrsta medie a diagnosticului este de 27 ani. Pentru cazurile diagnosticate la vrste tinere determinismul genetic este cel mai frecvent implicat n etiopatogenie. Aproximativ 50% dintre bolnavi dezvolt stenoze intestinale. La nivelul obstruciei n partea proximal, la nivelul unei fisuri ce prinde toate straturile peretelui intestinal, se pot dezvolta fistule sau perforaii. Riscul de malignizare este de 6 ori mai mare n boala Crohn. CAZ CLINIC Pacientul B.A. n vrst de 28 de ani din mediu urban se adreseaz Institutului de Gastroenterologie i Hepatologie Iai, n luna noiembrie 2008, pentru dureri n flancul i fosa iliac dreapt, diaree cronic (2-5 scaune pe zi) alternnd cu perioade de tranzit normal, febr, frisoane i scdere ponderal (4 kg n 5 luni). Simptomatologia a debutat insidios de aproximativ 5 luni.

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Pacientul este nefumtor, neag consumul de alcool. A fost apendicectomizat n urm cu 1 an, iar de 5 luni este tratat n ambulator cu inhibitori de pomp de protoni pentru gastroduodenit cu Helicobacter pylori. Examenul clinic la internare relev un pacient palid, subponderal, cu o formaiune tumoral palpabil la nivelul fosei iliace drepte, de aproximativ 10 cm, ferm, dureroas, fix profund. Examenele de laborator arat un sindrom inflamator nespecific (proteina C reactiv = 48 U/mL, fibrinogen = 518 mg/dL, leucocite = 10500 /mmc), o anemie microcitar de 10,8 g/dL cu o hiposideremie de 13 g/dL, o trombocitoz de 581000/mmc i uoar colestaz. Markerul tumoral ACE (Antigen Carcino-Embrionar) a fost negativ precum i intra-dermo-reacia la PPD. Ac pANCA (efectuai datorit sindromului colestatic intrahepatic) au avut valori normale sugernd o colestaz inflamatorie. Trombocitoza a fost interpretat n acelai sens.

Fig. 1. Tomografie computerizat Tumor ileocecal cu fistul ileo-rectal

Ecografia abdominal a identificat o formaiune solid, n cocard, situat pe topografia cecului. S-a efectuat colonoscopie care a identificat la 14 cm de marginea anal o leziune infiltrativ-ulcerat de 3 cm diametru din care s-au prelevat cupe biopsice, rezultatul histopatologic fiind nespecific. Deoarece examinarea colonoscopic nu a putut fi efectuat dect pn la 40 cm de marginea anal, examinarea endoluminal a fost completat cu o clism baritat care a evideniat la nivelul colonului ascendent o imagine neregulat cu ulceraii marginale i nuane de semiton. Nu s-a reuit opacifierea ileonului terminal. S-a efectuat tomografie computerizat care a evideniat o formaiune tumoral ileo-cecal cu fistul ileo-rectal, corespondent ca localizare leziunii inflamatorii identificate colonoscopic (Fig. 1). S-a intervenit chirurgical; intraoperator s-a constat o tumor cu caractere inflamatorii, de ceco-ascendent i ileon terminal, cu fistul ileo-rectal. S-a efectuat rezecie larg ileal i hemicolectomie dreapt cu suprimarea fistulei i restabilirea continuitii tubului digestiv (Fig. 2). Examenul histopatologic a relevat un aspect tipic de boal Crohn cu determinri granulomatoase dar i prezena unor zone de degenerare malign n focar (Fig. 3). Evoluia postoperatorie a fost favorabil, pacientul fiind externat peste 7 zile. Controalele ulterioare au artat remisiunea complet a simptomatologiei.

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DISCUII Procesul patologic din boala Crohn are determinare panmural i tendina de extensie extramural asociind frecvent complicaii [1]. Localizrile pot fi unice sau multiple, etajate iar rezecia leziunii nu are valoare curativ pentru boal, aceasta putnd recidiva pe un alt segment al tubului digestiv. Incidena bolii este de 1-6/100.000 locuitori iar prevalena de 10-100/100.000 locuitori, cu mari variaii geografice [2]. Localizrile cele mai frecvente sunt la nivel ileo-cecal (40%), al intestinului subire (30%) i colonului (25%), dar se poate ntlni pe orice segment al tractului digestiv [3].

Fig. 2 Piesa operatorie ileo-colon drept cu excizia peretelui rectal n zona fistulei i a traiectului fistulos (n cartu, traiectul fistulos cateterizat)

Fig. 3 Examen histopatologic (hematoxilin-eozin) A Granulom submucos; B Fisur parietal; C Boal Crohn cu focare de displazie i degenerare malign

Simptomatologia este dominat de diaree, dureri abdominale i scdere ponderal [4]. Pot coexista simptome legate de complicaii sau manifestri extradigestive (artrite, osteoporoz, litiaz renal, eritem nodos, pyoderma gangrenosum, uveite, episclerite, trombembolii, pericolangite cronice, etc). Examenele de laborator relev un sindrom inflamator nespecific, de real utilitate n supravegherea bolnavilor fiind determinarea proteinei C reactive [5]. Diagnosticul impune utilizarea endoscopiei digestive inferioare care arat un aspect inflamator localizat cu friabilitate mucoas, sngerare uoar, ulceraii aftoide sau liniare, aspect hipertrofic nodular de pietre de pavaj [6,7]. Se poate utiliza i

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examenul radiologic cu contrast baritat efectuat n varianta cu dublu contrast, dar colonoscopia are avantajul posibilitii de obinere de cupe bioptice n vederea examenului histopatologic care este definitoriu n diagnostic [8,9]. Fistulele interne sunt o complicaie frecvent (20-40%) n boala Crohn, putnd apare ntre segmente ale tubului digestiv sau ntre un segment de tub digestiv implicat n procesul patologic i organele nvecinate [10]. Malignizarea la pacienii cu boal Crohn este mai frecvent dect n populaia general, dup unii autori comparabil cu cea din rectocolita ulcero-hemoragic fiind dependent de amploarea determinrilor, vechimea bolii i rspunsul la tratament medical [11]. De aceea, la pacienii cu boal Crohn, se impune screeningul colonoscopic. CONCLUZII Boala Crohn trebuie depistat precoce naintea complicaiilor care sunt de resort chirurgical. ntruct cancerul de colon este mai frecvent la pacienii cu boal Crohn, se impune screeningul colonoscopic al acestora. Tratamentul de elecie n cazurile cu localizare ileo-colic, suspecte de malignizare, const n hemicolectomie dreapt lrgit pe ileon. Prezena fistulelor interne implic rezecii lrgite.
BIBLIOGRAFIE Farmer RG, Hawk WA, Turnbull RB, Jr. Clinical patterns in Crohn`s disease: a statistical study of 615 cases. Gastroenterology. 1975; 68: 627-635. 2. Mekhjian HS, Switz DM, Melnyk CS, Rankin GB, Brooks RK. Clinical features and natural history of Crohn`s disease. Gastroenterology. 1979; 77: 898-906. 3. Bauer JJ, Sher ME, Jaffin H, Present D, Gelerent I. Transvaginal approach for repair of rectovaginal fistulae complicating Crohn`s disease. Ann Surg. 1991; 213(2): 151-158. 4. Sher ME, Bauer JJ, Gelerent I. Surgical repair of rectovaginal fistulas in patients with Crohn`s disease: transvaginal approach. Dis Colon Rectum. 1991; 34: 641-647. 5. Bauer JJ, Harris MT, Grumbach NM, Gorfine SR. Laparoscopic assisted intestinal resection for Crohn`s disease. Which patients are good candidates? J Clin Gastroenterol. 1996; 23(1): 44-46. 6. Van Rosendaal GM. Inflamatory bowel disease. CMAJ. 1989; 141(2): 113-123. 7. Fazio VW, Wu JS. Surgical therapy for Crohn`s disease of the colon and rectum. Surg Clin North Am. 1997; 77(1): 197-210. 8. 8 Marcello PW, Schoetz DJ Jr, Roberts PL, Murray JJ, Coller JA, Rusin LC, Veidenheimer MC. Evolutionary changes in the pathologic diagnosis after ileoanal pouch procedure. Dis Colon Rectum. 1997; 40(3): 263-269. 9. Price AB. Overlap in the spectrum of nonspecific inflammatory bowel disease colitis indeterminate. J Clin Pathol. 1978; 31: 567-573. 10. Marcello PW, Milsom JW, Wong SK. Laparoscopic restorative proctocolectomy: case matched comparative study with open restorative proctocolectomy. Dis Colon Rectum. 2000; 43(5): 604608. 11. Yamazaki Y, Ribeiro MB, Sachar DB, Aufses AH, Greenstein AJ. Malignant colorectal strictures in Crohn`s disease. Am J Gastroenterol. 1991; 86(7): 882-885. 1.

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VIDEO ASSISTED THYROIDECTOMY


C. Bradea First Surgical Clinic, St. Spiridon Hospital Iai Gr.T. Popa University of Medicine and Pharmacy Iai
VIDEO ASSISTED THYROIDECTOMY (Abstract): Video assisted techniques were documented by M. Gagner (1996 video assisted parathyroidectomy), Henry (1999), Shimizu (1999), Ohgami (2000), Miccoli (2000 video assisted parathyroidectomy and thyroidectomy). The advantage of this kind of surgery: aesthetics i.e. trying to make only small scars on the neck. Our first case of video assisted thyroidectomy was a female 50 years of age, with multinodular goiter, nodules of 2-3 cm in each lobe, admitted in our clinic in December 2008. History of the disease: 9 years; treatment: hormones pills. The refractive thyroid goiter became surgical in the last four years. The intervention was delayed because of pulmonary tuberculosis the patient suffered from. The video assited technique is inspired from Websurg site (Miccoli technique, 2007), modified by the author. We started with general anesthesia, patient lying, without hiper extension of the neck. The skin incision was on midline of the neck, 15 mm long, horizontal, at 2 cm above the inferior limit of the neck, with electric scalpel. By this skin incision we entered the thyroid space gland with classical instruments; then we introduce a 10 mm, 0 degree telescope, together with a 5 mm Ligasure grasp. After coagulation and section with Ligasure, the superior thyroid pedicle, the right thyroid lobe was dissected all around. Finally, we extracted the right thyroid lobe and then we severed with Ligasure the inferior right thyroid pedicle. The same procedure was used on the left side; it neednt any drainage; the closure was anatomically tipical. The evolution was uneventful. The histopathological exam result was chronical Hashimoto thyroiditis. Conclusions: Video assisted thyroidectomy can be considered feasible and safe and allows for an excellent cosmetic result and has possible new promising indications such as prophylactic thyroidectomy. Not all patients are eligible for this procedure, but in selected cases it can be a valid option for the surgical treatment of thyroid diseases. KEY WORDS: VIDEO ASSISTED SURGERY, VIDEOSCOPIC SURGERY SKILL, SELECTED PATIENTS. Correspondence to: Costel Bradea, MD, PhD; Assoc. Professor of Surgery, First Surgical Clinic, St. Spiridon Hospital Iai, Independenei Street No. 1, 700111, Iai, Romania; e-mail:costelbradea@yahoo.com*

BACKGROUND From Kocher neck incision, along years, the surgeons tried to make smaller and smaller incisions because, in general, the patients are females. The aesthetic result of the operation has always been an important aspect for them. The first video assisted surgical techniques started with M. Gagner who made the first a parathyroidectomy, in 1996. Then, other authors, Henry, Miccoli, Oghami, Shimizu, stated that videoresection of nodular goiters is feasible with good results on selected patients (without gigantic goiters). CASE REPORT A 50 year old female with multinodular goiter, with nodules of 2-3 cm at echography, in both thyroid lobes was admitted in our clinic. The hystory of the disease was of 9 years with medical treatment;in the last 4 years the goiter was refractive to the
received date: 10.01.2009 accepted date: 20.01.2009
*

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hormonal pills. The surgical intervention was delayed because of a pulmonary tuberculossis, treated in a clinic of pulmonary diseases. The general cardio-pulmonary and endocrine status was normal before the surgical intervention. Our source of inspiration was Miccolis technique, 2007, modified by the author, for video-assisted thyroidectomy. We started with the patient lying, without neck hyperextension; general anesthesia is used. The incision at the skin was made by electric scalpel, 15 mm long, horizontal, at midline of the neck, at 2 cm above the inferior line of the neck. We entered by this incision with classical instruments the thyroid region; then we introduced a 10 mm 0 degree rigid telescop together with a 5 mm Ligasure device by the same incision. We dissected and transected with Ligasure device the superior right thyroid pedicle. Then we dissected all around the right lobe (Fig.1). The right thyroid lobe was extracted; by the same incision the inferior pedicle also with Ligasure is resected. On the left side, the same procedure was applied; no drainage was used; the incision was inclosed in layers. The evolution was uneventful. The histopathological exam result was chronical Hashimoto thyroiditis.

Fig. 1 Video assisted thyroidectomy Intraoperatory view

DISSCUSION The thyroid gland begins to form on 17-th day of embryologic development between the first and second pharyngeal pouch, like an epithelial cord which penetrates the floor of the oral cavity and reaches the anterior side of trachea. The thyroid gland consists of two lobes joined by an isthmus; it normally weights 20 grams; each lobe is of 2/3/5 cm. It is covered by strap muscles (sternothyroid and sterno-hioid). The recurrent nerves lie in the trachea-esphageal grooves. The arterial supply is from inferior and superior thyroid arteries, branches of external carotid and thyrocervical trunk.There are three thyroid veins: superior, middle and inferior whom drains in the internal jugular vein. The lymphatic drainage of the thyroid gland is

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extensive. It consists of the central compartment (periglandular space) and a lateral one which are separated by the carotid sheet. A number of details must be clarified before to start a video-operate: the size of thyroid gland, the adherences after a previous operation or in our case of thyroiditis. During the operation we mustnt disrupt the capsule (the nodules are often suspected for a carcinoma). Small papillary carcinomas have been resected by this technique for two years (low risk carcinomas) with encouraging oncologic results [1]. The patient must have a normal thyroid gland function at the time of the operation. The position of pacient is supine with or without neck hyperextension. The incision must be made in an avascular zone,in a bloodless plane, with a electrocautery protected blade. Any bleeding is embaressing and can block the operation. The retractions are very gentle on strap muscles and thyroid tissues. A 5 mm, 30 degrees telescope is ideal. Dissections are made with 2 mm atraumatic instruments. An aspirator-spatula is very important for direct washing and aspiration the smoke. The first vessel to be ligated is middle thyroid vein with 3 mm vascular clips, ultrasonic scalpel or Ligasure device. The tip of the electric scalpel must be carefully checked because a high temperature can damage the larynx and the recurrent laryngeal nerves. The inferior part of the thyroid gland is severed after it has been pulled out. No drainage is necessary. The wound is closed with absorbable sutures. Complication rates are not high in video-thyroidectomy; is a safe operation with an acceptable time, following a short learning curve [1]. Video assisted total thyroidectomy is feasible with good oncologic and cosmetic results [2]. Large multinodular goiters are not eligible for minimal invasive surgery. The presence of lymph nodes and high risk carcinomas are a contra-indication for video resection [1]. It is possible to make prophylactic thyroidectomy to persons with Multiple Endocrine Neoplasia [3]. Total thyroidectomy for Multifocal Micropapillary Cancer is, also, feasible by video surgery [4]. The utilization of new devices for dissection, coagulation and division (harmonic, Ligasure) instead of the conventional technique as it ensures a dry field and a shorter operation time [5]. CONCLUSION Video assisted thyroidectomy can be considered feasible and safe and allows for an excellent cosmetic result and has possible new promising indications such as prophylactic thyroidectomy. Not all patients are eligible for this procedure, but in selected cases it can be a valid option for the surgical treatment of thyroid diseases.
1. 2. 3. 4. 5. REFERENCES Miccoli P. Minimally invasive video-asisted thyroidectomy. WeBSurgs World University, 2004-2007. Ghorayeb BY. Minimally invasive video assisted thyroidectomy. Otolaringology Houston on line magazine. Skinner MA, Moley JA, Dilley WG, Owzar K, Debenedetti MK, Wells SA Jr. Prophylactic thyroidectomy in multiple endocrine neoplasia type 2A. The New England Journal of Medicine. 2005; 353(11): 1105-1113. American Thyroid Association. Total or near total thyroidectomy in patients with multifocal micropapillary cancer. Cancer/Oncology. 04oct2008. United States National Institute of Health. Govern trials. Harmonic FOCUS versus Conventional Technique in Total Thyroidectomy for Benign Thyroid Dissease.

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TYPE II DIABETES MELLITUS: MEDICAL OR SURGICAL DISEASE ?

Type II Diabetes Mellitus: medical or surgical disease ?


Gianfranco Silecchia
Dept. of Surgery Paride Stefanini Policlinico Umberto I La Sapienza University of Rome,Italy

G. Silecchia Department of Surgery Paride Stefanini Policlinico Umberto I, La Sapienza University of Rome, Italy The incidence of type II diabetes mellitus (T2DM) is increasing in all the world. In this way the comorbidities and complications of the T2DM as well as death related T2DM are also increasing. It was demonstrated by many studies that T2DM is a medically incurable disease, chronic and progressive, and despite all the medical therapy and life style changing, more than 20% from the patients have a poor glycemic control. On the other hand, some surgical procedures, initially performed for morbid obesity (bariatric surgery) revealed good results to control the diabetes and even the metabolic syndrome. This paper presents the advantages and disadvantages of three main surgical procedures: gastric by-pass, sleeve gastrectomy and gastric banding. All of these procedures are very effectiveness to control the diabetes and metabolic syndrome. Further studies are necessary to establish the guidelines for the treatment (and even prophylaxis) of T2DM.

Conference presented at 4-th National Congress of Romanian Association for Endoscopic Surgery, October 30-th, 2008, Iai, Romania

T2DM Projected Global Incidence


Projected 2012 US diabetic Population 22.7 MM European diabetic Population 15.1 MM WORLD diabetic Population 226.5 MM
15,120 22,700 29,400 50,800

COST 2007 *

IFEGS

DIABETES : $ 174 billion T2DM 90-95% (1/3 undiagnosed) Diabetes is the most costly disease, consuming one out of every 7 dollars* The annual cost medical care per pt : $10,683 (2002) OBESITY :$ 117 billion (64.000.000 BMI 30-40) HEALTH CARE $ 2,3 trillion 2007 $ 2,2 2016

13,600 8,670

US

4,260 4,320 India Turkey Pakistan Egypt

6,370 4,780 Bangladesh China Philippines Indonesia

7,620

7,250
2000 2012

Japan

*source ADA

Brazil

Wild et al Diabetes Care 27:10471053, 2004

Types II Diabetes (T2DM)

Diabetes Mortality

80% of all patients are overweight/obese


Diabetes is the SIXTH cause of death in the USA.

2002: 71,000 died , but another 186,000 died from diabetes related conditions.

Hyperinsulinemia Insulin Resistance Ultimate beta cell failure DIET RESISTANCE !

. 2000 : 2.9 million WORLDWIDE deaths


http://www.diabetes.org/diabetes-statistics/cost Diabesity, Dr. Katherine Kaufman, former ADA president, Bantam Books, 2005 Roglic G et al Diabetes Care 2005

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T2DM Disease State


T2DM Management
HbA1c (%) Classification 6 Controlled 7 Good 8 Poor 9 Uncontrolled

Maintain Treatment

Change Treatment
Diet, and physical activity
Phase I Phase II Phase III Phase IV

Treatment

Oral Pharmaceuticals Oral and Insulin Insulin Only Hypertension Cardiovascular Nephropathy Amputation Blindness

Medical Therapy

Comorbidities

% of Diab Pop

42.3

21.1

15.4

21.1

Diabetes Related Deaths


5

p<0.0001

Medical Therapy
CONCLUSION

Hazard ratio

T2DM is a medically incurable disease, chronic and progressive

21% decrease per 1% decrement in HbA1c


0.5 0 5 6 7 8 9 10 11

Updated mean HbA1cUKPDS 35. BMJ 2000; 321: 405-12

1 in 5 persons still has poor glycemic control

Medical Therapy
Conclusions
Diabetes processes of care and intermediate outcomes have improved nationally in the past decade. But1 in 5 persons still has poor glycemic control

T2DM Management

Surgical Therapy

Improvements in diabetes processes of care and intermediate outcomes: United States, 1988-2002. Ann Int Med 2006;144(7):465-473

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Questions
Is there a role for gastrointestinal surgery in the management of T2DM? How does surgery control T2DM? Is T2DM cure a direct result of bariatric surgery or simply a favorable side-effect

An old concept..

Surgery, Surgery, Gynecology & Obstetrics; Obstetrics; February 1955

DIABETES SURGERY LONGLONG-TERM GOALS

.REVIVAL :METABOLIC SURGERY!

1995
NORMAL BLOOD GLUCOSE LEVEL HbA1c < 7% STOP DIABETIC DRUGS REDUCTION OF DIABETESDIABETES-RELATED COCO-MORBIDITIES

2006

2004

REDUCE DIABETESDIABETES-RELATED MORTALITY

Gastric by-pass and T2DM


Early effect on diabetes Mortality for diabetes

28%

9%

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1998, Annals of Surgery RETROSPECTIVE STUDY

(GBP n=608)

RESOLUTION DIABETES IGT TIMING OF IMPROVEMENT TIMING OF RESOLUTION 82.9% 98.7% 6 days 3 months

GIP

GILP

IGFIGF-1 LEPTIN

2001, World J Surg

Before any significant change of BMI !!

Gut Hormone Discovery

..Top 4 Gut Hormones


GLP-1 Enteroglucagon

Secreted by ileal L-cells in (rapid) response to a meal


Food intake stimulates its release fasting reduces it

PYY (3-36)

GIP Gastric Inhibitory Peptide / Glucose Dependant


1967 Gastric Bypass
Rehfeld J, 2004

Insulinotrophic Peptide (Secreted by duodenal k-cells)

Ghrelin 80% secreted from gastric fundus

Review

Rubino & Gagner 2002, Annals of Surgery

?
CURE OF TYPE II DM
GBP BPD (Scopinaro ) (Scopinaro) 85% 99%
BARIATRIC SURGERY OR METABOLIC SURGERY ?

ONLY WEIGTH LOSS EFFECT La scelta dellintervento. ???

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Bariatric Surgery Efficacy :T2DM


Author
Scopinaro 2005 Buchwald 2007
(Meta - 135.246 pts)

Procedure
BPD Gastric Bypass Lap Band (selected pts) Sleeve Gastrectomy

Resolution
98% 83,4% 73% 83%

Dixon et al 2008
prospective Jama

Vidal 2008
(limited 1 y Follow up)

Worldwide Interest in Metabolic Surgery


Diabetes Surgical treatment

Diabetes Surgery Symposium Rome, Italy (March 29-31, 2007)

Bariatric Surgery is Effective, But Not Equal


Benefit
100%

BPD Roux-en-Y Sleeve ??

Surgeons (1/3 of the panel) Endocrinologists Basic Scientists

Gastrointestinal bypass procedures can improve diabetes by mechanisms beyond changes in food intake and body weight. Gastrointestinal surgery may be appropriate for the treatment of T2DM in patients who are appropriate surgical candidates with BMI of 30 to 35 who are inadequately controlled by lifestyle and medical therapy

Excess Weight Loss

International multidisciplinary voting panel of experts

Major points of consensus

Diabetes Resolution Resolution Rate Rate Diabetes

50%

Banding

10%

0.001 Risk

0.01

0.1

10

30 Day Mortality

Adapted from Buckwald H, et al, Bariatric surgery, a systematic review and metaanalysis, JAMA. 2004;292:1724-1737 and Maggard M, et al, Meta-Analysis: Surgical Treatment of Obesity, Ann Intern Med. 2005;142:547-559.

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LRYGBP and T2DM remission


Resolution:158/191
FPG<110 mg/dl HbA1c normal No medication FU > 5 years

(83%)
GBP SLEEVE

Ob Surg 2008

Factors associated to resolution Shorter T2DM duration Better level of initial HbA1c Non-insulinic Treatment Higher weight loss
Improvement Resolution %EBL 42 %EBL 62 Schauer PR, Annals of Surgery 2003

Vs

SG is as effective as GBP in inducing remission of T2DM (84.6%) and the Metabolic Syndrome. Syndrome.

Effect of Laparoscopic MiniMini-Gastric Bypass for Type 2 Diabetes Mellitus: Mellitus: Comparison of BMI >35 and <35 kg/m(2).
Lee WJ, Wang W, Lee YC et Al. LAP MINI GBP 201 pts DM2 / IFG

Oct 2007

BMI <35 n= 44

BMI 3535-45 n= 114 1 year RESOLUTION

BMI >45 n=43

89.5% 76.5%

Normal plasma gluc. gluc. CURE DM2 *


HbA1C< 7 LDL< 150

98.5% 92.4%

p= 0.087 p= 0.059

TRIGL< 150

Rome Experience / Head: prof. prof. N. Basso


N =110 Diabetics/IGT

45 N=
LAGB

45 N=
RYGBP

20 N=
LSG

MEAN F -U 36 MONTHS
CLINICAL EVALUATION
(weight, BMI,fasting glyacemia, HbA1c%, insulin,HOMA-IRI)

CURED

YES

Stop medical treatment NO

NOT CURED

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RESULTS
STOP MEDICAL TREATMENT
Obesity Surgery, Surgery, 18, 2008

SUCCESS RATE: STOP MEDICAL TREATMENT LSG


Tot. Pts 110 Group A (69 pts)
T2DM/IGT old diagnosis Medical treatment
3 Tri m .

3.3

AGB (45 Pts)

RYGB (45 Pts)

LSG (20 Pts)

HbA1c = 5.9%

LRYGBP

2 Tri m .

3.2

HbA1c = 6.4%

46.6%

74%

66.6%
p< 0,05

LAGB

1 Tri m .

12.6
3 6 9 12 15

HbA1c = 5.9%

CURE / IMPROVEMENT : 74.5%


Mean F.U. 36.3 months

months

T2DM & METABOLIC syndrome

Questions
Is there a role for gastrointestinal surgery in the management of T2DM? How does surgery control T2DM? Is T2DM cure a direct result of bariatric surgery or simply a favorable side-effect

The Physiologic Basis for Surgery

Gut Hormones and Bariatric Surgery


Aug 2004
Intake

Grehlin

EARLY HORMONAL CHANGES AFTER GBP


Processing

Usage Stomach
Insulin Glucose

p<0.05

(3 weeks p.o.)

GLP-1 GIP CCK PYY

INSULIN LEPTIN IGFIGF-1

Storage Liver
Leptin Adiponectin Resitin

Bowel

Fat

ACTH No significant variations of BMI

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GIP PLASMA LEVEL DIABETIC VS NON DIABETIC

Before any significant variation of BMI !

r te Af

U. F. hs nt o m

..when compared to preoperative levels, levels, there were no significant changes in enteroentero-endocrine ormone levels in the diabetic cohort postoperatively postoperatively

GASTROINTESTINAL DIABETES SURGERY


2004, Annals of Surgery

EVIDENCE / EFFECT

OBESE

NON OBESE

CURE OF NON OBESE DIABETIC RATS

NOT PRIMARILY RELATED TO WEIGHTWEIGHT-LOSS

Foregut Theory

Exclusion of the duodenum results in inhibition of a putativesignal that is responsible for insulin resistance and/or abnormal glycemic control (T2DM)
Rubino et.al, Ann Surg, 2006

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Incretins and Anti-Incretins


Effect of Duodenum
Duodenal Exclusion vs Inclusion in food passage
OGTT AUC

69000 64000 59000 54000 49000 44000 Duodenal Pass. Duod. Exclus Duodenal Pass. Duod. Exclus

Rubino et.al, Ann Surg, 2002

Rubino et.al, Ann Surg, 2006

The Hindgut Theory


Animate Model Results Hindgut Theory


ILEAL TRANSPOSITION EXPERIMENTAL RESULTS Mean GLP-1 secretion 0-15 minutes post glucose infusion (GK rats)
40 35 30 25 20 15 10 5 0 Day 45 IT Control Sharm

The more rapid delivery of undigested nutrients to the distal bowel upregulates the production of L-cell derivatives like GLP-1
Mason E. Obes Surg 2005 15, 459-461 Rubino et.al, Ann Surg, 2006

* p=0.05

Patriti et.al. Obes Surg, 2005

Hindgut Conclusions

Duodenal Bypass Surgery

Conclusions

ILEAL TRANSPOSITION is effective in inducing improved glycemic control independent of weight and food intake The potential mechanism of action may be insulin independent (i.e. enhanced glucose uptake, utilization) In this study, GLP-1 does not appear to the mediator of this effect
Patriti et.al. Obes Surg, 2005

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DIABETES SURGERY GASTROINTESTINAL BYPASS PATHOPHYSIOLOGY


1. 2. WEIGHT CALORIC INTAKE

T2DM & THE METABOLIC EFFECTS OF BARIATRIC SURGERY

Novel Surgical Options

3. MALABSORPTION (lipids -BPD) (lipidsBPD) 4. EARLY DELIVERY OF FOOD TO DISTAL ILEUS 5. BYPASS OF THE DUODENUM AND PROXIMAL JEJUNUM

ENDOCRINE PATHWAY

2007
3 weeks T2DM REMISSION (5 pts) pts)

Up to date 2008:
DJB 40 cases (BMI 2222-34) FollowFollow-up 9-12 months T2DM full remission 78% No correlation with weight loss or gain

Endo-sleeve : future treatment of T2DM ?

23 Pts

Mortality rate 2.6% Morbidity rate 10.2% PrePre-op BMI 30.1 PostPost-op BMI 24.9 (FU 7 months) months) Glycemic control 86.9% Improvement 13.1%

16 Pts

Normal TGR 71% Normal blood pressure 95.8%

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DIABETES SURGERY
2008
12 pts 12 weeks 2 explantation after 9 days No device complications Mean EWL 23%

Who is the candidate ?


Pt with good beta cells function and reserve
(NO RELATED WITH BMI)

Laparoscopic Metabolic Surgery


Severity of Diabetes

PARAMETER THAT MAY PREDICT Beta cells FUNCTION AND SURGICAL OUTCOME ?

High Interposition with Gastrectomy BPD

Roux en Y Duodenal Exclusion procedure Sleeve gastrectomy Banding ?

Mid

C- PEPTIDE LEVEL

PROPRO-INSULIN/ INSULIN RATIO

Low 25 30 New Market Development 35 40 45 50

BMI

Current Market Development

THE WINNER IS

METABOLIC SURGERY

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PROF. DR. DOC. COSTACHE LAZR (1919-2008)

IN MEMORIAM

Personalitate marcant a chirurgiei ieene, Prof. dr. doc. Costache Lazr s-a nscut pe 4 iunie 1919, n comuna Tansa, jud. Iai, unde a urmat i coala primar. A fost admis ntiul la Liceul Mihail Koglniceanu din Vaslui, n 1931. Este absolvent al Liceului Naional din Iai (1939). Urmeaz cursurile Facultii de Medicin din Iai, pe care o absolv n 1945. nc din studenie a fost atras de arta i de tiina chirurgical. Este aspirant al Institutului de Anatomie din Iai n perioada 1942-1944 i preparator prin concurs al Clinicii Chirurgicale i Ortopedice, Facultatea de Medicin Iai, n perioada 1943-1946. Devine asistent universitar n 1949 i ef de lucrri la Clinica I Chirurgie, IMF Iai, n 1957. Obine titlul de confereniar universitar n 1968 i de profesor titular prin concurs, la aceeai clinic, n 1970. i-a susinut teza de doctorat, intitulat Tratamentul chirurgical al chistului hidatic pulmonar, n 1958. A fost eful Clinicii I Chirurgie n perioada 1966-1984. A contribuit efectiv la pregtirea profesional a 42 promoii de studeni, crora le-a dezvoltat simul clinic i ataamentul fa de omul suferind. A fost un bun organizator. Venit la catedr, a pus bazele noului nvmnt de chirurgie, conferind clinicii un statut de mare disciplin, menit s contribuie la pregtirea solid, teoretic i practic a studenilor. Prof.dr.doc. C. Lazr a organizat n clinic activitatea de specializare i de perfecionare a medicilor chirurgi din toat Moldova, o parte din conductorii seciilor de chirurgie din aceast regiune fiind elevii lui. n activitatea didactic folosea demonstraiile clinice i un bogat material anatomopatologic i imagistic ilustrativ. Urma al profesorului Vl. Buureanu, a continuat direciile principale de dezvoltare a clinicii, contribuind n mod hotrt la dezvoltarea chirurgiei tiroidiene, toracice i, mai ales, a chirurgiei digestive. Activitatea chirurgical susinut, desfurat alturi de Prof. dr. Vl. Buureanu, a avut o influen major asupra formrii sale profesionale. Chirurg de excepie, dotat cu manualitate, frumuseea i naturaleea gestului chirurgical, a rmas toat viaa devotat chirurgiei clasice. n acest domeniu a modernizat tehnicile de tratament i a adaptat noi procedee chirurgicale. A fost membru titular al Societii Internaionale de Chirurgie, al Uniunii Medicale Balcanice, preedinte al seciei de chirurgie a Societii de Medici i Naturaliti Iai timp de peste 30 de ani (1972-2003), perioad n care edinele se

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desfurau cu regularitate i aveau o nalt inut academic. Este unul din fondatorii societii medicale Asociaia Chirurgilor din Moldova. A fost membru de onoare al Societii Romne de Chirurgie i membru al Asociaiei Oamenilor de tiin din Romnia. A fost conductor de doctorat din 1984. A editat, n 1972, pentru prima oar la Iai, un curs de chirurgie pentru studeni, n 3 volume, cuprinznd toat patologia chirurgical, bine sistematizat, ceea ce a fcut s apar i o a doua ediie n 1980. De asemenea, n 1978, a publicat mpreun cu M.R. Diaconescu prima monografie despre hipertiroidie, aprut la editura Junimea. A participat la tratatul de chirurgie de sub redacia Prof. dr. E. Proca, n care a scris capitolul despre hernii. Este autorul a 146 de articole publicate n reviste din ar i din strintate i a participat cu 300 lucrri tiinifice la simpozioane, consftuiri i congrese naionale i internaionale. Pentru bogata activitate tiinific i s-a decernat, n 1972, titlul de doctor docent. De asemenea, a obinut o serie de ordine i medalii pentru aportul su la dezvoltarea medicinii. A format profesional, n stilul specific colii profesorului Buureanu, numeroi chirurgi, parte dintre ei devenind profesori de chirurgie. Muli dintre colaboratorii Prof. dr. doc. C. Lazr au atins treapta ierarhic cea mai nalt n activitatea didactic chirurgical i au devenit efii unor importante servicii chirurgicale din Iai. Devenit profesor consultant, Prof. dr. doc. C. Lazr a dus o via demn, nconjurat de respectul tuturor. A venit n continuare n clinic, la creterea renumelui creia i-a dedicat toat activitatea sa. A ndrumat doctoranzi din servicii chirurgicale din toat ara contribuind la dezvoltarea lor profesional. Personalitate complex, academic i tiinific, Prof. dr. C. Lazr a lsat imaginea chirurgului sobru, devotat spitalului, un simbol al longevitii colii ieene de chirurgie. A fost un om exigent cu el nsui i cu toat echipa, ridicnd astfel prestigiul clinicii la standarde deosebite. n sufletul nostru i vom pstra venic amintire. E. Trcoveanu

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CHIRURGIA
Vol 103, Nr. 6, Noiembrie Decembrie 2008 A aprut ultimul numr pe 2008 al prestigioasei reviste Chirurgia, revista Societii Romne de Chirurgie, cotat ISI i care ofer un material consistent i de actualitate sub form de referate generale, articole originale, tehnici operatorii, cazuri clinice, imagini pentru chirurgi, comemorri i recenzii. n rubrica REFERATE GENERALE, M. Stamatakos i colab. de la 2nd Department of Propedeutic Surgery, School of Medicine, Athens University, Laiko Hospital, Greece, ne prezint actualiti n boala hidatic a tractului urinar. Echinococcoza tractului urinar se ntlnete foarte rar, interesnd 2-4% din cazuri. Aceast entitate patologic trebuie inclus n diagnosticul diferenial al leziunilor nlocuitoare de spaiu la nivelul tractului urinar, indiferent de vrst, n special la pacienii din zone endemice. n cadrul ARTICOLELOR ORIGINALE, Dr. A.E. Nicolau continu seria articolelor dedicate suturii laparoscopice a ulcerului duodenal perforat. Autorii, care compar un lot de 174 de bolnavi operai prin abord clasic cu un lot de 85 de pacieni operai laparoscopic, consider c sutura laparoscopic cu epiploonoplastie asociat medicaiei antiulceroase, este terapia de elecie n UDP la pacienii tineri care nu prezint factori de risc. n continuare, Rodica Brl i colab. de la Clinica de Chirurgie General i Esofagian condus de prof.dr. S. Constantinoiu prezint un interesant studiu prospectiv care a urmrit supravieuirea la distan a unui lot de 43 de pacieni cu rezecii esogastrice cu limfodisecie abdomino-mediastinal pentru adenocarcinom de jonciune esogastric efectuate n perioada 2001-2006. Supravieuirea la 1 an a fost de 77,74%, iar la 2 ani de 62,8%. Supravieuirea la distan este dependent de vrst, grading-ul tumoral, numrul de metastaze ganglionare i stadiul pT, fr a fi dependent de tipul Siewert, clasa ASA, abordul chirurgical, tipul rezeciei, numrul de ganglioni disecai, abdominali sau mediastinali. Autorii concluzioneaz c rezultatele nefavorabile la distan obinute prin intervenia chirugical ca unic msur terapeutic indic necesitatea unei abordri multimodale pre i postoperatorii utiliznd metode de selecie a pacienilor cu predicie ct mai bun pentru tratamentul neoadjuvant. De la Clinica I Chirurgie, Spitalul Universitar Sf. Spiridon, Iai, Prof. Dr. E. Trcoveanu i colab. au efectuat un studiu retrospectiv n perioada 1990-2007, cnd au fost operai 114 pacieni cu ginecomastie uni- sau bilateral. Diagnosticul i, mai ales, tratamentul ginecomastiilor se vor face n echip multidisciplinar care cuprinde imagist, endocrinolog, morfopatolog i chirurg. Medicul practician trebuie s tie c n

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spatele unei ginecomastii se poate afla un cancer mamar, chiar la vrste tinere. Tratamentul chirurgical al ginecomastiei trebuie individualizat, n funcie de gradul de hipertrofie mamar. Hipertrofia glandular adevrat necesit o excizie chirurgical a esutului glandular i examinare histopatologic ulterioar, evitnd astfel capcanele oncologice. Liposucia poate fi utilizat ca o tehnic adjuvant pentru optimizarea rezultatelor estetice dup excizia esutului glandular. Liposucia exclusiv trebuie limitat la cazurile de pseudoginecomastie. Dr. A. Miron i colab. de la Sp. Elias au evaluat prospectiv nerandomizat, eficacitatea pregtirii mecanice n chirurgia colonului. A fost comparat un lot de 60 de pacieni cu pregtire mecanic preoperatorie a colonului cu un lot de 39 de pacieni la care intervenia chirurgical s-a desfurat pe colon nepregtit. Autorii nu au gsit diferene semnificative ntre cele 2 loturi n ceea ce privete complicaiile postoperatorii, concluzionnd c interveniile chirurgicale colorectale se pot desfura fr pregtirea mecanic preoperatorie a colonului, cu rezultate similare sau superioare. Efremidou E.I. i colab de la Universitatea din Thrace, Grecia prezint rezultatele unui studiu - Carcinomul colorectal: corelaii ntre vrst, sex i distribuie anatomic, care constat c n perioada 1982-1997 a crescut incidena cancerului colorectal n regiunea de nord a Greciei, n special la femei i btrni i localizrile pe colonul stng. n continuare, dr. V. Cauni i colab. de la Clinica de Urologie, Spitalul Clinic de Urgen Sfntul Ioan Bucureti analizeaz jeturile ureterale prin ecografie Doppler, att din punct de vedere morfologic (form, durat), ct i din punct de vedere al velocitii, n diagnosticul litiazei tractului urinar superior. Dr. S. Pantea i colab. de la Clinica II Chirurgie Timioara, dup un studiu pe 56 de cazuri, recomand plasarea laparoscopic a cateterului de dializ peritoneal. n cadrul rubricii TEHNICI OPERATORII: ATITUDINE PERSONALA, I.N. Mate de la Clinica de Chirurgie General i Esofagian, Sp Clinic Sf. Maria, Bucureti ne prezint tehnica substituiei cu me intraperitoneal n eventraiile voluminoase. Dac obiectivul interveniei n defectele de mici dimensiuni este restabilirea anatomiei locale, prin simpla reinserie tendinoas a muchilor abdominali, pentru defectele mari sau complexe, conteaz doar posibilitatea reabilitrii conteniei parietale. Protecia visceral este asigurat prin interpoziie epiplooic, care trebuie s depeasc cu 5 cm defectul parietal. Mea trebuie fixat uniform (fr cute), dar lejer. Ancorarea de structurile parietale trebuie s fie solid, cu fire separate monofilament (de polipropilen sau nylon), preferabil cu ace cu seciune rotund pentru a nu deteriora ochiurile texturii. Dup ce se plaseaz 1-2 tuburi multiorificiale n spaiul de decolare a sacului peritoneal, se sutureaz planurile superficiale deasupra meei, n tensiune i fr spaiu de retenie. Autorul recomand acest tip de substituie pentru c nu comport o disecie parietal laborioas; complicaiile locale i generale sunt reduse, iar incidena recidivei este redus. Aa cum ne-a obinuit, Prof. Dr. Nicolae Constantinescu n rubrica ARC PESTE TIMP comenteaz articolul Complication rare aprs une opration pour appendicite chronique al lui Traian Nasta i Stephan Balcou, aprut n Revista de Chirurgie din 1937. Cazul operat de Traian Nasta i colab. n 1936 i prezentat n 1937, nti la Societatea de Chirurgie din Bucureti i apoi publicat n paginile Revistei de Chirurgie, suscit interes chiar dup trecerea a peste 70 de ani. La rubrica CAZURI CLINICE i gsim pe: Prof. Dr. Mircea Beuran i colab. care ne prezint un caz de pseudo-anevrism de artera cistic ce a determinat o fistul

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arterio-biliar, manifestat cu melen important i colangit la 7 luni de la intervenia laparoscopic. M. Florea i colab. ne prezint un caz de fistul extern a unui pacient diabetic cu chist hidatic hepatic. D. Tamiolakis i colab. de la Regional Hospital of Chania, Crete, Grecia ne prezint o serie de 5 cazuri cu chisturi de canal tireoglos, iar N. Galie ne prezint un caz de chist hidatic sternal. n rubrica IMAGINI PENTRU CHIRURGI, un colectiv de la Institutul Clinic Fundeni, din clinica Prof. dr. I. Popescu, ne prezint un caz de mezoteliom chistic peritoneal benign care este o entitate patologic foarte rar. Prezentarea este nsoit de imagini foarte sugestive, IRM pelvis, aspectul postoperator al piesei de rezecie i imagini ale examenului imunohistochimic. n cadrul rubricii IN MEMORIAM, este rememorat personalitatea Prof. Dr. Doc. Costache Lazr (1919-2008), care a fost eful Clinicii I Chirurgie n perioada 1966-1984. Urma al profesorului Vl. Buureanu, a contribuit n mod hotrt la dezvoltarea chirurgiei tiroidiene, toracice i mai ales a chirurgiei digestive. A fost membru titular al Societii Internaionale de Chirurgie, al Uniunii Medicale Balcanice, preedinte al seciei de chirurgie a Societii de Medici i Naturaliti Iai timp de peste 30 de ani (1972-2003), perioad n care edinele se desfurau cu regularitate i aveau o nalt inut academic. Este unul din fondatorii societii medicale "Asociaia Chirurgilor din Moldova". Personalitate complex, academic i tiinific, prof. dr. C. Lazr a lsat imaginea chirurgului sobru, devotat spitalului, un simbol al longevitii colii ieene de chirurgie. La final, este prezentat sinteza evenimentelor de la ultimul congres ARCE (E. Trcoveanu, C. Copescu i A.E. Nicolau), desfurat la Iai n perioada 29-31 octombrie 2008, i care a reunit peste 400 participani din ar i din strintate. Succesul congresului a fost garantat prin participarea unor personaliti ale chirurgiei europene i romneti, care au prezentat conferine pe subiecte de interes de mare actualitate: Nagy Habib (UK), John Lotz (UK), Jose Schiappa (Portugalia), Robrecht Van Hee (Belgia), Pierre Mendes Da Costa (Belgia), Hendrik Van Damme, Gianfranco Silecchia (Italia), academician Gh. Ghidirim, Eugen Maloman, Vladimir Hotineanu (Chiinau), Nicolae Angelescu, Mircea Beuran, Silviu Constantinoiu, Ctlin Vasilescu, Ctlin Copescu, Victor Tomulescu, D. Ungureanu, A.E. Nicolau (Bucureti), Lazr Fulger (Timioara), Constantin Copotoiu (Tg. Mure), Liviu Vlad, Aurel Andercou (Cluj Napoca), Vasile Srbu (Constana), Ion Georgescu (Craiova). naintea Congresului s-au desfurat trei cursuri post-universitare: Inguinal hernia surgery (R. Van Hee - EAcSS), Efficient participation in scientific events (J. Schiappa EAcSS), Laparoscopia n abdomenul acut (A.E. Nicolau, Lazr Fulger, E. Trcoveanu - ARCE), care s-au bucurat de o larg audient. Apreciem c acest congres a fost o reuit datorit numrului mare de participani, cursurilor precongres cu o larg audien, demonstraiilor operatorii captivante, evalurii progreselor obinute n ultimii ani i, nu n ultimul rnd, diseminrii experienelor colectivelor care practic chirurgia laparoscopic, cu evaluarea impactului noilor inovaii tehnologice asupra practicii chirurgicale.

A. Vasilescu

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MINIMALLY INVASIVE PLATE OSTEOSYNTHESIS IN LONG BONE FRACTURES


Paul Dan Srbu La Casa de Editur Venus, n 2008, a aprut volumul Osteosinteza minim invaziv cu plci n fracturile oaselor lungi, nsoit de CD, rezultatul unei colaborri multinaionale prestigioase. Monografia Osteosinteza minim invaziv cu plci n fracturile oaselor lungi, realizat sub redacia Dr. Paul-Dan Srbu, cu o prefa susinut de Prof. Dr. Wilhelm Friedl din Germania, este o pledoarie pentru respectul prilor moi n fracturile complexe epifizometafizo-diafizare. Aceast apariie editorial colectiv n cadrul unui grant de cercetare este ludabil, mai muli autori din Romnia i strintate contribuind excelent cu experiena lor profesional la susinerea avantajelor incontestabile ale osteosintezei biologice cu plci. Remarcm capitole foarte interesante legate de: evoluia MIPO (P. Botez i colab.), MIPO prin abord anterior n fracturile diafizei humerale (W.D. Belangero i B. Livani din Brazilia), plcile cu stabilitate angular i tehnicile MIPO (N. Schwarz i colab. din Austria), tratamentul de recuperare a genunchiului (Margrit List -Germania), tehnica MIPO n fracturi subtrohanteriene, femur distal, tibie proximal (P. Srbu i colab.), tehnica MIPO n fracturile tibiei distale (R. Mihil i colab). Dr. Paul-Dan Srbu, cel care a introdus n premier naional tehnicile MIPO n Romnia, adaug crii un CD cu tehnici chirurgicale, aceste contribuii video ntregind valoarea incontestabil a monografiei. Bazat pe o bogat experien chirurgical i pe studiul unei bibliografii recente manualul conceput n stil european este uor de parcurs datorit manierei concise, ordonate i clare, fiind sistematizat didactic. Condiia grafic deosebit fac lectura agreabil. Apariia acestei cri reprezint un eveniment editorial deosebit, nbogind literatura de specialitate, fiind util studenilor, specialitilor, rezidenilor de ortopedie n momentul n care conceptul chirurgical miniminvaziv devine din ce n ce mai important n practica chirurgical curent. E. Trcoveanu

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WORLD JOURNAL OF SURGERY


Vol. 32, nr. 12, 2008

The first part of the journal is dedicated to BREAST CANCER SURGERY. De Kok M. et al present Implementation of an Ultra-short-stay Program After Breast Cancer Surgery in Four Hospitals: Perceived Barriers and Facilitators. The objective of this study was to identify barriers and facilitators that professionals see when implementing a program incorporating ultra-short hospital admission in the treatment of breast cancer. Aggarwal V. et al made a Feasibility Study of Safe Breast Conservation in Large and Locally Advanced Cancers with Use of Radiopaque Markers to Mark PreNeoadjuvant Chemotherapy Tumor Margins. This novel indigenous method of identifying tumor margins with sterile silver wire markers is safe, inexpensive, practical, and effective; and it may help perform safe breastconserving surgery in patients with locally advanced breast cancer. Malycha L.P.et al present the results of international symposium ISW 2007 in Montreal. The subject for the symposium was Oncoplastic Breast Surgery who is probably best described as a seamless joining of extirpative and reconstructive breast surgery performed by a single surgeon. The presenters and authors are well-known breast surgeons from Australia, Croatia, India, Sweden, and South Africa. The modern breast surgeon can play a crucial role in minimizing physical disfigurement and improving the quality of life of breast cancer patients. Breast oncoplasty is an emerging subspecialty of surgery. The new model of breast oncoplasty proposes a seamless integration of breast surgery and plastic surgery into a common training program. The need for bringing together skills of a surgical oncologist and a plastic and reconstructive surgeon into a single surgeon cannot be overemphasized. Denewer A. et al recommend skin-sparing mastectomy with immediate breast reconstruction using our new modification of extended latissimus dorsi flap allows single-stage, totally autologous reconstruction with satisfactory aesthetic results and low morbidity. Chan W. W. S. et al present the benefit of ultrasonography in the detection of clinically and mammographically occult breast cancer. In section ENDOCRINE SURGERY, Yano Y. et al present Long-Term Changes in Parathyroid Function After Subtotal Thyroidectomy for Graves Disease. Subtotal thyroidectomy was performed in 275 patients with Graves disease. The phenomenon of an elevated serum PTH level after surgery for Graves disease was

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observed in 21% of the patients with postoperative hypocalcemia despite the achievement of normal serum calcium levels by calcium and vitamin D supplementation. Morita N. et al from Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan evaluated expression of P53 protein, immunohistochemically in sections of paraffin-embedded tissue in 68 papillary thyroid carcinoma and 196 lymph node metastases. The results of this study suggest that immunohistochemistry for P53 in the primary tumor could be useful in the clinical evaluation of patients with PTC. Moreover, P53 protein overexpression in lymph node metastasis may be useful as a treatment guide or target for lymph node recurrences. Alfalah H et al from University Hospital, Lille, France made a retrospective review of 70 patients operated on between January 1995 and December 2005 for follicular thyroid carcinoma. Follicular thyroid carcinoma results in metastases to regional lymph nodes in 7% of cases but only to the ipsilateral neck side. Tumor size is the only factor that impacts it and not recommend lymph node dissection in follicular thyroid carcinomas <4 cm. In section UPPER GASTROINTESTINAL TRACT SURGERY, Morgagni P et al from Italy analysed the impact in survival a resection line involvement after gastric cancer surgery. Infiltration of resection line significantly affects long-term survival of advanced gastric cancer. The impact on prognosis is independent of lymph node involvement. The conclusion of this study is for the patients in good general condition for whom radical surgery is possible should be considered for reoperation. In next section, HEPATOPANCREATOBILIARY SURGERY, Akita H studies the utility of Indocyanine green retention after 15 min measured by pulse dye densitometry to predict residual liver function prior to hepatectomy, and Nakagohri T. present Surgical Outcome and Prognostic Factors in Intrahepatic Cholangiocarcinoma. Tewari M. et al recommend a cholecystectomy in locally advanced unresectable cancer of the gallbladder with a better median survival compared with only bypass and biopsy procedures. The findings in this may justify a palliative cholecystectomy in selected patients with locally advanced GBC. Sarr G.M. comments this study and said Tewari, Sharma, and Kumar offer a memorable lesson: take out the gallbladder if technically feasibleit will benefit the patient! Chen H et al from Department of Hepatobiliary Surgery, Foshan, Guang Dong, The Peoples Republic of China present a variant of pancreaticojejunostomy anastomosis technique with a pancreatic fistula rate of 0% and low intra-abdominal complication rate. In this tehnique, performed in 52 cases, a 4-cm pancreatic stump would be invaginated into the jejunum and the capsular edge of the transected pancreas and the free end of the jejunum were sewn circumferentially with continuous running sutures (polypropylene 4/0). The mean hospital stay was 12.6 3.2 days. The overall incidence of surgical complications was 9.6%. No patient developed pancreatic leakage/pancreatic fistula. The four patients with bile leakage, intra-abdominal collection, and abscess were treated successfully with percutaneous drainage. One patient (1.9%) died of respiratory failure on postoperative day 7. He had no intraabdominal complication after the operation. In COLORECTAL SURGERY section, Kim S.H. et al from Koreea, performed a 10 laparoscopic-assisted combined colon and liver resection for primary colorectal cancer with synchronous liver metastases. Surgical procedures for colorectal cancer included 5 low anterior resections, 3 anterior resections, 1 right hemicolectomy,

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and 1 subtotal colectomy. Combined hepatic surgery included 6 major hepatectomies, 3 segmentectomies, and 1 tumorectomy. All procedures were successful, with no conversions to open surgery required. The median operation time was 439 min (range: 210690 min), and the median estimated blood loss was 350 ml (range: 3001,200 ml). There was no surgical mortality or major morbidity, except in one patient in whom postoperative bleeding at the site of para-aortic node dissection was promptly controlled. In section TRAUMA AND CRITICAL CARE GENERAL SURGERY, Thoma M. et al from University of Cape Town, South Africa conducted a prospective observational study of 203 patients with penetrating neck injuries. 159 with stab wounds and 42 with gunshot wounds. A vascular injury was identified in 27 (13.3%) patients, pharyngoesophageal injury in 18 (8.9%) patients, and an upper airway injury in 8 (3.9%) patients. Only 25 (12.3%) patients required surgical intervention. A further 8 (3.9%) patients had therapeutic endovascular procedures. The remaining 158 (77.8%) patients, either asymptomatic or with negative work-up, were managed expectantly. There were no clinically relevant missed injuries. The conclusions was a selective nonoperative management of neck injuries based on clinical examination and selective use of adjunctive investigational studies is safe in a high-volume trauma center. Gauer JM et al from Department of Surgery, Schaffhausen, Switzerland present Twenty Years of Splenic Preservation in Trauma: Lower Early Infection Rate Than in Splenectomy. During a 20-year period, 155 patients were prospectively evaluated. In 98 patients (63%), the spleen could be preserved by nonoperative (64 patients, 65%) or operative (34 patients, 35%) treatment and 57 patients (37%) needed splenectomy. There were no differences in age, sex, or trauma score between the groups, but a higher early infection rate in patients with splenectomy compared with patients with splenic preservation (p < 0.005) was observed, even if the patients were matched with respect to multiple trauma using the Injury Severity Score (p < 0.01). According to the data evaluated in this study and the literature reviewed the autors are a strongly advocate that the treatment of splenic trauma consists whenever possible in splenic preservation. Hemodynamically unstable and/or polytraumatized patients will benefit from an improved immunity if treated with operative splenic preservation instead of total splenectomy. Nonoperative treatment should be chosen whenever possible, especially in younger patients with mono- or oligotrauma being hemodynamically stable, but also in older patients with a good general health before the trauma. This number is closed with sections SURGICAL PRACTICE and LETTERS TO THE EDITOR.

A. Vasilescu

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