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

2 [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 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. 2 [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).

Autorii trebuie s informeze redacia despre un posibil conflict de interese. Informaii suplimentare despre conflictul de interese sunt disponibile la adresa: http://www.icmje.org/#ep.

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CUPRINS

EDITORIAL REZIDENIATUL N CHIRURGIE - PROBLEME NOI, SOLUII VECHI. DECALOGUL PREGTIRII REZIDENILOR...........................................109 E. Trcoveanu, R. Moldovanu Clinica I Chirurgie I. Tnsescu Vl. Buureanu Centrul de Cercetare n Chirurgia Clasic i Laparoscopic Universitatea de Medicin i Farmacie Gr.T. Popa Iai ARTICOLE DE SINTEZA CHIMIOTERAPIA INTRAPERITONEAL: MODELUL CANCERULUI OVARIAN...............................................................................................................115 L. Miron, M. Marinca Clinica de Oncologie, Spitalul Clinic de Urgene Sf. Spiridon Iai Universitatea de Medicin i Farmacie Gr. T. Popa Iai DIAGNOSTICUL PANCREATITEI ACUTE BILIARE...............................................................123 Elena Gologan (1), A. N. Pantazescu (2), Gh. Blan (1) (1) Institutul de Gastroenterologie i Hepatologie, Iai Universitatea de Medicin i Farmacie Gr.T. Popa Iai (2) Clinica Chirurgical, Spitalul de Urgene Sf. Ioan, Iai ARTICOLE ORIGINALE INGUINAL HERNIA REPAIR IN THE 21-ST CENTURY..........................................................136 J.C. Lotz Staffordshire General Hospital, Stafford, England RIGHT COLECTOMIES: INDICATIONS, TECHNIQUES, AND RESULTS, RETROSPECTIVE STUDY OF 110 PATIENTS...........................................................................140 S. Zaytouni, Ch. Simoens, V. Thill, D. Smets, P. Mendes Da Costa Department of Digestive, Thoracic and Laparoscopic Surgery CHU Brugmann, ULB Brussels, Belgium CALCIUM LEVEL, A PREDICTIVE FACTOR OF HYPOCALCEMIA FOLLOWING TOTAL THYROIDECTOMY................................................................................148 Ancua Leahu, Vanessa Carroni, G. Biliotti Department of Clinical Physiopathology, Section of Surgery University of Florence, Italy SCREENING FOR COLORECTAL CANCER WITH FECAL OCCULT BLOOD TESTING AND COLONOSCOPY: CORRELATION OF CLINICAL DATA, SITE, SIZE AND DISEASES STAGE..................................................153 Iuliana Tarai (1), Gabriela Florena Dumitrescu (2), Anca Indrei (3), P. Plmdeal (4), Anca Trifan (5), C. Stanciu (5), (1) Departament of Gastroenterology, St. Spiridon Emergency Clinical Hospital Iai (2) Department of Pathology, Prof. Dr. N. Oblu Emergency Clinical Hospital Iai

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(3) Department of Anatomy and Embriology, Gr.T. Popa University of Medicine and Pharmacy Iasi (4) Department of Pathology, St. Mary Emergency Clinical Hospital Iai (5) Institute of Gastroenterology Iai TRANSFERUL LIBER DE MARE EPIPLOON SOLUIE TERAPEUTIC N CHIRURGIA DEFECTELOR DE PRI MOI.........................................165 Camelia Tama (1), S. Shaukat (1), C. Moroanu (2), Dana Turliuc (3), L. Popa (1), R. Ni (1), Cristina Stnescu (1), P. Srbu (4), Snziana Volocaru (1) Universitatea de Medicin i Farmacie Gr.T. Popa Iai (1) Clinica de Chirurgie Plastic i Reconstructiv, Spitalul Clinic de Urgene Sf. Ioan Iai (2) Compartimentul de Chirurgie Vascular, Spitalul Clinic de Urgene Sf. Ioan, Iai (3) Clinica de Neurochirurgie, Spitalul Clinic Sf. Treime, Iai (4) Clinica de Ortopedie, Spitalul Clinic de Urgene Sf. Ioan, Iai CAZURI CLINICE SUPERIOR MESENTERIC ARTERY SYNDROME: AN UNUSUAL CAUSE OF DUODENAL OBSTRUCTION A CASE REPORT AND LITERATURE REVIEW..................................................................172 S.B. Saha, A. Mandal, D. Deoghuria Department of Surgery and Radiodiagnosis. Bankura Sammilani Medical College, Bankura, West Bengal, India INTESTINUL SUBIRE, POSIBILITATE RAR DE METASTAZ DIGESTIV, SECUNDAR NEOPLASMULUI OVARIAN................................................................................176 Maria-Gabriela Roca (1), D.C. Mariciuc (1), I. Radu (1), D. Ferariu (2), V. Scripcariu (1) (1) Clinica a III-a Chirurgie, Centrul de Cercetare n Chirurgie Oncologic i Training n Chirurgie General, Universitatea de Medicin i Farmacie Gr.T. Popa Iai (2) Laboratorul de anatomie patologica, Spitalul Sf. Spiridon Iai CERVICAL NECROTIZING FASCIITIS......................................................................................182 G. Dimofte (1), Gabriela Lozneanu (1), D Pieptu (2), R Moldovanu (1), M Danciu (3), E Trcoveanu (1) Gr.T. Popa University of Medicine and Pharmacy Iai, Romania (1) First Surgical Unit, St. Spiridon Hospital Iai (2) Department of Plastic Surgery, St. John Emergency Hospital Iai (3) Department of Pathology, St. Spiridon Hospital Iai HERNIA RETROSTERNALA (HERNIA MORGAGNI) LA COPIL - CONSIDERAII ASUPRA A 2 CAZURI.....................................................................................187 Dana Mndrescu, G. Aprodu, V. Munteanu Clinica de Chirurgie Pediatric Spitalul Clinic de Urgene pentru Copii Sf. Maria Iai ANATOMIE SI TEHNICI CHIRURGICALE TEHNICA PRELEVRII FICATULUI PENTRU TRANSPLANT.............................................192 C. Lupacu Clinica I Chirurgie, Spitalul Sf. Spiridon Iai Universitatea de Medicin i Farmacie Gr.T. Popa Iai PROTEZAREA VALVULAR AORTIC MINIM-INVAZIV................................................198 Ctlina Maria Moldovanu (1), O. tiru (2)

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(1) Clinica a III-a Medical Cardiologic G. Enescu, Universitatea de Medicin i Farmacie Gr.T. Popa Iai (2) Clinica de Chirurgie Cardiovascular, Institutul de Boli Cardiovasculare Prof. Dr. C.C. Iliescu, Bucureti Universitatea de Medicin i Farmacie Carol Davila Bucureti ARTICOLE MULTIMEDIA CAROTID ARTERY DISEASE........................................................................................................204 H. Van Damme Department of Vascular Surgery, University Hospital of Lige, Belgium ISTORIA CHIRURGIEI ISTORICUL CHIRURGIEI PARATIROIDELOR........................................................................216 E. Trcoveanu (1), A. Vasilescu (1), R. Van Hee (2) (1) Clinica I Chirurgie, Spitalul Sf. Spiridon Iai Universitatea de Medicin i Farmacie Gr.T. Popa Iai (2) University of Antwerp, European Academy of Surgical Sciences (EAcSS) ACADEMICIANUL GHEORGHE GHIDIRIM LA 70 ANI.........................................................220 RECENZII I NOUTI TRATAT DE CHIRURGIE, VOL. VIII..........................................................................................223 Irinel Popescu (sub redacia) Editura Academiei Romne, Bucureti 2008, ISBN 978-973-27-1679-3 AL XI-LEA SIMPOZION AL SECIUNII ROMNE A IASGO................................................225 TERAPIA ONCOLOGIC. OPIUNI BAZATE PE DOVEZI....................................................228 Lucian Miron (sub redacia) Ed. Institutul European Iai, 2008, ISBN 978-973-611-538-7 OSTEOASINTEZA MINIM INVAZIV CU PLCI - FIXATOARE INTERNE......................230 Paul-Dan Srbu Casa de Editur Venus, 2008

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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 i al redaciei. Copyright Jurnalul de chirurgie, Iai, 2005-2009

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REZIDENIATUL N CHIRURGIE - PROBLEME NOI, SOLUII VECHI. DECALOGUL PREGTIRII REZIDENILOR.


E. Trcoveanu, R. Moldovanu Clinica I Chirurgie I. Tnsescu Vl. Buureanu Centrul de Cercetare n Chirurgia Clasic i Laparoscopic Universitatea de Medicin i Farmacie Gr.T. Popa Iai
RESIDENCY IN SURGERY NEW PROBLEMS, OLD SOLUTIONS. THE DECALOGUE OF RESIDENTS SURGICAL TRAINING (Abstract): The training in general surgery rapidly evolved, especially due to the possibilities offered by new technologies. This training should include several successive stages of training that will allow future surgeon to specify a diagnosis, establish an operative indication, to choose and carry out an appropriate surgical technique. The main objectives of preparing residents for general surgery are: acquisition of knowledge of surgical pathology to successful make a diagnosis; the acquisition of therapeutic algorithms to establish a surgical indication or medical treatment; acquisition of theoretical knowledge and practical skills to perform the chosen operative technique; to provide appropriate postoperative care, to recognize any postoperative complications and to resolve in a timely and appropriate manner. So, the training in general surgery has to provide basic skills behavior, rule based behavior and knowledge based behavior. KEY WORDS: SURGICAL TRAINING, MINIMALLY INVASIVE SURGERY, SIMULATORS, SURGICAL RESIDENCY Coresponden: Prof. Dr. Eugen Trcoveanu, Clinica I Chirurgie, Spitalul Clinic Sf. Spiridon Iai, Bd. Independenei, nr. 1, Iai, 700111; e-mail: etarco@iasi.mednet.ro

Pregtirea rezidenilor n chirurgia general a cunoscut o evoluie rapid legat, pe de o parte, de modificrile procesului educaional cerute de rezideni i adoptate cu uurin de profesori, i pe de alt parte, de posibilitile oferite de noile tehnologii informaionale. Astfel, procesul de pregtire al rezidenilor a evoluat de la concepia Halstedian, n care tnrul chirurg nva operaiile de la maetrii chirurgiei n amfiteatre, vznd doar gesturile chirurgicale, la programe de training speciale, care sunt difereniate n funcie de tipul de intervenie care trebuie nvat [1]. Aceast pregtire trebuie s includ, spre deosebire de alte specialiti medicale, mai multe etape succesive de formare, care vor permite viitorului chirurg s precizeze un diagnostic, s stabileasc o indicaie operatorie, s aleag i s efectueze un gest chirurgical adecvat. Deci, obiectivele majore ale pregtirii rezidenilor de chirurgie general, care pot s le asigure competene finale, sunt: - dobndirea unor cunotine solide de patologie chirurgical pentru a formula un diagnostic; - nsuirea unor algoritmuri terapeutice prin care s stabileasc o indicaie chirurgical sau un tratament medical; - alegerea unei tehnici chirurgicale potrivite dintr-un arsenal terapeutic variat; - s realizeze, n condiii sigure pentru pacient, tehnica operatorie aleas; - s asigure ngrijiri postoperatorii pertinente, s recunoasc eventuale complicaii postoperatorii, pe care s le rezolve n timp util i n mod adecvat [2].

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inta programului de pregtire a rezidenilor n chirurgie este de a produce competene profesionale, de a evalua cunotinele teoretice i de a crea abiliti practice. Chirurgii se confrunt cu creterea presiunii dinuntrul i dinafara sistemului pentru a clarifica nivelurile de competen n practica medical. Pentru a obine competene se poate apela la orice mijloc de pregtire, dup definirea curriculei de pregtire din specialitile chirurgicale [3]. Educaia preuniversitar i universitar este primordial deoarece dezvolt o cultur fundamental care permite chirurgului s evolueze. Vocaia, despre care nimeni nu mai vorbete, este esenial. Pentru a deveni un bun chirurg, ca i pentru a deveni un bun violonist, trebuie s-i plac ceea ce faci. Pentru a ajunge un bun chirurg trebuie s te antrenezi zilnic, trebuie s fii inteligent, muncitor, rezistent la stres, s ai manualitate. Aceast profesie nobil necesit un veritabil act de credin, impune anumite sacrificii, pe care trebuie s le accepi de la nceput i cere o structur uman particular. Vocaia, ca i n trecut, trebuie ndrumat de maetri nzestrai cu har pedagogic care trebuie s insufle juniorilor dragostea i devotamentul pentru profesie [4]. Problemele cu care se confrunt n prezent nvmnul medical universitar i postuniversitar sunt: - pregtire de cultur general insuficient n liceu, cu interes sczut pentru medicin; - pregtire medical general insuficient n facultate, cu interes sczut pentru chirurgie; - examen de admitere la rezideniat care selecteaz candidai fr aptitudini, fr vocaie, fr interes pentru specialitate; - pregtire n rezideniat formal, cu numr prea mare de rezideni, unii ajuni n sistem prin echivalri necompetiionale i, pe de alt parte, formatori neimplicai; - absena motivaiei din cauza posturilor neatractive la terminarea pregtirii. n final, dup eforturi de formare costisitoare, tnrul specialist pleac din ar pentru a-i oferi competena n diverse spitale din Uniunea European. S-a ajuns, astfel, ca n unele spitale europene s se formeze comuniti de medici romni. Orientarea spre medicin trebuie s se fac nc din anii de liceu, n care trebuie s se asigure o pregtire general solid, i, mai ales, s se stimuleze aptitudinea de a nva continuu, de a se upgrada. Interesul pentru medicin a sczut semnificativ deoarece facultatea a rmas printre puinele la care se mai d examen de admitere, se nva mult, practic toat viaa, este o profesie neapreciat i nerespectat de oficialiti, mass-media i unii pacieni, este pltit execrabil. n facultate a sczut gradul de pregtire medico-chirurgical prin reducerea numrului de ore sptmnal, att teoretice, ct i practice, mai ales la chirurgie. Chirurgia ofer nc mari posibiliti de atragere a studenilor. n facultate trebuie s se caute studenii care au aptitudini i vocaie pentru chirurgie prin organizarea de cercuri tiinifice atrgtoare, cursuri opionale care s le suscite interesul i s le completeze pregtirea, dezvoltarea abilitilor practice prin workshopuri, sprijinirea Societii Studeneti de Chirurgie din Romnia i chiar nceperea pregtirii pentru examenul de rezideniat folosindu-se la examenele de an i de licen aceeai tematic i aceeai bibliografie. Admiterea n rezideniat se face prin examen naional, care este, de fapt, cel mai greu din cariera medical. Sistemul de ntrebri cu rspunsuri multiple selecteaz

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indivizi care pot nva automat rspunsurile, care ajung rezideni n chirurgie fr a avea cunotine temeinice de anatomie i patologie chirurgical. Numrul rezidenilor de chirurgie general se micoreaz n ultimii ani, ca i n Europa occidental, chirurgia nemaifiind n topul preferinelor celor care au fost admii la examenul de rezideniat. Dificultile actuale ale funciei de rezident de chirurgie general, adugate perspectivelor unei carene de locuri de munc i, mai ales, veniturile inferioare fa de chirurgii de alte specialiti i determin, cu siguran, pe viitorii notri rezideni s priveasc spre alte specialiti chirurgicale mai puin grele i mai bine pltite. La acestea se adaug feminizarea profesiunii, cu responsabiliti parentale mai precoce, posibilitatea introducerii repausului compensatoriu dup grzi, cu reducerea timpului de lucru [5]. Rolul rezidenilor n cadrul acordrii de ngrijiri medicale n serviciile chirurgicale este preios, fie c este vorba de vizit, prescripii medicale, de activitatea de salon, de bloc operator sau de gard. Surplusul de munc al chirurgilor seniori le reduce disponibilitatea pentru formarea rezidenilor, pe care i consider, n mod nedrept, ca mai puin motivai. ntoarcerea la atracia acestei frumoase specialiti se va baza, probabil, pe apariia a numeroase oportuniti profesionale, att n sectorul public, ct i n cel privat, determinate de posturile rmase vacante. Formarea rezidenilor de chirurgie general necesit un echilibru ntre nvmntul teoretic formal, nvarea practic prin colaborare n echipa chirurgical i delegarea responsabilitii. Aceste trei aspecte ale formrii lor reprezint programe uniforme de pregtire chirurgical i corespund funciilor lor de ngrijire i prezenei lor medicale, indispensabile bunei funcionri a serviciilor de chirurgie [6]. n prezent, programele de pregtire a rezidenilor trebuie s asigure pentru chirurg nsuirea a diferite cunotine teoretice i manevre practice, care s asigure [1]: 1) comportamentul bazat pe calificri de baz (skill based behavior) nsuirea gesturilor chirurgicale de baz, cunoatere instrumentarului, a normelor de asepsie i antisepsie, coordonarea micrilor, recunoaterea reperelor anatomice etc.; 2) comportamentul bazat pe reguli (ruled based behavior) nvarea timpilor operatori, executarea diferitelor intervenii, probleme de indicaie chirurgical. 3) comportamentul bazat pe cunoatere (knowledge based behavior) nsuirea de cunotine i abiliti practice care s permit rezolvarea unor situaii critice, a unor incidente / accidente intraoperatorii, a unor probleme complexe de tactic chirurgical. Acest ultim nivel de cunoatere este permanent perfectibil i trebuie actualizat n funcie de datele din literatur, precum i de noile achiziii tehnologice. Organizarea acestor programe de pregtire chirurgical ar trebui s survin n cadrul unor proiecte naionale, controlate de Societatea de Chirurgie i Centrul Naional de Perfecionare, cu etape unanim acceptate de toate centrele universitare, integrate n programul de pregtire i evaluare a competenelor din comunitatea european. Aceste programe pot asigura meninerea standardelor de excelen. 1. Invmntul teoretic al rezidenilor de chirurgie este reprezentat de cursurile din tematica Centrului Naional de Perfecionare, cursuri de patologie i tehnic chirurgical, prin prezentarea i discutarea cazurilor clinice ce se opereaz zilnic n edinele de staff, prin edine de referate tip Journals Club (reuniuni medicale update pentru discutarea unor subiecte n funcie de ultimele nouti din literatur).

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Primul obiectiv al acestui nvmnt teoretic este acumularea de cunotine. Este nevoie, n acest scop, s se ofere rezidenilor accesul la informatie i s li se elibereze timpul necesar acestei acumulri. Locul noilor tehnologii de formare este, n general, subutilizat, fie c este vorba de site-urile de pregtire de pe Internet, de accesul on-line la revistele tiinifice, de suportul video pentru nvarea tehnicii. Participarea la realizarea lucrrilor de cercetare clinic, de redactare medical sau de lectur critic a articolelor pentru revistele tiinifice este un complement important pregtirii rezidenilor [2,5]. 2. Invarea practic prin colaborare se realizeaz la patul bolnavului, n ambulator sau la blocul operator. ntocmirea foilor de observaie, vizita la patul bolnavului, prescrierea medicaiei, alegerea examenelor paraclinice, tratamentul postoperator, prevenirea complicaiilor tromboembolice i a infeciilor nosocomiale sunt elemente eseniale ale ngrijirilor n chirurgie, necesitnd un nvmnt riguros fondat pe protocoale de ngrijire, sub supravegherea unui medic primar. Un medic primar nu poate ndruma mai mult de trei rezideni. nvarea tehnicii chirurgicale se bazeaz, n principal, pe calitatea rezidentului de ajutor operator. Ideal ar fi ca un rezident s intre zilnic n sala de operaii, sau nu mai puin de trei ori pe sptmn, deoarece chirurgia se nva numai n blocul operator. Acest proces relativ ndelungat presupune rbdare att din partea seniorului, ct i a juniorului, trecerea de la observator la practicant de timpi operatori simpli, la realizarea de acte operatorii de complexitate crescut. Acest proces implic mari responsabiliti pentru ambii parteneri. Sunt unele circumstane care ne pun n situaia de a nu ajuta un rezident, fie c este vorba de complexitatea interveniei, de identitatea pacientului, de presiunea programului operator, de orarul ndrumtorului sau de vrsta seniorului. Realizarea de intervenii de ctre rezideni rmne un element esenial al pregtirii n chirurgie n situaii de chirurgie electiv sau, mai rar, n urgen. A vedea este bine, a face este i mai bine [5]. Simulatoarele de chirurgie laparoscopic permit un antrenament al gesturilor fr risc pentru pacieni [1,6]. Simulatoarele tip black box asigur nsuirea tehnicilor de baz, n timp ce pelvitrainer-ele de ultim generaie i simulatoarele de realitate virtual permit nsuirea tehnicilor chirurgicale i chiar rezolvarea unor situaii critice [1]. 3. Delegarea responsabilitii este o etap esenial a nvmntului n chirurgie, care vizeaz transmiterea autonomiei tehnice i lurii deciziei. Ea se obine gradat spre sfritul rezideniatului. Deprinderea de a delega cere un efort particular i o mare responsabilitate din partea ndrumtorului. Tentaia de a pstra monopolul deciziei medicale i al tehnicii chirurgicale este mare, cu riscul de a se vedea deposedat de dreptul de expertiza. Al doilea aspect l reprezint tendina de a delega, din comoditate, prea uor totalitatea activitilor chirurgicale rezidentului. Trebuie avut grij s se delege activiti tot mai complexe i s se lase loc de iniiativ i de decizie tinerilor colaboratori [5]. 4. Este necesar actualizarea curriculei de pregtire. Trunchiul comun al rezideniatului de chirurgie general impune efectuarea unui stagiu de anatomie chirurgical, chirurgie operatorie i chirurgie experimental [7]. S-a introdus un stagiu de etic, dar anatomia, care este esenial, a fost uitat [8]. Respectarea i efectuarea stagiilor la celelalte specialiti (ATI, chirurgie plastic, ortopedie, urologie, ginecologie, chirurgie toracic, neurochirurgie) este important. Asistm la formalizarea acestor stagii, din cauza lipsei de interes a instructorilor acestor specialiti, preocupai

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de pregtirea rezidenilor lor, fapt la fel de nociv ca i lipsa de pregtire a rezidenilor acestor specialiti n domeniul chirurgiei generale. Sunt n curricul intervenii care nu se mai practic precum vagotomiile, piloroplastiile; n schimb lipsesc, i ar trebui introduse, noiuni de chirurgie robotic, NOTES [9]. 5. Stagiile ar putea s beneficieze de o contractualizare a funciei rezidenilor din serviciu. Acest contract ar fi redactat i semnat de ctre eful de serviciu i rezidenii si. El ar defini obligaiile de serviciu, de acordare de ngrijiri, de grzi, de ajutor operator, de realizare a documentelor medicale, de codificare, de participare la activitatea de evaluare i de cercetare clinic. n schimb, eful de serviciu ar garanta existena unui birou al rezidenilor dotat cu un post informatic cu acces la internet, organizarea de edine de staff, reuniuni medicale, de cursuri, al unui minim (ca numr i ca tip) de intervenii care s fie realizate de ctre fiecare rezident supravegheat de un chirurg ndrumtor, de intervale sptmnale libere, fr constrngeri de serviciu, dedicate acumulrii de cunotine. In funcie de orientarea chirurgical a serviciului respectiv, realizarea unui contract de obiective pedagogice ar putea s conduc la validarea de module teoretice specifice fiecrui serviciu [5]. 6. O mai bun evaluare a stagiilor de chirurgie. Exist n prezent un caiet de rezident n care se noteaz fiecare examen de sfrit de stagiu i activitatea practic. Ar fi util evaluarea reciproc: a valorii stagiului de ctre rezident i a rezidentului de ctre eful serviciului [10]. Aceste evaluri ar trebui s fie centralizate i salvate ntr-un sistem informatic la nivelul facultilor n scopul de a obine un feed-back i o transparen a informaiilor ntre diferitele servicii. Ele ar avea avantajul de a furniza o informaie obiectiv util n special pentru atribuirea posturilor de rezideni diferitelor servicii chirurgicale. Ar fi foarte necesar ca dup primul an de stagiu la disciplina de baz, disciplina mam, s se dea un examen n care s se evalueze progresele rezidenilor, cel puin teoretice, abilitile practice pentru confirmarea progresului i trecerea la urmtoarea etap. Sunt situaii n care nu se nregistreaz un progres i nici perspective de viitor, moment n care rezidentul ar trebui reorientat spre practica medical ambulatorie sau un alt profil medical. 7. Dezvoltarea de noi metode pedagogice este foarte important. Utilizarea site-urilor de pregtire pe internet, accesul la revistele tiinifice online, utilizarea unei videoteci pentru nvarea unei tehnici chirurgicale, dezvoltarea sistemelor de ,,antrenament, a simulatoarelor pentru gesturile laparoscopice, sunt metode care permit lrgirea mijloacelor de formare a tinerilor chirurgi. Rezidenii trebuie s fie nscrii, cu sume modice, suportate de universitate sau firme, n societile tiinifice de profil, care s le asigure participarea gratuit la seminarii de pregtire, la congrese naionale i internaionale sau abonamentul la site-urile de pregtire online [11]. 8. Promovarea mobilitii. Chiar dac stagiile la un alt spital universitar sunt recomandate, puini rezideni solicit acest lucru. Armonizarea studiilor medicale la nivelul Europei fac posibil realizarea unui stagiu de chirurgie ntr-o ar din Uniunea European. Un astfel de proiect necesit convenii ntre faculti, care s se refere n mod special la schimburi de rezideni. Experiena noastr cu universitile din Belgia a demonstrat c acest lucru este fezabil i foarte benefic pentru tinerii chirurgi n formare. Acest tip de proiect pedagogic ar favoriza i colaborrile de cercetare clinic ntre echipele chirurgicale europene [12]. Este extrem de util ca n anii terminali rezidenii s se detaeze n spitale judeene acreditate de universitate, unde se vor integra efectiv, n special n programul operator.

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9. Protejarea funciei rezidentului din aceast specialitate. Delegarea responsabilitii este o etap esenial pentru dezvoltarea autonomiei tehnice chirurgicale i luarea deciziei. Totui, tendina actual este de a reduce prerogativele rezidenilor, sub pretexte de neles, cum ar fi calitatea ngrijirilor, creterea implicaiilor juridice n caz de complicaii i refuzul consecinelor medicale ale curbelor de nvare. Aceast evoluie aparent benefic pentru pacieni, se face n detrimentul formrii tinerilor chirurgi de mine, a cror pregtire tehnic ncepe din ce n ce mai trziu i poate fi incomplet. ndrumtorii universitari de chirurgie general trebuie s protejeze statutul de chirurg n formarea rezidenilor, permindu-le luarea de decizii i realizarea de gesturi operatorii simple. Ar fi necesar atribuirea responsabilitii medico-legale rezidentului, n funcie de nivelul de pregtire, fapt care ar responsabiliza rezidentul n luarea deciziilor i nsuirea cunotinelor. n schimb, comunitatea noastr trebuie s poat garanta o calitate a ncadrrii care s permit ca aceast delegare de responsabilitate s nu duc la un risc de complicaii suplimentare pentru bolnavi [5]. 10. Rezidentul de chirurgie trebuie s se implice n activitatea de cercetare a clinicii care l ajut n formarea sa. Este recomandat ca rezidentul de an mare s prezinte cazuri clinice la studeni, s comunice la o societate de chirurgie cel puin o lucrare tiinific i s publice un articol ca prim autor ntr-o revist de profil. n concluzie, crile, nvmntul socratic, simul de observaie clinic, munca n echip, accesul n laboratorul de anatomie, chirurgie experimental, simulatoare, participarea la edinele de staff, seri anatomoclinice interdisciplinare, congrese, simpozioane, rmn valori fundamentale ale pregtirii rezidenilor de chirurgie. Metodele noi nu exclud pregtirea clasic care a dat bune rezultate dea lungul anilor, ci completeaz i fac mai atractiv chirurgia general.
BIBLIOGRAFIE Dankelman J, Wentink M, Stassen HG. Human reliability and training in minimally invasive surgery. Minim Invas Allied Technol. 2003; 12: 1229-1235. 2. Becmeur F, Grandadam S, Kirch M, Mutter D. What education means in surgery? A surgery among surgical residents in University Hospital in Strasbourg. Ann Chir. 2004; 129(8): 405-409. 3. Trcoveanu E. Pregtirea chirurgical a rezidenilor. Jurnalul de chirurgie. 2005; 1 (1): 1-2. 4. Trcoveanu E. A fi chirurg n zilele noastre. Jurnalul de chirurgie. 2005; 1(3): 246-249. 5. Dousset B. Training of digestive surgeons: a necessary task. Ann Chir. 2004; 129(8): 395-398. 6. Pellen M, Horgan L, Roger Barton J, Attwood S. Laparoscopic surgical skills assessment: can simulators replace experts? World J Surg. 2009; 33(3): 440-447. 7. Manuel-Palazuelos JC, Alonso-Martn J, Rodrguez-Sanjuan JC, Fernndez Daz MJ, Gutirrez Cabezas JM, Revuelta-Alvarez S, Morales-Garca DJ, Gmez-Fleitas M. Surgical resident training program in minimally invasive surgery experimental laboratory (CENDOS). Cir Esp. 2009; 85(2): 84-91. 8. Standring S. New focus on anatomy for surgical trainees. ANZ J Surg. 2009; 79(3): 114-117. 9. Mukherjee M, Siu KC, Suh IH, Klutman A, Oleynikov D, Stergiou N. A virtual reality training program for improvement of robotic surgical skills. Stud Health Technol Inform. 2009; 142: 210214. 10. Mason V, Balloo S, Upton D, Heer K, Higton P, Shiralkar U. Surgeons' experience of learning psychological skills: a preliminary evaluation of a psychological skills training course. Ann R Coll Surg Engl. 2009 Apr 2. [Epub ahead of print] 11. Seymour NE. Integrating simulation into a busy residency program. Minim Invasive Ther Allied Technol. 2005; 14(4): 280-286. 12. Mendes da Costa P, Detry R, Meurisse M. Surgical training in Belgium. Results of a prospective study conducted in the french-speaking part of the country. Jurnalul de chirurgie. 2006; 2(2): 163-167. 1.

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CHIMIOTERAPIA INTRAPERITONEAL: MODELUL CANCERULUI OVARIAN


L. Miron, M. Marinca Clinica de Oncologie, Spitalul Clinic de Urgene Sf. Spiridon Iai Universitatea de Medicin i Farmacie Gr. T. Popa Iai
INTRAPERITONEAL CHEMOTHERAPY: THE EXAMPLE OF THE OVARIAN CANCER (Abstract): Intraperitoneal (IP) administration is an effective route for drug delivery, with a pharmacologic advantage that can be exploited for the treatment of ovarian cancer. There is now a growing body of clinical data demonstrating a survival advantage for patients with advanced stages of ovarian cancer treated by IP chemotherapy compared with the standard intravenous (IV) treatment route. While IP chemotherapy has been shown to determine an improvement in survival, many investigators argue that the formidable toxicity, complexity, and quality of life alterations associated with IP therapy make it mandatory that it should be compared prospectively to a less toxic and more convenient regimen, such as IV carboplatin/paclitaxel. The barriers to implementing this treatment into clinical practice appear to be toxicity concerns, and a lack of technical expertise with the peritoneal infusion devices. The role of IP chemotherapy in colo-rectal carcinoma is not well established. However, cytoreductive surgery and intraperitoneal hyperthermic chemotherapy may be of potential benefit in selected patients with locally disseminated disease. KEY WORDS: INTRAPERITONEAL CHEMOTHERAPY, EFFICACY, OVARIAN CANCER Coresponden: Conf. Dr. Lucian Miron, Clinica de Oncologie, Spitalul Sf. Spiridon Iai, Bd. Independenei nr. 1, 700111; e-mail: lucmir@gmail.com*

n ciuda faptului c oncologii au utilizat nc din anii 50 calea de administrare intraperitoneal (IP) a agenilor terapeutici, abia n 1978, Dedrick RL i colab. au prezentat, ntr-un articol de referin, un model teoretic de administrare IP a agenilor antineoplazici [1]. Ulterior, aceasta a evoluat de la stadiul de concept la cel de procedur pe care terapeuii o pot utiliza n practica clinic curent. Cavitatea peritoneal este drenat de limfatice n vena port. Din acest motiv, administrarea IP permite obinerea unor concentraii crescute ale chimioterapicelor n circulaia portal, fr necesitatea cateterizrii venei porte. De asemenea, chimioterapia intraperitoneal (CIP) n doze foarte mari (high-dose) administrat pe suprafaa peritoneal, crete citotoxicitatea local [2]. Spre deosebire de chimioterapia pe cale intravenoas (IV), CIP reprezint o modalitate de a obine concentraii crescute de substane citotoxice n contact direct cu seroasa peritoneal, ce posed un clearance sczut fa de circulaia sistemic. Substanele cu greutate molecular crescut i lipofilie sczut au un avantaj farmacologic [3]. Administrarea IP a chimioterapiei prezint avantaje comparativ cu cea IV: atinge concentraii locale crescute, care s penetreze n tumorile de volum redus, i depirea chimiorezistenei; timp de expunere prelungit a tumorii la aciunea agenilor, cu accelerarea aciunii anumitelor clase de
*

received date: 20.01.2009 accepted date: 25.03.2009

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citostatice; diminuarea toxicitii sistemice, permind (teoretic) o mai bun toleran la tratament [4]. CIP a nregistrat n ultimii ani succese n tratamentul cancerelor ovariene (CO). n aceast lucrare este detaliat modelul oferit actual de aceast neoplazie, urmat de altfel i n cancerele digestive [5]. Agentul ideal pentru administrarea IP ar trebuie s includ proprieti cum ar fi o activitate biologic crescut n cancerul respectiv pe modele preclinice, i atingerea unor concentraii crescute tumoricide sau expunere prelungit cu impact regional potenial mai crescut, favorabil comparativ cu administrarea sistemic. Datorit patternului de repartiie plasm-peritoneu, agenii cu greutate molecular crescut i fr lipofilie prezint caracteristici optime pentru aplicarea IP [6]. Spre deosebire de alte tumori solide, CO prezint o modalitate unic de diseminare. Dei boala metastazeaz i pe cale limfatic sau hematogen, calea principal de diseminare este n interiorul cavitii abdominale i/sau a pelvisului, pe calea seroasei peritoneale. Urmnd hidrodinamica lichidului peritoneal prin spaiile parieto-colice, celulele maligne ascensioneaz spre diafragm i apoi coboar n pelvis lsnd depozite tumorale n multiple sedii intraperitoneale [3]. Standardele actuale de tratament ale pacientelor cu CO epiteliale avansate constau n chirurgia cu efort citoreductiv maxim (ce presupune absena tumorilor restane macroscopic evidente) urmat de ase cicluri de chimioterapie cu citostaticele cisplatin (sau carboplatin) i paclitaxel. Totui, rezultatele sunt departe de a fi satisfctoare: timpul mediu pn la progresie este de 15-18 luni i supravieuirea median rmne mai redus de 3 ani [7,8]. Pentru acele paciente la care se obine un rspuns clinic dup chimioterapia sistemic de linia I, chimioterapia IP este potenial benefic, n special cnd tumora este limitat la cavitatea peritoneal [9]. Studiile ce au evaluat raportul concentraiilor peritoneale n diferite puncte ale peritoneului depesc cu mult concentraiile plasmatice (de ex. cisplatin 20:1, carboplatin 18:1, doxorubicin 400:1, paclitaxel 1.000:1) [10]. Au fost examinai numeroi ageni citostatici, n studii de faz I, n termenii siguranei i proprietilor farmacocinetice n administrarea IP. n cancerul ovarian este de remarcat c administrarea IP este satisfctoare n termenii profilului toxic local pentru unii ageni (de ex. cisplatin, carboplatin, paclitaxel), ns nu i pentru alii (mitoxantron, doxorubicin) [11]. n tumorile ovariene epiteliale avansate, CIP poate fi recomandat la paciente cu boal rezidual microscopic care nu au suferit rezecie de intestin (candidate ideale); studii recente demonstreaz c i cele cu tumori iniiale voluminoase, dar cu citoreducie optim, pot beneficia de acest tratament [12]. Pe baza datelor disponibile actual, regimul de chimioterapie de preferat n administrare IP este cisplatin (75-100 mg/m2) i taxani (paclitaxel) [6]. n cursul ultimilor 10 ani au devenit disponibile rezultatele a 7 studii randomizate care au evaluat administrarea chimioterapiei IP n prima linie de tratament a CO. A fost comparat administrarea chimioterapiei pe cale IV fa de cea combinat, IV i IP, dup chirurgia primar, la pacientele cu citoreducie optim [9]. n ciuda ratelor de rspuns (RR) crescute dup chimioterapia cu cisplatin, pacientele cu CO epiteliale prezint rspuns complet (RC), demonstrat prin interveniile tip second-look sau de interval negative, n 20-25% din cazuri. Numai un subgrup de paciente n stadiul III de boal, cu citoreducie chirurgical optim, pot obine rezultate

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mai favorabile: timp de progresie a bolii (progression free survival, PFS) de 19-21 de luni i supravieuire median de 49-57 de luni [5]. Definiia citoreduciei optime s-a schimbat n timp, de la nici un nodul > 2 cm la absena nodulilor tumorali > 1 cm [8,9]. Meta-analiza recent a 198 de studii (34.440 paciente) a demonstrat c cel mai bun regim cu administrare IP, n termenii ameliorrii supravieuirii, este o combinaie de sruri de platin i taxani; acest protocol poate ameliora riscul relativ de mortalitate n 55% din cazuri, comparativ cu monoterapia non-IP fr platin sau taxani. Comparativ cu monoterapia, asociaiile pe baz de derivai de platin, cu sau fr administrare IP, determin o reducere cu 40% a riscului relativ de deces, iar combinaiile de platin i taxani fr administrare IP determin o reducere cu 42% a acestui risc [11]. n trei studii prospective randomizate recente ntreprinse n CO n stadiul III, cu chirurgie optimal (GOG-114, GOG-158 i GOG-172), CIP a ameliorat supravieuirea comparativ cu tratamentul standard IV. n toate cele trei studii a fost administrat acelai regim de referin (control) cisplatin / paclitaxel IV care a determinat rezultate aproape identice n termenii supravieuirii generale mediane: 52, 50 i respectiv 49 luni (Tabel I) [13-15].
Tabelul I Rezultatele studiile de faz III [13-15] comparnd chimioterapia intraperitoneal cu cea intravenoas n cancerul ovarian avansat cu volum rezidual redus* Supravieuire fr progresie a bolii (median)
Cisplatin IP vs IV (toi pacienii au GOG-114 primit ciclofosfamid IV) Cisplatin IP vs IV (toi pacienii au GOG-158 primit paclitaxel IV) Cisplatin/paclitaxel IP vs cisplatin IV GOG-172 (toi pacienii au primit paclitaxel IV)

Supravieuire general (median) 49 vs 41 luni (p=0,002; HR=0,76) 63 vs 52 luni (p=0,05; HR=0,81)

28 vs 22 luni (p=0,01; HR=0,78)

23,8 vs 18,3 luni 65,5 vs 49,7 luni (p=0,05; HR=0,77) (p=0,03; HR=0,73) *IP, intraperitoneal; IV, intravenos; HR hazard ratio

Datele de supravieuire ale celui mai recent dintre acestea, GOG-172, au readus n actualitate indicaia CIP, prin rezultatele semnificativ mai bune, n ciuda toxicitii substaniale (71% dintre paciente au putut completa cele 6 cicluri ale protocolului de tratament). Supravieuirea fr boal (DFS) la 2 ani a fost de 66% (mediana de 33 luni); supravieuirea median depete 65 luni. Pacientele randomizate n braul experimental (cisplatin 100 mg/m2 IP n ziua 1, paclitaxel 60 mg/m2 n ziua 8) au prezentat efecte toxice (astenie, durere, efecte gastrointestinale, hematologice sau neurologice) semnificativ mai numeroase, cu scderea calitii vieii n primul an dup administrare [15]. Rezultatele acestui studiu au condus prompt la anunul formulat de National Cancer Institute (NCI) n ianuarie 2006: trebuie acordat atenie regimurilor de chimioterapie cu administrare IP cu cisplatin (100 mg/m2) i paclitaxel la pacientele cu cancere ovariene cu citoreducie optim [17,18]. Condiia necesar a rspunsului optim la CIP este obinerea unui volum rezidual tumoral postoperator sub 1 cm. Din acest motiv, cele mai bune rezultate se obin prin tratamentul de consolidare la pacientele ce au obinut un rspuns patologic complet la protocoalele cu cisplatin n linia I. n absena unei chirurgii de citoreducie optim

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(tumori reziduale peste 1 cm), supravieuirea median este de 59,4 luni la pacientele tratate cu carboplatin / paclitaxel IP, comparativ cu 55,4 luni la cele tratate cu cisplatin / paclitaxel IV [19]. Actual, se consider c i CIP se asociaz cu o reducere cu 21,6% a riscului de deces, iar pentru categoria de paciente cu citoreducie optim chirurgical beneficiul nseamn un ctig n supravieuirea median de circa 12 luni [20]. n ciuda acestor date, utilizarea CIP n cancerul ovarian nu este adoptat universal, exceptnd centrele i terapeuii cu experien n practicarea acestei strategii. Obieciile raportate includ: a) toxicitatea la cisplatin; b) complicaiile asociate accesului peritoneal i c) procedura laborioas, timpul lung, efortul i antrenamentul necesar personalului n programul de tratament [21]. Iniial, n CIP se utilizau cateterele de dializ Tenckhoff, care prezint dou probleme majore. Prima, fenestraiile cateterului tind s formeze teci de fibrin, ceea ce conduce la aderene n cavitatea peritoneal; a doua, prezena unei cuff-ului din dacron, care poate migra n peritoneu i determina ocluzie intestinal. n prezent, majoritatea practicienilor recomand, pentru administrarea CIP, utilizarea unui sistem de acces venos subcutan tip port securizat prin suturi neresorbabile la fascia peretelui abdominal, conectat la un cateter monolumen de poliuretan de calibru 9,6 [22]. Tehnica de administrare presupune inseria cateterului IP, care se face cu ocazia laparotomiei sau citoreduciei primare i dureaz ntre 15 i 30 de minute, implicnd tipic urmtorii pai: incizie transversal separat efectuat la distana de 2-3 degete sub rebordul costal stng, inferior de marginea costal, pe linia medioclavicular; crearea unui buzunar subcutan pentru a introduce camera port implantabil; suturarea camerei port de fascie, la patru coluri, utiliznd fir 2-0 de nailon / poliprolen; tunelizarea cateterului deasupra fasciei pe o distan de 10 cm de la camera port; se practic o deschidere redus n peritoneu, la un punct situat la 6 cm lateral de ombilic; clamparea captului proximal al cateterului i introducerea acestuia n cavitatea peritoneal, prin tunelul subcutanat spre port; conectarea cateterului la sistemul port i introducerea n cavitatea peritoneal (aproximativ 10 cm); verificarea permeabilitii cateterului cu un jet de ser fiziologic heparinizat; nchiderea inciziei transversale [4]. Administrarea CIP poate fi amnat pn la 24h. Unii terapeui au comunicat o reducere a ratelor complicaiilor de la 17% la 10% prin amnarea implantrii cateterului cu ocazia rezeciei intestinale la momentul citoreduciei primare. S-a constatat c rezecia de sigmoid sau recto-sigmoid, dar nu i alte tipuri de rezecie intestinal sau colostomii practicate cu ocazia citoreduciei primare, se asociaz cu un risc crescut de eec al CIP [23]. Sistemul port se spal cu 10 mL heparin de 100U/cm3. Citostaticul(ele) este(sunt) n general mixat(e) n 1000 mL ser fiziologic (NaCl 0,9%) nclzit la 37C i perfuzat(e) ct mai rapid n sistemul port; se perfuzeaz nc 1 L ser fiziologic pentru a asigura distribuia larg n cavitatea peritoneal, dac nu survine durerea abdominal. Se va avea n vedere prehidratarea IV cu 1 L ser fiziologic i meninerea diurezei la 100 mL/h naintea administrrii de cisplatin IP [24]. Studiile actuale au preconizat 6 cicluri de chimioterapie IP, dar numai 42% din pacieni au putut completa acest program. Chimioterapia IP este ntrerupt prematur datorit a trei motive principale: 1) problemele legate de cateterul intraperitoneal; 2) durerea abdominal asociat infuziei i, 3) intolerana la dozele mari de cisplatin (100 mg/m2) [11].

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Complicaiile CIP survin mai frecvent n mini neexperimentate, motiv pentru care aceast modalitate terapeutic rmne rezervat echipelor pluridisciplinare antrenate. Administrarea IP este asociat cu o toxicitate mai mare dect administrarea IV: mielosupresie (leucopenie < 1000 GA/mm3), infecii, greuri, vrsturi, neuropatie, disconfort sau durere abdominal (frecvent), tulburri metabolice. Trebuie avut n vedere riscul de peritonit chimic (greuri, vrsturi, diaree, febr, leucocitoz), fistule, iritaie a tractusului gastro-intestinal sau chiar perforaie intestinal (2,3%, n asociere cu administrarea IP de paclitaxel), i aceste complicaii trebuie tratate prompt. Complicaiile legate de cateter apar la 1 din 5 paciente, incluznd probleme legate de sistemul port, obstrucia cateterului, infecii ale esutului subcutanat. Notificarea NCI precizeaz: pacienii cu chimioterapie intraperitoneal sunt mult mai susceptibili s prezinte infecii, febr, durere abdominal, greuri, vrsturi i creterea toxicitii neurologice. Toxicitatea terapiei nu a permis NCI s specifice un anumit regim pentru CIP [22]. Au fost sugerate o serie de posibile modificri ale regimului de CIP comparativ cu cel utilizat n studiile clinice randomizate menionate, cu scopul de reduce efectele secundare asociate tratamentului. Acestea includ: a) reducerea dozei de cisplatin IP de la 100 mg/m2 la 75 mg/m2; b) nlocuirea cisplatin IP cu carboplatin la unii pacieni (sau chiar la toi!); i c) administrarea unui numr limitat de cicluri de CIP (de ex. 3-4 fa de cele 6 planificate n studiile clinice menionate) [24]. Teoretic, ar exista mai multe ci de ameliorare a rezultatelor terapeutice n CO, n afara CIP: testarea de noi ageni citostatici sau de noi terapii biologice, terapii cu intensitatea dozei crescut, ritmarea interveniilor chirurgicale alternativ cu terapiile citostatice (cu taxani), terapii de meninere i consolidare i aplicarea de variate scheme i doze de ageni. Alte cancere, precum cele digestive, ar prezenta, teoretic indicaiile de administrare a CIP. Neoplaziile asociate frecvent cu carcinomatoza peritoneal sunt: apendiculare, colo-rectale, gastrice, mezoteliomul peritoneal i boala metastatic primar peritoneal (cu punct de plecare neprecizat). Aproximativ 10-30% din pacienii care au cancere gastro-intestinale pot dezvolta boal metastatic peritoneal (carcinomatoz peritoneal) la momentul diagnosticului, iar aceasta poate mbrca aspecte diferite, de la o evoluie lent la una foarte agresiv, n funcie de tipul histologic i gradul de difereniere tumoral. Pacienii cu carcinomatoz peritoneal netratat prezint o supravieuire median de circa 6 luni. Mijloacele terapeutice actuale disponibile sunt: chirurgia citoreductiv, chimioterapia intraperitoneal, radioterapia, fototerapia i terapiile cu dioxid de carbon. Tratamentele oncologice sistemice au cunoscut progrese remarcabile n carcinoamele colo-rectale n ultimele dou decade, rolul chimioterapiei IV fiind bine stabilit n aceste tumori. Chirurgia citoreductiv i CIP hipertermic ar putea fi, de asemenea, potenial benefice la anumii pacieni selectai cu boal diseminat local; unii ageni citostatici (cisplatin, mitomicin C, oxaliplatin) pot fi propui i pentru administrare IP. Totui, CIP prezint i limite n aplicarea n cancerele digestive prin indisponibilitatea unor ageni terapeutici eficace n administrarea IP, printr-un impact limitat / absent asupra metastazelor hepatice, retroperitoneale sau mezenterice, monoterapie vs. polichimioterapie, toxicitate, complexitate i acceptabilitatea terapiei. Este de subliniat rolul decisiv al chirurgii de citoreducie n cancerele digestive, scopul acesteia fiind a nltura toate masele tumorale, necesitnd rezecia organelor

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afectate i a peritoneului. Statusul de rezecie este judecat dup completarea citoreduciei chirurgicale. A fost propus un index de citoreducie tumoral, efectuat pe 13 cadrane abdominale ipotetice: fiecare cadran primete un scor de la 0 la 3, unde 0 este considerat fr boal rezidual, 1 tumori < 0,5 cm, 2 tumori cu dimensiuni ntre 0,5-5 cm i 3 tumori peste 5 cm. Ideal, citoreducia este considerat optimal dac cel mai mare reziduu tumoral restant are < 2,5 mm n diametrul maxim. Dei asocierea CIP n regim hipertermic pare s determine unele rezultate la anumite categorii de pacieni cu cancere digestive, este de remarcat absena studiilor prospective randomizate la pacienii numai cu carcinomatoz peritoneal. CIP nu poate fi propus ca un standard actual de tratament n cancerele digestive [25,26]. CONCLUZII Administrarea CIP n cancerul ovarian reprezint o modalitate terapeutic promitoare, dei accesibil numai n centrele cu experien n practicarea acestei metode. Regimurile IP utilizate actual nu reprezint cu siguran ultimul pas, lund n considerare toxicitile observate. Este evident c n practica zilnic CIP nu poate fi admis de rutin. n cancerele digestive cu metastazare intraperitoneal, CIP singur / asociat hipertermiei, dei potenial benefic la o subcategorie de pacieni, rmne n curs de studiu. Obstacolele n calea implementrii acestui tratament n practica clinic rmn toxicitatea crescut i absena expertizei tehnice n manevrarea cateterelor intraperitoneale. Sunt necesare noi modaliti de ameliorare a profilului toxic, cum ar fi utilizarea a diferite tipuri de catetere, momentul optim de plasare a cateterului, durata chimioterapiei i utilizarea altor ageni. Este necesar a se studia dac un numr mai redus de administrri de IP prezint aceeai eficacitate. De asemenea, este de ateptat ca noii ageni biologici, cum ar fi bevacizumab, s prezinte beneficii superioare i o toxicitate mai redus la pacientele cu CO n stadiu III cu citoreducie optimal comparativ cu cele cu boal mai extins.
1. 2. 3. 4. BIBLIOGRAFIE Dedrick RL, Myers CE, Bunga PM, et al. Pharmacokinetic rationale for peritoneal drug administration in the treatment of ovarian cancer. Cancer Treat Rep. 1978; 62: 1-9. Bergman F. Carcinoma of ovary: A clinico-pathological study of 86 autopsied cases with special reference to mode of spread. Acta Obstet Gynecol Scand. 1966; 45: 211-231. Markman M. Intraperitoneal chemotherapy in the management of ovarian cancer: rationale and results. In Abstract book of 20th International Congress on Anticancer Treatment. Paris, February 3-6, 2009: 140-142. Cannistra SA, Gershenson DM, Recht A. Ovarian cancer, fallopian tube carcinoma, and peritoneal carcinoma. In: DeVita VT Jr, Lawrence TS, Rosenberg SA, DePinho RA, Weinberg RA, editors. DeVita, Hellman, and Rosenbergs Cancer-principles and practice of oncology. 8-th edition, Philadelphia: Wolter Kluwer / Lippincott Williams & Wilkins; 2008. p. 15681594. du Bois A, Quinn M, Thigpen T, Vermorken J, Avall-Lundqvist E, Bookman M, Bowtell D, Brady M, Casado A, Cervantes A, Eisenhauer E, Friedlaender M, Fujiwara K, Grenman S, Guastalla JP, Harper P, Hogberg T, Kaye S, Kitchener H, Kristensen G, Mannel R, Meier W, Miller B, Neijt JP, Oza A, Ozols R, Parmar M, Pecorelli S, Pfisterer J, Poveda A, Provencher D, Pujade-Lauraine E, Randall M, Rochon J, Rustin G, Sagae S, Stehman F, Stuart G, Trimble E, Vasey P, Vergote I, Verheijen R, Wagner U; Gynecologic Cancer Intergroup; AGOOVAR; ANZGOG; EORTC; GEICO; GINECO; GOG; JGOG; MRC/NCRI; NCIC-CTG; NCI-US; NSGO; RTOG; SGCTG; IGCS; Organizational team of the two prior International OCCC. 2004 Consensus statement on the management of ovarian cancer: final document of

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the 3rd International Gynecologic Cancer Intergroup Ovarian Cancer Consensus Conference (GICG 2004). Ann Oncol. 2005; 16 (suppl.8): vii7-vii12. Ozols RF, Bundy BN, Greier BE et al. Paclitaxel and carboplatin compared to paclitaxel and cisplatin in patients with optimally resected stage III ovarian cancer: a Gynecologic Oncology Group study. J Clin Oncol. 2003; 21: 3194-3200. DuBois A, Harter P. The role of surgery in advanced and recurrent ovarian cancer. Ann Oncol. 2006; 17 (suppl.10): x235-x240. Covens AL. A critique of surgical cytoreduction in advanced ovarian cancer. Gynecol Oncol. 2000; 78: 269-274. Bookman MA, Greer BE, Ozols RF. Optimal therapy of advanced ovarian cancer: carboplatin and paclitaxel versus cisplatin and paclitaxel (GOG 158) and an update on GOG182 - ICON5. Int J Gynecol Cancer. 2003; 13 (suppl.2): 149-155. Vermorken JB. The role of intraperitoneal chemotherapy in epithelial ovarian cancer. Int J Gynecol Cancer. 2000; 10 (suppl 1): 26-32. Armstrong DK. Role of intraperitoneal therapy in the management of ovarian cancer - an overview. In: Perry MC, editor. American Society of Clinical Oncology Educational Book. Alexandria: American Society of Clinical Oncology; 2006. p. 314-315. Alberts DS, Liu PY, Hannigan EV, O'Toole R, Williams SD, Young JA, Franklin EW, ClarkePearson DL, Malviya VK, DuBeshter B. Intraperitoneal cisplatin plus intravenous cyclophosphamide for stage III ovarian cancer. N Engl J Med. 1996; 335(26): 1950-1955. Markman M, Bundy BN, Alberts DS, Fowler JM, Clark-Pearson DL, Carson LF, Wadler S, Sickel J. Phase III trial of standard-dose intravenous cisplatin plus paclitaxel versus moderately high dose carboplatin followed by intravenous paclitaxel and intraperitoneal cisplatin in small-volume stage III ovarian carcinoma: an intergroup study of the Gynecologic Oncology Group, and Eastern Cooperative Oncology Group. J Clin Oncol 2001; 19(4): 10011007. Armstrong DK, Bundy B, Wenzel L, Huang HQ, Baergen R, Lele S, Copeland LJ, Walker JL, Burger RA. Intraperitoneal cisplatin and paclitaxel in ovarian cancer. N Engl J Med. 2006; 354(1): 34-43. Markman M, Reichman B, Hakes T, Rubin S, Lewis JL Jr, Jones W, Barakat R, Curtin J, Almadrones L, Hoskins W. Evidence supporting the superiority of intraperitoneal cisplatin compared to intraperitoneal carboplatin for salvage therapy of small volume residual ovarian cancer. Gynecol Oncol. 1993; 50(1): 100-104. Bristow RE. Surgical Issues in intraperitoneal therapy. In: Perry MC, editor. American Society of Clinical Oncology Educational Book. Alexandria: American Society of Clinical Oncology; 2006. p. 320-323. Markman M, Walker JL. Intraperitoneal chemotherapy of ovarian cancer: a review, with a focus on practical aspects of treatment. J Clin Oncol. 2006; 24(6): 988-994. Markman M, Rowinsky E, Hakes T, Reichman B, Jones W, Lewis JL Jr, Rubin S, Curtin J, Barakat R, Phillips M. Phase I trial of intraperitoneal taxol: a Gynecologic Oncology Group study. J Clin Oncol. 1992; 10(9): 1485-1491. Krasner CN. New approaches for intraperitoneal therapy. In: Perry MC, editor. American Society of Clinical Oncology Educational Book. Alexandria: American Society of Clinical Oncology; 2006. p. 323-330. Gore M. Intraperitoneal chemotherapy in ovarian cancer remains experimental. J Clin Oncol. 2006; 24(18): 4528-4530. Ozols RF. The pros and cons on intraperitoneal therapy in ovarian cancer. In: Abstract book of The 18th International Congress on Anti-Cancer Treatment, Paris: 2007. p. 63-67. McGuire WP. Randomized trials of intraperitoneal therapy: what they reveal and what they do not. In: Perry MC, editor. American Society of Clinical Oncology Educational Book. Alexandria: American Society of Clinical Oncology; 2006. p. 315- 320. Ozols RF. Intraperitoneal chemotherapy with cisplatin in ovarian cancer: comparison with standard intravenous carboplatin and paclitaxel. Gynecol Oncol. 2006; 106; 1-6. Rao G, Crispens M, Rothenberg ML. Intraperitoneal chemotherapy for ovarian cancer: overview and perspectives. J Clin Oncol. 2007; 25(20): 2867-2872. Aebi S, Castiglioni M. Epithelial ovarian carcinoma: ESMO Clinical recommendations for diagnosis, treatment and follow-up. Ann Oncol. 2008; 19(suppl.2): i14-i16.

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Levine EA, Ronnett B, Mansfield PF, Eng C. Overview of cytoreductive surgery and intraperitoneal hypertermic chemotherapy for peritoneal dissemination of appendiceal and colorectal neoplasms. In: Govindan R, editor. American Society of Clinical Oncology Educational Book. Alexandria: American Society of Clinical Oncology; 2008. p. 153-159.

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DIAGNOSTICUL PANCREATITEI ACUTE BILIARE


Elena Gologan1, A. N. Pantazescu2, Gh. Blan1 1 Institutul de Gastroenterologie i Hepatologie, Iai Universitatea de Medicin i Farmacie Gr.T. Popa Iai 2 Clinica Chirurgical, Spitalul de Urgene Sf. Ioan, Iai
THE DIAGNOSIS OF ACUTE GALLSTONE PANCREATITIS (Abstract): Acute gallstone pancreatitis is a severe form of pancreatitis caused by an ampullary blocked gallstone. The clinical course combines elements of severe pancreatitis and obstructive jaundice with angiocolitis. Complications are very frequent in the absence of spontaneous, interventional or surgical desobstruction. The diagnosis is based upon clinical features, biochemical paramethers with cholestasis, hyperamilasemia, hyperamilasuria, hyperlipasemia, metabolic disorders. Imagistic assay is undoubtful necessary for the diagnosis; it allows identifying most of the complications, and some of these investigations are very useful in the desobstruction procedures, done at proper moment. KEY WORDS: GALLSTONE PANCREATITIS, ULTRASOUND, COMPUTED TOMOGRAPHY, ENDOSCOPIC RETROGRADE CHOLANGIO-PANCREATOGRAPHY Coresponden: Dr. Elena Gologan, Institutul de Gastroenterologie str. Independenei, nr.1, 700111; e-mail: elenagologan2007@yahoo.com* i Hepatologie, Iai,

INTRODUCERE Dei prima colecistectomie pentru litiaza vezicular i prima intervenie pentru litiaza de ci biliare au fost efectuate n secolul al XIX-lea, primele corelaii ntre litiaza biliar i pancreatita acut au fost realizate de ctre Fitz n anul 1889 i Opie n anul 1901 [1]. Ulterior, dezvoltarea rapid a metodelor de investigaie radiologic cu contrast a cilor biliare, respectiv colangio-colecistografia intravenoas, colangiografia intraoperatorie, colangiografia percutan transhepatic (PTC), colangio-pancreatografia retrograd endoscopic (ERCP) i a metodelor de explorare cu ultrasunete prin abord transabdominal (US), intraoperator (IOUS), endoscopic (EUS) sau intraductal (IDUS), precum i a metodelor de explorare imagistic cu radioizotopi sau a celor prin rezonan magnetic (MRCP) a revoluionat paleta metodelor diagnostice n patologia biliopancreatic [2]. Mai mult, apariia coledocoscopiei, iniial rigide i ulterior flexibile, a sfincterotomiei endoscopice i tehnicilor derivate de tratament intervenional precum i apariia chirurgiei laparoscopice au constituit pai nainte n ncadrarea i rezolvarea pancreatitelor biliare [3]. ETIOLOGIE Definit ca un sindrom clinico-biologic secundar unui proces inflamator acut al parenchimului pancreatic, uneori i cu extensie extrapancreatic, pancreatita acut recunoate multiple cauze care trebuie ct mai bine definite, deoarece terapia se dorete a fi modulat etiologic.
received date: 12.01.2009 accepted date: 27.02.2009
*

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De departe cele mai frecvente cauze de pancreatite acute (PA) sunt alcoolul i litiaza biliar reprezentnd aproximativ 80% dintre cauzele PA. Alte posibile cauze sunt: metabolice (dislipidemiile, hipercalcemia), infecioase (virale, bacteriene, parazitare), iatrogene (postintervenionale sau postchirurgicale), genetice, autoimune, neoplazice, toxice, traumatice, vasculare, sarcina, congenitale (fibroza chistic, pancreasul inelar, pancreasul divisum), ereditare etc. Totui, un procent de circa 10% dintre pancreatite, rmn fr o cauz definit, fiind ncadrate n final ca idiopatice. CLASIFICARE PA biliar este produs prin calculi veziculari propriu-zii migrai n calea biliar principal (CBP) litiaza secundar, sau formai n aceasta litiaza primar, sau microcalculi microcristale sau achene avnd o compoziie dominant de colesterol. O clasificare util din perspectiv clinic a PA este cea care recunoate dou forme clinico-evolutive: uoar evolueaz fr complicaii sau anomalii funcionale, cu recuperare bun; sever evolueaz cu complicaii loco-regionale i la distan, cu insuficien pancreatic i nu are tendin la remisie spontan; Raportat tipurilor anatomopatologie, PA recunosc dou forme: edematoas cu edem interstiial; necrotico-hemoragic cu necroze parenchimatoase, hemoragii i extensie extraglandular. INCIDEN Dac incidena global a PA este de 1-5 cazuri la 10.000 locuitori pe an, PA biliar reprezint 35-45% din totalitatea cazurilor de PA. Riscul relativ de PA la pacienii cu litiaz biliar este de pn la 35 de ori mai mare dect n populaia general, mai ales n situaia calculilor cu dimensiuni sub 5 mm [4]. Brbaii prezint un risc mai mare dect femeile [4]. Anomaliile de ci biliopancreatice (canal cistic larg, coledococel etc.) precum i asocierea cu anomalii ale metabolismului lipidelor se constituie de asemenea n factori de risc pentru PA biliar. n plus, la pacienii colecistectomizai pentru litiaz biliar vezicular riscul de PA este semnificativ mai sczut, ceea ce sugereaz c principalul mecanism de producere a PA biliare este migrarea de calculi din colecist i blocarea lor tranzitorie sau permanent la nivelul convergenei bilio-pancreatice [5]. Ceea ce este cert, este faptul c 1/5 pn la 3/4 dintre pacienii cu o PA prezint la adresare litiaz biliar vezicular [3]. Aceasta nu nseamn numaidect c etiologia pancreatitei este biliar. De multe ori n practica clinic se ntlnesc cauze mixte, cel mai frecvent asocierea litiazei biliare cu etilismul acut, care face mai dificil aprecierea statistic a repartiiei PA pe etiologii strict definite. FIZIOPATOLOGIE Factorul declanator al PA biliare este dat de blocarea calculului la nivel ampular, cel mai adesea fiind reprezentat de migrarea unuia sau mai multor calculi veziculari n cile biliare, dar uneori putnd fi incriminai i calculi provenii din cile biliare intra sau extrahepatice. Exist o serie de factori favorizani pentru acest proces: canal cistic larg, existena unui canal comun bilio-pancreatic, prezena unor diverticuli juxta sau peripapilari, odditele scleroase, hipertonia obstructiv a sfincterului Oddi etc.

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Secvena fiziopatologic a declanrii PA biliare presupune: obstrucia ampular, activarea intracanalar a enzimelor pancreatice, eliberarea de mediatori proinflamatori cu leziuni iniiale ductale i parenchimatoase, iar apoi, extracapsulare sau la distan edem interstiial, leziuni vasculare i ischemice. Se declaneaz un rspuns inflamator sistemic n cadrul cruia aciunea sistemic a enzimelor pancreatice eliberate sub form activ va declana o insuficien multiorganic. DIAGNOSTIC CLINIC Este cel mai adesea relevat de o durere extrem de intens abdominal, de etaj superior n bar, frecvent iradiat dorsal stng sau dorsal bilateral n centur. Uneori sediul iniial al durerii este localizat n hipocondrul drept. La unii pacieni se poate identifica un factor declanator evident ingestia de alimente colecistokinetice. Intensitatea durerii este extrem chiar n condiiile administrrii de medicaie antalgic. Alteori, durerea este att de intens nct pacientul poate avea senzaia de anxietate, de moarte iminent sau poate prezenta stare sincopal prin reacie vasomotorie. Caracterul durerii este progresiv pe termen scurt dup care se menine la intensitate mare, ore sau zile. Pacienii pot adopta o poziie antalgic de anteflexie (n scopul decomprimrii structurii pancreatice, situat retroperitoneal). Frecvent asociaz greuri i vrsturi care ns nu amelioreaz durerea. n formele severe pacienii pot prezenta de la nceput o stare general alterat cu dezechilibre majore hidroelectrolitice i metabolice, expresie a aciunii sistemice a enzimelor eliberate i avnd insuficiene multiorganice adesea cu final letal [6]. Uneori tabloul este de oc toxico-septic sau cardiorespirator sau fenomene de encefalopatie pancreatic, cu delir, halucinaii, confuzie. Sunt prezente adesea semne generale: frisoane, febr moderat sau mare, tahipnee, tahicardie sau bradicardie, oc hipovolemic sau numai hipotensiune. Se pot constata fenomene de ileus, cu oprirea tranzitului, iradierea difuz abdominal a durerii cu distensie extrem dureroas i vrsturi abundente ce dezechilibreaz rapid pacientul. Icterul sau subicterul poate fi mecanic, determinat prin obstrucie biliar, ca urmare unei litiaze coledociene sau secundar edemului pancreatic, coleciilor cefalice compresive pe coledoc sau ca urmare a unei insuficienei hepatice acute sau hepatopatii cronice asociate. Examenul clinic general i local relev: - la inspecia general: facies ce exprim durerea extrem de intens, transpiraii reci, extremiti palide, cianotice sau marmorate, icter sclero-tegumentar; - manifestri digestive: abdomen destins, gazos sau lichidian, uneori asimetric prin prezena fuzeelor sau coleciilor, echimoze ale peretelui abdominal secundare fuzrii enzimelor pancreatice cu autoliza necrotic a peretelui abdominal, cu localizare predominant n flancul stng (semnul Grey Turner) i periombilical (semnul Cullen) (Fig. 1). La palpare se poate constata sensibilitate pe topografia pancreasului sau difuz abdominal, formaiuni abdominale ce exprim colecii sau zone de necroz, hepatomegalie, splenomegalie. Alteori pacienii pot prezenta ascit n cantitate moderat. - manifestri pleuropulmonare: pleurezie (cel mai adesea stng) caracterizat prin coninut important de amilaze, sindroame de condensare de tip pneumonic sau bronhopneumonic, dispnee, tuse, hemoptizii, insuficien respiratorie;

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manifestri cardiovasculare: hipotensiune arterial (oc), tahicardie, pericardit, miocardit, insuficien cardiac; manifestri neuropsihice: confuzie, halucinaii, delir, obnubilare, meningoencefalit, hemoragii cerebrale, pareze, com; manifestri renale: hematurie, insuficien renal acut; manifestri osteoarticulare: artrite, osteonecroze.

A
Fig. 1 Echimoze ale peretelui abdominal secundare unor fuzee necrotice n cadrul unei pancreatite acute necrotico-hemoragice A. Echimoz n flanc semnul Grey Turner; B. Echimoz periombilical semnul Cullen

Formele clinice de pancreatit acut biliar sunt comune cu cele ale oricrui tip de pancreatit acut, indiferent de etiologie: 1. Forma uoar superpozabil anatomopatologic formei edematoase, cu evoluie clinic cel mai adesea bun sub tratament conservator medical; n cazul etiologiei biliare aceste forme corespund frecvent situaiilor de pasaj litiazic transpapilar spontan sau facilitat medicamentos; 2. Forma sever este definit de prezena insuficienelor de organ i a complicaiilor locale i generale, corespunznd cel mai frecvent formei anatomopatologice de pancreatit acut necrotico-hemoragic; n pancreatita acut de etiologie biliar aceasta apare la blocarea calculului la nivel ampular fr eliminarea spontan a acestuia. EXPLORRILE PARACLINICE Se pot grupa n dou categorii care sunt complementare: 1. Examene biochimice Hiperamilazemia are valoare chiar de la debutul afeciunii crescnd precoce; chiar dac se poate ntlni i n alte afeciuni (parotidite, litiaz salivar), o valoare mai mare de 3-5 ori limita normalului este puternic sugestiv pentru pancreatit acut. Revenirea acestora la normal poate fi rapid n 24 de ore pn la cteva zile n cazul unei evoluii favorabile sau se poate menine perioade lungi dac apar complicaii. Alteori, amilazele pot avea valori doar puin crescute sau chiar normale n condiiile unei stri foarte grave a pacientului, probabil datorit epuizrii structurale i enzimatice a pancreasului, aceast situaie fiind mai rar n cazul pancreatitelor acute biliare i mai frecvent n cazul celor de etiologie alcoolic. Amilazuria crete n urma amilazemiei i revenirea este mai tardiv, dar oricum, ambii parametri au o evoluie temporal rapid

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cel puin comparativ cu lipazemia. Raportul amilazurie / amilazemie peste 5, este nalt sugestiv pentru pancreatit. Valori iniial crescute ale amilazei serice i urinare vor fi decelate ca persistente doar la 10% dintre pacieni dup ziua a 5-a de evoluie a bolii. Amilaza, ca marker enzimatic n pancreatite este n general mult crescut n cele biliare comparativ cu cele de alte etiologii (toxic, etanolic) la aceleai leziuni distructive parenchimatoase [7]. n unele centre se poate determina chiar izoenzima P a amilazei care este de origine pancreatic. Alte situaii clinice n care putem asista la creteri ale nivelului seric i urinar al amilazelor pot fi sistematizate dup cum urmeaz: afeciuni ale glandelor salivare - parotidita i tumorile salivare, alte sindroame de abdomen acut chirurgical - ulcere perforate sau penetrante n pancreas, infarct enteromezenteric, ocluzii intestinale, sindroame limfoproliferative, macroamilazemie etc. Pentru diagnosticul i urmrirea pancreatitei se mai poate utiliza clearance-ul amilazelor raportat la cel al creatininei [8]. Lipaza seric este de asemenea crescut, fiind un marker fidel pentru pancreatita acut, deoarece creterile sunt mai prelungite comparativ cu amilaza [7,8]. n PA se pot determina i enzimele proteolitice (tripsin, chimotripsin) dar nu se utilizeaz nc n practica curent. Dintre acestea, de utilitate pare s fie nivelul tripsinogenului urinar avnd sensibilitate i specificitate mari [9]. Un alt parametru sangvin i urinar util, este peptidul activator al tripsinogenului (TAP) care crete precoce n PA i poate fi folosit ca predictor al severitii [9]. Sindromul inflamator nespecific include determinarea markerilor proinflamatori: proteina C reactiv, fibrinogenul, interleukina 6 dar i examinare hematologic ce identific o leucocitoz cu neutrofilie i uneori deviere la stnga a formulei leucocitare [9]. Un sindrom hepatocitolitic important este cel mai frecvent asociat PA biliare dect celor de alt etiologie i are o evoluie ondulant pe parcursul supravegherii biochimice a cazului [10]. Sindromul biochimic de colestaz relevat de creterea fosfatazei alcaline, a bilirubinei totale cu predominena celei directe, a colesterolului seric este apanajul mai ales a formelor biliare de PA n care aceti parametri cresc mult mai mult comparativ cu celelalte forme de pancreatit acut [10]. Este obligatorie i determinarea parametrilor de severitate ce exprim dezechilibre profunde hidro-electrolitice, metabolice i acidobazice: ionogram seric i urinar, rezerv alcalin, gazometrie sangvin, calcemie, glicemie, parametri de retenie azotat. n unele cazuri de dificultate diagnostic, dac pacientul prezint ascit sau pleurezie se vor efectua determinri biochimice i bacteriologice din lichidele obinute prin paracentez sau toracentez, cu constatarea unor exsudate inflamatorii cu coninut crescut de enzime pancreatice i uneori cu elemente de suprainfecie, altfel sugerat i de aspectul macroscopic hemoragic sau purulent (Fig. 2). Se pot defini o serie de elemente particulare care, din punct de vedere biochimic, ridic o puternic suspiciune de etiologie biliar n cazul unei pancreatite acute: - valori mult crescute ale amilazelor; - sindrom hepatocitolitic major, cu evoluie ondulant; - sindrom colestatic major fr tendin la descretere. 2. Explorri imagistice Explorarea imagistic a pancreasului trebuie privit prin prisma unor consideraii anatomice ale organului n sine (organ situat profund, retroperitoneal, cu o

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densitate structural comparabil cu a viscerelor nvecinate, cu numeroase variante anatomice de structur glandular, ductale i vasculare) precum i prin prisma nevoii de identificare a etiologiei biliare a pancreatitei i de excludere a altor posibile cauze incriminabile n geneza acesteia. n legtur cu faptul c examenul clinic obiectiv local este adesea nerelevant iar explorrile biologice sunt nespecifice, este explicabil utilizarea curent a unor investigaii imagistice sofisticate i costisitoare ntr-o ierarhie care uneori poate lsa aparena unui exces nejustificat. Severitatea clinico-evolutiv a unor forme clinice de pancreatit acut biliar, nevoia de detaliu atunci cnd trebuie luate decizii vitale au impus dezvoltarea i perfecionarea acestora i justific folosirea lor ori de cte ori este nevoie.

Fig. 2 Aspectul lichidului de puncie peritoneal la un pacient cu pancreatit acut biliar necrotico-hemoragic A. hemoragic; B. purulent

Trebuie s menionm c la originea istoric a investigaiilor imagistice st explorarea radiologic, fie fr contrast (radiografia abdominal pe gol, radiografia toracic), fie cu contrast baritat (radiografia gastroduodenal), ambele oferind ns doar elemente indirecte de suferin pancreatic. Astzi sunt practicate doar n varianta fr contrast, pentru excluderea altor cauze de abdomen acut: perforaii intestinale, ocluzii etc. n pancreatita acut radiografia abdominal pe gol poate releva: calculi radioopaci veziculari, calcificri pancreatice, ansa santinel (parez a unei anse jejunale din proximitatea pancreasului), nivele hidroaerice ntr-un ileus dinamic, pneumoperitoneu n perforaiile secundare, iar cea toracic, revrsat lichidian pleural stng. Investigaiile radiologice clasice nu pot ns stabili un diagnostic cert al afeciunii pancreatice i, cu att mai mult, nu pot oferi relaii asupra severitii, etiologiei sau formelor anatomo-clinice de pancreatit. ntr-o ierarhizare care ine cont de utilitatea i beneficiul clinic, explorrile actuale de baz pot fi grupate n urmtoarea secven: ecografia abdominl (ultasonography - US), computer-tomografia (CT), ecoendoscopia (endoscopic ulatrasonography - EUS), colangio-pancreatografia retrograd endoscopic (endoscopic retrograde cholangiopancreatography - ERCP), imagistica prin rezonan magnetic (IRM), colangio-pancreatografia prin rezonan magnetic (magnetic resonance cholangiopancreatography - MRCP), arteriografia. Aceast ierarhie nu trebuie privit ca

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absolut, adesea fiind utile investigaii ntr-o secven modificat, dictat de particularitile clinico-evolutive i etiologice ale cazului. Ecografia, cu toate posibilele limite legate de fereastra ecografic, de posibilitile uneori dificile de identificare a leziunilor i chiar a organului ca atare, de stabilire a corelaiilor cu severitatea i prognosticul, rmne prima investigaie de utilitate real n diagnosticul pancreatitei acute biliare. Poate identifica cu mare acuratee litiaza biliar, dilataiile cilor biliare sau pancreatice, ofer relaii cu privire la dimensiunile i ecostructura pancreasului, identific adesea zone de necroz intra- i peripancreatice, abcese, colecii, ascita (Fig. 3). Este o modalitate neinvaziv, ieftin, repetitiv, putnd fi efectuat i la patul bolnavului. Explorarea ecografic poate identifica originea litiazic a unei PA biliare n 3070% dintre cazuri, rezultatele fiind dependente de: gradul de dilataie al cilor biliare, obinerea unei ferestre ecografice adecvate, aparat i examinator.

Fig. 3 Pancreatit acut necrotico-hemoragic ecografie hepatobiliopancreatic A. arie de necroz voluminoas la nivelul pancreasului cefalo-corporeal; B. necroz masiv de pancreas corporeo-caudal; C. structur hiperecogen cu con de umbr posterior situat n lumenul cii biliare distale (calcul coledocian)

Ecoendoscopia necesit aparatur special i un investigator experimentat dar ofer relaii mai fidele asupra cii biliare principale i ductelor pancreatice permind stabilirea cauzei unei pancreatite acute n majoritatea cazurilor: litiaz, mici tumori pancreatice, pancreas divisum etc. Are indicaie major n orice pancreatit acut suspect de a fi biliar i la care ecografia transabdominal nu a putut identifica cu siguran litiaza de cale biliar. Computer tomografia este examenul de referin, indispensabil n ncadrarea formelor necrotico-hemoragice sau a complicaiilor putnd preciza adesea i etiologia pancreatitei. Poate fi realizat cu sau fr contrast i necesit seciuni de 3-5 mm. De mare utilitate sunt reconstruciile tridimensionale mai ales atunci cnd se preconizeaz o intervenie chirurgical. Face parte din investigaiile de baz care definesc criteriile actuale de severitate (clasificarea Balthazar). Permite identificarea cu mare acuratee a complicaiilor loco-regionale ale unei pancreatite acute biliare [11]. Clasificarea Balthazar referitoare la severitatea unei pancreatite acute recunoate 5 grade n raport cu constatrile explorrii computer tomografice: A - pancreas normal; B - creterea n volum a pancreasului cu conservarea conturului glandei; C - inflamarea

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pancreasului cu infiltraia grsimii peripancreatice, cu neregulariti de contur; D - o colecie peripancreatic; E - prezena mai multor colecii fluide peripancreatice i la distan de pancreas. Examenul CT cu soluie de contrast aduce detalii ample asupra densitii i omogenitii parenchimului nainte i dup contrast, tipului i gradului de necroz pancreatic, extensiei fuzeelor intra- i extrapancreatice (abdomino-pelvin, mediastinal, pleuro-pericardic), existenei unei litiaze coledociene sau pancreatice. Tot prin CT se pot identifica formele cu gangren gazoas, infiltrrile cu steatonecroz, coleciile localizate abdominal (Fig. 4). CT efectuat n varianta spiral poate diagnostica litiaza de cale biliar aflat la originea unei pancreatite acute n pn la 85% dintre cazuri [12].

B
Fig. 4 Pancreatit acut - aspecte CT A. colecie voluminoas peripancreatic i subpancreatic; B. necroz cefalic fuzat periduodenal

Abcesul pancreatic este identificat ca avnd coninut cu densitate lichidian, perete neregulat, vizibil bine la contrast, uneori i bule aerice n interior. Complicaiile vasculare sunt identificate cu mare acuratee: tromboze ale venelor peripancreatice, pseudoanevrismele (care ns reclam angiografie de confirmare), fistulele arteriovenoase (splenice). Imagistica prin rezonan magnetic are o valoare limitat, fiind util doar atunci cnd datorit contraindicaiilor, nu rare atta vreme ct formele severe care reclam prompt explorri imagistice asociaz constant insuficiene de organ, nu se poate efectua CT cu contrast. Este de preferat s fie efectuat cu contrast (gadolinium) pentru detalii de structur pancreatic. Are indicaie absolut n pancreatitele acute la femei gravide sau la cei cu alergii la contrastul CT [13]. Colangiopancreatografia prin rezonan magnetic este o investigaie neinvaziv dar care aduce relaii doar cu privire la cile biliopancreatice. Este util n cazurile la care etiologia pancreatitei este obscur putnd identifica frecvent calculi biliari sau pancreatici de mici dimensiuni (Fig. 5). Nu este util dac prin US sau CT spiral cu contrast s-a precizat etiologia biliar a unei pancreatite acute, situaie cnd este de preferat din start varianta retrograd endoscopic Colangiopancreatografia retrograd endoscopic este o explorare radioendoscopic cu utilitate att diagnostic ct i terapeutic putnd fi continuat, acolo unde este cazul, cu procedee de dezobstrucie a cii biliare acolo unde este cazul (Fig. 6).

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Permite realizarea unor procedee terapeutice de decomprimare a cilor biliopancreatice prin extracia endoscopic a calculului sau calculilor dup o prealabil sfincterotomie endoscopic (realizat dup colangiografie i pancreatografie care vor preciza numrul, poziia i dimensiunea calculilor precum i prezena unor posibile variante anantomice sau anomalii ale cilor bilio-pancreatice care se pot constitui n factori favorizani ai litiazei i care, n plus, pot influena decizia terapeutic).

Fig. 5. Pancreatit acut colangio IRM calcul supraampular

Fig. 6 Pancreatit acut endoscopie digestiv superioar i ERCP A. papil protruziv prin calcul blocat ampular; B. sfincterotomie endoscopic; C. cateterizarea papilei ntr-o PA biliar complicat cu angiocolit purulent

Indicaia major a ERCP este deci PA biliar, mai ales la vrstnici sau la pacieni cu risc operator mare. Are rezultate diferite n funcie de severitatea PA i de timpul scurs de la debutul bolii. n formele severe nu difer morbiditatea i mortalitatea fa de intervenia chirurgical, dar difer semnificativ de tratamentul conservator; n plus scade durata de spitalizare a acestor pacieni [14]. Angiografia permite confirmarea anevrismelor arteriale asociate i definirea hrii vasculare preoperator. n rare situaii o PA este diagnosticat intraoperator. Aceasta se poate ntmpla n caz de indecizie diagnostic dup epuizarea tuturor metodelor de investigaie paraclinic i persistena unei stri grave a pacientului.

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Aprecierea severitii unei pancreatite acute biliare este extrem de important pentru stabilirea unei atitudini terapeutice optime. Aceasta se realizeaz pe criterii combinate clinice, de laborator i imagistice. Dintre multiplele propuneri de scoruri de severitate le menionm pe cele mai folosite n practica clinic: scorul Ranson i scorul Glasgow, care difereniaz formele uoare de cele severe de pancreatit (Tabelele I, II) [15,16]:
Tabelul I Scorul Ranson internare vrsta peste 55 de ani leucocitoz peste 16.000/mmc LDH peste 350 UI/L glicemie peste 2 g/L TGP peste 250 UI/L dup 48 de ore scderea hematocritului cu peste 10% creterea ureei serice cu peste 5 mg/dL calcemie sub 8 mg/dL TA sistolic sub 60 mmHg deficitul de baze peste 4 mEg/L sechestrare de fluide peste 6 L

Tabelul II Scorul Glasgow vrsta peste 55 de ani leucocitoz peste 15.000/mmc LDH peste 600 UI/L glicemie peste 1.8 g/L serinemie sub 32 g/L calcemie sub 8 mg/dL TA sistolic sub 60 mmHg uree seric peste 45 mg/dL

DIAGNOSTICUL DIFERENIAL ntr-o pancreatit acut biliar este dificil de efectuat, mai ales n formele severe cu insuficiene multiorganice, cnd, este greu de precizat leziunea primar care a declanat cascada cataclismic. Diagnosticul diferenial se face cu: ocluzia intestinal (prin bride, tumori, volvulus, hernie), infarctul entero-mezenteric (trombotic sau embolic), infarctul miocardic acut (mai frecvent n localizarea sa inferioar), perforaia de organ (stomac, duoden, diverticul, apendice, sarcin tubar), indiferent de procesul patologic care o produce. COMPLICAII Pot fi sistematizate n complicaii comune tuturor pancreatitelor, care pot fi de ordin locoregional sau sistemic (la distan) i complicaii specifice etiologiei biliare a PA. Complicaiile locoregionale sunt consecina necrozei pancreatice i extensiei acesteia extrapancreatic. Din punct de vedere al structurii compoziionale, de aspect al coleciilor i raportat evoluiei de la momentul acut, acestea pot fi: colecii fluide, necroze pancreatice, abcese pancreatice i pseudochisturi. Coleciile fluide au o structur dominant enzimatic, fiind expresia procesului inflamator al parenchimului pancreatic cu exsudaie important asociind rupturi canalare pancreatice ce stau la originea lor; survin precoce n evoluia unei pancreatite acute putnd fi localizate intrapancreatic sau putnd fi fuzate peripancreatic sau la

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distan [17]. Majoritatea au o tendin spontan la resorbie sub tratament conservator i doar rareori se impune o terapie activ n cazul creterilor rapide cu efecte compresive asupra structurilor sau organelor nvecinate. Necrozele pancreatice pot fi localizate sau pot interesa tot pancreasul fiind apanajul formelor severe de PA [18]. Apariia acestora, sugerat clinic de instalarea unei stri septice cu febr important, alterarea strii generale, cu dureri abdominale i aprare la palpare i dovedibil la examenul CT cu contrast, este un factor predictiv pentru o evoluie adesea nefast cu mortalitate ridicat. La rndul ei, necroza parenchimului pancreatic se poate complica cu suprainfecie, lucru relativ frecvent i dependent de mrimea necrozei (pn la 70% dintre cazuri) i realizat prin migrare bacterian din compartimentul intestinal [19]. Dac identificarea zonelor de necroz pancreatic beneficiaz de aportul CT cu contrast i al US ca metod de supraveghere dinamic, diagnosticul suprainfeciei necrozelor pancreatice trebuie susinut bacteriologic prin examenul bacteriologic al specimenelor obinute prin puncie aspirativ cu ac fin [20]. Uneori necrozele pancreatice sterile pot evolua cu resorbie spontan, alteori se pot suprainfecta. Aceast evoluie depinde n primul rnd de mrimea necrozei, localizarea ei, statusul imun al pacientului i gradul de agresivitate microbiologic. n unele cazuri pot persista ca zone cu material necrotic (sechestre) peste 30 de zile dar fr s se organizeze sub forma unui pseudochist. Abcesele pancreatice se dezvolt n interiorul parenchimului pancreatic, n vecintate sau la distan dup cum a fuzat necroza pancreatic care precede suprainfecia, care s-a resorbit n majoritatea cazurilor i care a permis formarea abcesului. Abcesul pancreatic sau peripancreatic sau la distan prezint un perete propriu inflamator ceea ce face pe de o parte s mpiedice penetrana antibioticelor local iar pe de alt parte s mpiedice diseminarea septic secundar [21]. Pseudochistul pancreatic reprezint o colecie fluid survenit n evoluia tardiv a unei zone de necroz pancreatic i care capt un perete propriu, adesea gros, inflamator, fibros dar neepitelial. n 30% dintre cazuri survine n pancreatitele acute biliare, adesea fiind asimptomatic [22]. Doar atunci cnd sunt de mari dimensiuni pot determina fenomene compresive pe organele i structurile nvecinate, fiind indicat drenajul acestora la dimensiuni de peste 6 cm, cu examinarea citologic, biochimic i bacteriologic a coninutului aspirat pentru diferenierea de chistadenoame i chistadenocarcinoame (sau pentru calificarea unei persistene a fenomenelor pancreatitice), mai ales atunci cnd apariia structurii chistice nu este precedat de un tablou clinic tipic de pancreatit acut. Tromboza inflamatorie a venei splenice aflat n imediata vecintate a structurii pancreatice este una dintre complicaiile vasculare frecvente i genereaz la rndul ei un sindrom de hipertensiune portal cu splenomegalie, varice esofagiene i gastrice ce pot complica hemoragic n cadrul unei hipertensiuni portale segmentare (prehepatice). Alteori tromboza poate interesa venele mezenterice cu ischemie enteromezenteric i ascit. Apariia pseudoanevrismelor survine n urma deschiderii unui pseudochist ntr-o arter, cel mai adesea n artera splenic sau gastroduodenal. Ascita este secundar unei inflamaii peritoneale (exsudativ) prin difuzarea enzimelor pancreatice intraperitoneal la efracia capsulei pancreatice fiind bogat n enzime pancreatice decelabile la un examen biochimic de rutin. Alteori reflect hipertensiune portal n obstruciile vasculare secundare trombozei.

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Fistulele pot surveni ca soluii de comunicare ntre cile pancreatice i cavitatea peritoneal sau chiar transcutanate, retroperitoneale, transdiafragmatice intrapleurale sau ntre diferite segmente ale tubului digestiv. Peritonitele secundare apar nu att la deversarea n cavitatea peritoneal a sucului pancreatic ct mai ales la suprainfecia acestuia. Complicaiile sistemice se raporteaz toxicitii enzimelor pancreatice i sepsisului generalizat secundar. Acestea pot fi: insuficien respiratorie, sindromul de detres respiratorie al adultului, pleurezii enzimatice sau septice, pareze diafragmatice, insuficien renal cu retenie azotat i dezechilibre majore hidroelectrolitice i acidobazice, tulburri severe de coagulare, miocardopatii, pericardite, encefalopatia pancreatic, hemoragii digestive superioare sau inferioare, necroze lipoidice care se pot extinde parietal, infarcte medulare cu aplazie secundar, artrite reactive sau septice, ischemie acut retinian. Toate aceste entiti sunt consecina difuziunii enzimelor pancreatice n circulaia sistemic cu afectarea diverselor structuri i organe. Complicaiile specifice etiologiei biliare sunt rezultatul obstruciei biliare care este de o dimensiune important mai ales n variantele de calculi blocai ampular. Angiocolitele acute au ca expresie clinic un icter cu caracter obstructiv (urini hipercrome, scaune acolice, prurit, dureri de hipocondru drept), la care se adaug elemente septice (febr, frisoane, sindrom biochimic i hematologic inflamator). Beneficiaz n plus de diagnostic imagistic ecografic sau colangiografic (pentru precizarea cert a naturii leziunii obstructive). Abcesele hepatice sunt expresia diseminrii ca abcese secundare n cadrul unui sepsis cu punct de plecare ampular, adesea fiind secundare angiocolitelor (abcese colangitice). Sunt diagnosticate ecografic i/sau CT cu substan de contrast, iar tratamentul presupune nu numai antibioterapie ci, n primul rnd, dezobstrucia ampular, procedeu care efectuat la momentul potrivit asigur adesea i remisia fenomenelor pancreatitice. CONCLUZII Pancreatita acut biliar este o afeciune redutabil, fiind secundar blocrii unui calcul la nivel ampular (migrat din colecist sau format in situ) cu obstrucia concomitent att a cii pancreatice ct i a celei biliare. Diagnosticul clinic recunoate cel mai frecvent elemente de pancreatit acut, combinate cu elemente de icter obstructiv cu angiocolit. Diagnosticul imagistic este obligatoriu att n ceea ce privete aprecierea strii parenchimului pancreatic, ct i pentru ncadrarea etiologic a unei pancreatite acute. Dac ultrasonografia este o investigaie uzual, fiabil i real util, computer tomografia este obligatorie, fcnd parte dintre investigaiile ce definesc criterii de severitate ale bolii, iar explorrile de cale bilio-pancreatic (ERCP) pot avea i o dimensiune complementar curativ-intervenional.
1. 2. 3. 4. BIBLIOGRAFIE Opie EL. The aethiology of acute haemorrhagic pancreatitis. Johns Hopkins Hosp Bull. 1901; 12: 182-189. Mirizzi PL. Operative cholangiography. Surg Gynecol Obstet. 1937; 65: 702-708. Howard JM. Gallstone pancreatitis. In Howard JM, Jordan GL, Reber HA, editors. Surgical diseases of the pancreas. Philadelphia: Lea & Febiger; 1987. p. 256-283. Diehl AK, Holleman DL, Chapman JB, Shwesinger WH, Kurtin WE. Gallstone size and risk of pancreatitis. Arch Intern Med. 1997; 157: 1674-1678.

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5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22.

Moreau JA, Zinsmeister AR, Melton LJ, DiMango EP. Gallstone pancreatitis and the effect of cholecistectomy: a population-based cohort study. Mayo Clin Proc. 1988; 63: 466-470. Kalthoff L, Layer P, Clain JE. The course of alcoholic and nonalcoholic chronic pancreatitis. Dig Dis Sci. 1984; 29: 953-956. Agarwal N, Pitchumoni CS, Sivaprasad AV. Evaluating tests for acute pancreatitis. Am J Gastroenterol. 1990; 85(4): 356-366. Ammann RW. A critical appraisal of interventional therapy in chronic pancreatitis. Endoscopy. 1991; 23(3): 191-193. Kemppainen E, Mayer J, Puolakkainen P, Raraty M, Slavin J, Neoptolemos JP. Plasma tripsinogen activation peptide in patients with acute pancreatitis. Br J Surg. 2001; 88(5): 679680. Malka D, Hammel P, Sauvanet A, Rufat P, O'Toole D, Bardet P, Belghiti J, Bernades P, Ruszniewski P, Lvy P. Risk factors for diabetus mellitus in chronic pancreatitis. Gastroenterology. 2000; 119(5): 1324-1332. Balthazar EJ, Robinson DL, Megibow AJ, Ranson JH. Acute pancreatitis: value of CT in establishing prognosis. Radiology. 1990; 174(2): 331-336. Neitlich JD, Topazian M, Smith RC, Gupta A, Burrell MI, Rosenfield AT. Detection of choledocolithiasis: comparison of unenhanced helical CT and endoscopic retrograde cholangiopancreatography. Radiology. 1997; 203(3): 753-757. Morgan DE, Baron TH, Smith JK, Robbin Ml, Kenney PJ. Pancreatic fluid collections prior to intervention: evaluation with MR imaging compared with CT and US. Radiology. 1997; 203(3): 773-778. Balan Gh, Stanciu C. Metode i tehnici radioendoscopice n gastroenterologie. Iai: Editura Junimea; 2002. p. 31-72. Ranson JC. Acute pancreatitis. Curr Problems Surg. 1979; 16: 1-11. Wilson C, Heath DI, Imrie CW. Prediction of outcome in acute pancreatitis: a comparative study of Apache II, clinical assesement and multiple factor scoring system. Br J Surg. 1990; 77(11): 1260-1264. Uomo G, Molino D, Visconti M, Ragozo A, Manes G, Rabitti PG. The incidence of main pancreatic duct disruption in severe biliary pancreatitis. Am J Surg. 1998; 176(1): 49-55. Brown A, Orav J, Banks PA. Hemoconcentration is an early marker for organ failure and necrotizing pancreatitis. Pancreas. 2000; 20(4): 367-372. Cicalese L, Sahai A, Sileri P, Rastellini C, Subbotin V, Ford H, Lee K. Aerial translocation. Dig Dis Sci. 2001; 46(5): 1127-1132. Gloor B, Mller CA, Worni M, Stahel PF, Redaelli C, Uhl W, Bchler MW. Pancreatic infection in severe pancreatitis: the role of fungus and multiresistant organisms. Arch Surg. 2001; 136(5): 592-596. Venu RP, Brown RD, Marrero JA, Pastika BJ, Frakes JT. Endoscopic transpapillary drainage of pancreatic abscess: technique and results. Gastrointest Endosc. 2000; 51:(4Pt1): 391-395. Yeo CJ, Bastidas JA, Lynch Nyhan A, Fishman EK, Zinner MJ, Cameron LJ. The natural history of pancreatic pseudocysts documented by computedtomography. Surg Gynecol Obstet. 1990; 170: 411-414.

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INGUINAL HERNIA REPAIR IN THE 21-ST CENTURY


J.C. Lotz Staffordshire General Hospital, Stafford, England
INGUINAL HERNIA REPAIR IN THE 21-ST CENTURY (Abstract): In the nineteenth century, Bassini pioneered inguinal hernia repair and to this day many hernias are still repaired with similar sutured methods. The recurrence rate of these is seriously high up to 20% and long-term pain is common. Time and technology have moved on, but many surgeons have not. In the twenty first century, recurrence of less than 1% is attainable, with almost no significant pain. It is already over-time for change. KEY WORDS: INGUINAL HERNIA, LAPAROSCOPIC HERNIA REPAIR; TAPP Correspondence to: J C Lotz, MD, PhD, Staffordshire General Hospital, Stafford. ST16 3SA, England; e-mail: johnlotz_1@hotmail.com*

HISTORY The treatment of inguinal hernia is evident in history from ancient times. For centuries it was extremely limited by the deficiencies in treatment options because of pain. It was not until the nineteenth century that the introduction of general anaesthesia made real anatomical procedures possible. This gave Bassini the opportunity to make his international name in 1887. His eponymous procedure was subsequently modified and developed by many others on both sides of the Atlantic and right across Europe. Interestingly, the Shouldice operation, hailed as the best cure for many years, is technically very similar to Bassinis original description. Improvement in repair materials also proceded during the twentieth century. Silk had been preferred early on, but is liable to infection and loses its strength quickly. Kangaroo tendon, stainless steel wire and fascia lata (Gallie graft) all came and went. Monofilament nylon came into common use in the 1970s producing less infection and less initial recurrence, but it loses its strength after 2-3 years. This was improved on by the introduction of polypropylene by Natti in 1963, but not seriously taken up for many years. The importance of tissue tension became recognised at about this time. Pulling the repair together by sutures produces pain (worsened by postoperative oedema) and also ischaemia. This added to the pain and also contributed to repair failure. Lichtenstein (1987) [1] showed that tension-free repair using mesh, produced less pain and much better recurrence rates. However, the results of all anterior approaches tends to produce long-term wound discomfort. Why should this be so? To gain access to the anatomical defect, it is necessary to violate the anatomy of the anterior abdominal wall. Injury to the cutaneous nerves is very common. Temporary damage is almost universal. This is further increased by the necessary repair of the entry wound.
received date: 15.02.2009 accepted date: 1.03.2009
*

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A NEW APPROACH Rives (1974) and Stoppa (1981) advocated a posterior approach to the repair, which was tension free, but required a low laparotomy for access. Postoperative wound pain was still a problem, but the cutaneous groin nerves were not injured. Interestingly, this preperitoneal approach was not new. Dimitrie Cantemir had described it in 1716, from observation of Albanian surgeons, though an actual repair was not performed by them. Several preperitoneal devices have been used in the last 15 years. The Kugel plug and other patch/plug prostheses are introduced by an anterior approach. They all have the disadvantages of this access route. They all do not thoroughly cover the myopectineal orofice of Fruchaud and must therefore be regarded as potentially deficient.

18 16 14 12 10 8 6 4 2 0 1 2 3 4
Mesh Non Mesh

Fig. 1 Cumulative recurrence rate

LAPAROSCOPY The Stoppa procedure was not commonly used, due to its difficult access, but the repair concept was logically and mechanically sound the intra-abdominal pressure actually holds the mesh in place, rather than tending to push it off, as in the Lichtenstein procedure, particularly medially. Arregui was the first to propose an anatomical laparoscopic transabdominal preperitoneal repair (TAPP) in 1992 [2]. There were some early problems with the recognition of unfamiliar anatomy and no defined methodology. Postoperative pain, due to intra-abdominal nerve injury by staples fixing the mesh was also recognised. The outcomes however, were at least as good as open repair (EU Hernia Triallists, 2000) and quickly became better. RESULTS Most surgeons have no idea of their hernia results! They never look. It is common to assume that they are good, but it is rare for anybody to study what actually happens. One of the good outcomes of the advent of laparoscopic surgery was that many people wanted to assess results of the new technology and thus had also to study older methods. Multicentre trials and meta-analyses have many weaknesses, but in the 1990s, they did start to give indices to examine and question. Of primary importance in hernia repair are recurrence rate and the incidence of long-term symptoms (Fig. 1). The

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cumulative recurrence rate of sutured and open mesh repairs both get worse with time and then stabilise. The results for open sutured Bassini type repairs the results are alarmingly bad. (Table I); 15% recurrence was common, but up to 20% was reported. The Lichtenstein recurrence rates were much better, but pain and discomfort were still not good.
Table I Comparative recurrence (percents) Sutured < 20 Lichtenstein 4-8 Other laparoscopic 1 Stafford 0.6

Table II Long-term results (percents) Sutured Discomfort Pain Disability 15 - 53 9 - 14 5 Lichtenstein 19 4.5 - 9 3 Other laparoscopic 2 - 14 NA NA Stafford 16 0.3 0 NA Not Available

For laparoscopy, the recurrence was similar, but pain much better (Table II). That was in the early days. Since then, there have been good studies on large groups of patients [3,4]. Our Stafford study examined the results of 1,950 repairs beginning in 1992. This was a prospective series, later followed up by questionnaire. Two groups were studied, the first 629 hernias, which clearly showed a Learning Curve for both operating time and also for recurrence. The second series of 945 was much later, when the technique and outcomes had stabilised. It has shown a recurrence of only 0.6% and a long-term discomfort rate of 1.9%. These results already contain many patients who had repairs done 5-9 years before. None of these patients had limitation of normal activities. There were no cases of severe pain. Pain and discomfort are very subjective terms. The more objective approach is to see whether they interfere with normal life. OTHER BENEFITS One of the benefits unique to the laparoscopic approach, is the facility to check the contralateral anatomy. Rather surprisingly, this showed an incidence of 28.7% of unanticipated extra hernias. In addition, both ipsilateral and contralteral femoral hernias were found in 10.8%. These can all be repaired at the same operation, saving the patient a further procedure and period of convalescence. Laparoscopy thus provides cost benefits, certainly in Britain. When the total cost of a series of patients is examined in detail and in a two year timeframe, it is definitely cheaper, in spite of the use of some disposable devices. This is true of hospital costs alone, but may be different in other countries. Patient loss of work and time at

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home is an extra saving. Though this is very difficult to quantify, it is certainly important to the patient and his family. PATIENT SELECTION So, are all patients best treated laparoscopically? No. Emergency presentation, particularly if obstructed, is best treated open. There is no intraperitoneal space for laparoscopy and if bowel resection is needed this is not a feasible approach. Also, very large inguino-scrotal hernias are laborious, time-consuming and likely to get a scrotal haematoma. Most of the smaller, elective hernias are best treated laparoscopically, by trained surgeons . This training is now widely available, but not all surgeons are laparoscopists. If this cannot be done, a Lichtenstein repair is by far the best alternative approach and is quite easy to learn. This obviously means accepting the disadvantages of the anterior approach. In the 21st century there is no place for sutured repair for elective hernias. TWO BASIC NEEDS 1.Objective assessment Failure to do this is a basic sin of most surgeons past and present, regardless of the method we use. Many surgeons are doing their patients a dis-service by using inferior methods without even knowing it. Looking at results critically will produce a change in practice for the better. Not to do so is unethical. 2.Long-term follow up - Laparoscopic hernia repair has only been with us for 17 years. 10 year outcomes should now be assessed. Individual surgeons with large series should consider review and publication. This will provide a baseline for others to compare their outcomes. The Stafford series has some known 5-9 year results, but is about to be reviewed to produce 10 year figures for 774 repairs. WHERE ARE WE NOW? Sutured repair is still widely performed, with poor but unrecognised results. It should stop. Mesh repair in some form is now the norm, but where to put it is the present argument. The results for most patients are best with laparoscopy, but there are not very many people doing it. Why?!
1. 2. 3. REFERENCES. Lichtenstein IL, Shulman AG, Amid PK, Montelor MM. The tension-free hernioplasty. Am J Surg. 1989; 157(2): 188-193. Arregui ME, Davis CJ, Tucel O, Nagan RF. Laparoscopic mesh repair of inguinal hernia using a preperitoneal approach : a preliminary report. Surg Laparosc Endosc. 1992; 2(1): 53-58. Bittner R, Leibl B, Kraft K, Daubler P, Schwartz J. Laparoscopic hernioplasty (TAPP) complications and recurrences in 900 operations. Zentralblatt Chir. 1996; 121(4): 313-319. Wall ML, Cherian T, Lotz JC. Laparoscopic hernia repair The best option?. Acta Chir Belg. 2008; 108(2): 186-191.

4.

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RIGHT COLECTOMIES: INDICATIONS, TECHNIQUES, AND RESULTS, RETROSPECTIVE STUDY OF 110 PATIENTS
S. Zaytouni, Ch. Simoens, V. Thill, D. Smets, P. Mendes Da Costa Department of Digestive, Thoracic and Laparoscopic Surgery CHU Brugmann, ULB Brussels, Belgium
RIGHT COLECTOMIES: INDICATIONS, TECHNIQUES, AND RESULTS, RETROSPECTIVE STUDY OF 110 PATIENTS (Abstract): Background: The purpose of this retrospective study was to evaluate factors influencing morbidity and mortality associated with right or transverse colectomy. Methodology: We included all patients receiving a right or transverse colectomy from January 1-st, 2002 until December 31-st, 2007 for a total of 111 patients. Seventy-nine patients (71.8%) were treated with open surgery and 31 (28.2%) with laparoscopic surgery. Seven patients (22.6%) required a conversion from laparoscopic to open surgery. Results: Morbidity and mortality were 32.7% and 2.7%, respectively. The age, rate of local complications, duration of hospitalization and stays in the intensive care unit, tumor size, proportion of positive ganglions, and the rate of neoplasic recurrence were all statistically more common in patients treated with open surgery compared to laparoscopic surgery. There was no difference between groups in terms of male / female ratio, BMI, general morbidity, short- and long-term mortality, number of examined ganglions, and local recurrence. Patients with stage 1 disease were more common in the laparoscopic group. Conclusion: The lower rate of local morbidity, shorter hospital stay, and equivalent survival and long-term outcome recommend laparoscopic colectomy in patients whose medical status and disease stage allow for the use of this minimally invasive procedure. KEY WORDS: RIGHT COLECTOMY; LAPAROTOMY; LAPAROSCOPY; NEOPLASM; POLYP; INFLAMMATORY BOWEL DISEASE; DIVERTICULITIS; MORBIDITY; MORTALITY. Correspondence to: P. Mendes Da Costa, MD, PhD, Professor of Surgery, Department of Digestive, Thoracic and Laparoscopic Surgery, CHU Brugmann, Place A. Van Gehuchten, 4, B1020 Bruxelles, Belgium; e-mail: pierre.mdc@chu-brugmann.be*

INTRODUCTION Right or transverses colectomies are associated with a high rate of morbidity and mortality [1,3,6,9,11-17,20,22-27,31]. Numerous studies have attempted to determine risk factors associated with poor outcome in order to identify high-risk patients and, when possible, modify these risk factors [2,8,11,16,18,19,24,26,31]. Many authors questioned the impact of surgical technique. Indeed, in recent years the method of surgical intervention has varied, including both traditional open techniques and minimally invasive laparoscopic access. Several reports demonstrated that the less invasive approach of laparoscopy lead to a decreased duration of hospital stay and decreased morbidity [1,2,4,6,7,9,12-14,19,21-25,31]. However, there are still hesitations among surgeons concerning the use of laparoscopy in the treatment of the cancer patient [27]. The purpose of this retrospective study is to analyze the various factors influencing the morbidity and the mortality of right and transverse colectomies, and to

received date: 15.03.2009 accepted date: 25.03.2009

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estimates the impact of open versus laparoscopic approach on the long-term outcome of cancer patients. PATIENTS AND METHODS From January 1-st, 2002 until December 31-st, 2007, 110 patients were treated with right or transverse colectomy at the Brugmann University Hospital. Patients included 58 women and 52 men (female / male = 1.1). The mean age was 68.5 years old (range: 25-98 years old) and the mean body mass index (BMI) was 24.9 kg /m2 (13-34.8 kg/m2). Operating risk was estimated by the ASA score of the American Society of Anesthesiologists. Table I shows the indication for colectomy and the surgical approach.
Table I Indications of colectomies Open surgery (n=79)
number / percents from total

Laparoscopic surgery (n=31)


number / percents from total

Total (n=110)
number / percents from total

Colon cancer Polyp Ischemic colitis Crohns Disease Anastomotic fistula Diverticulitis Eventration Volvulus Caecum abscess Occlusion

52 / 47.27 8 / 7.27 8 / 7.27 2 / 1.82 3 / 2.72 2 / 1.82 2 / 1.82 0 1 / 0.91 1 / 0.91

16 / 14.54 8 / 7.27 0 4 / 3.64 0 0 0 2 / 1.82 0 1 / 0.91

68 / 61.82 16 / 14.54 8 / 7.27 6 / 5.45 3 / 2.72 2 / 1.82 2 / 1.82 2 / 1.82 1 / 0.91 1 / 0.91

Table II Number of patients with preoperative testing Preoperative tests Serum CEA* Abdominal CT-scan Colonoscopy Abdominal ultrasonography Barium enema Bone scintigraphy Thoracic CT-scan PET scan Number of patients / percents from total 68 / 61.82 58 / 52.73 46 / 41.82 36 / 32.73 34 / 30.9 15 / 13.64 9 / 8.18 3 / 2.72

* CEA= carcinoembryonnic antigen

Seventy-nine patients (71.8%) were with traditional open colectomy and 31 patients (28.2%) were treated with laparoscopy. Table II indicates the medical tests performed in case of colon cancer, for diagnosis and staging. Statistical analyses were performed by the Wilcoxon test for the comparison of continuous variables and by the Chi-squared test for discreet variables.

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RESULTS The conversion rate of laparoscopy to open surgery was 22.6%. The causes for conversion were: tumor not dissectable by laparoscopic approach (2 cases), adhesion of tumor to the right ureter (1 case), obesity (2 cases), tumor more extensive than expected (1 case). The overall morbidity rate was 32.7%, which included local morbidity (10.9%) and general morbidity (21.8%) (Table III). Importantly, the rate of anastomotic fistulae was 1.8%.
Table III Postoperative morbidity Morbidity Local complication
intra-abdominal abscess wound infection anastomotic fistula abscess evisceration stoma prolapse

Number of patients / percents from total 12 / 10.9


3 / 2.72 3 / 2.72 2 / 1.82 2 / 1.82 1 / 0.91 1 / 0.91

General complication
infection cardiovascular urinary systemic lung gastrointestinal

24 / 21.82
9 / 8.18 5 / 4.54 3 / 2.72 3 / 2.72 2 / 1.82 2 / 1.82

Table IV Characteristics of deceased patients* Patient Age (years) Sex ASA score U/P Operative indication Local complication General complication 1 80 Female 2 U Colon necrosis with caecum perforation 0 PE + intracranial bleeding 2 91 Man 4 P Cancer of the caecum 0 MOF Undifferentiated adenocarcinoma 7 from 11 lymphnodes were positives Negative margins Stage pT4N1M1 MOF 24 3 85 Female 3 P Cancer of the caecum Anastomotic leak + abscess Sepsis + MOF Well differentiated adenocarcinoma 10 negatives lymphnodes Negative margins Stage T4N0Mx + PE + sepsis and abdominal abscess 9

Histology

Right colon ischaemia

Autopsy Cause of death Day of death (postoperative day)

+ PE 19

*U/P - urgent/planned operation; PE - pulmonary embolism; MOF - multiorganic failure; autopsy + performed, - not performed

The mortality rate of this series was 2.7%, only one death was directly associated with surgical complications (Table IV).

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Tables V and VI include the morbidity and mortality rates according to method of surgical access and according to type of admission (programmed or urgent surgery).
Table V Morbidity and mortality according to method of surgical access Open surgery (n=79) Local complications General complications Mortality 12 (15.2%) 21 (26.6%) 3 (3.8%) Laparoscopy (n=31) 0 3 (9.7%) 0 p 0.02 0.05 0.53 Statistical significance S NS NS

S significant; NS not significant

Table VI Morbidity and mortality according to type of admission Planned operation (n=79) Local complication General complication Mortality 4 (5.1%) 14(17.7%) 2 (2.5%) Urgent operation (n=31) 8 (25.8%) 10 (32.3%) 1 (3.2%) p 0.002 0.09 0.53 Statistical significance S NS NS

S significant; NS not significant

Table VII Duration of hospitalization according to method of surgical access Open surgery (n=79) Total number of days in the Intensive Care Unit Duration of stay in the intensive care unit (days) Duration of hospitalization (days) 37 (46.8%) 2.1 (0-27 days) 19.9 (6-83 days) Laparoscopy (n=31) 9 (29%) 0.5 (0-4 days) 11.8 (5-38 days) p NA 0.03 <0.0001 Statistical significance NA S S

NA not available; S statistical

The average duration of hospitalization was 17.7 days (range 5-83). Forty-six patients were admitted to the intensive care unit (41.8%) for an average duration of 1.8 days (range 1-27). Table VII compares the duration of hospitalization and intensive care admissions according to the method of surgical access. Table VIII gives the results of the histological examination of excised tumors. The average follow-up of these patients was 23.6 months (range 2-63); Table IX indicates the rate of local recurrence, metastases, and long-term mortality. DISCUSSIONS In our series of 110 patients treated with right or transverse colectomy, the mean age was 68.5 years old (range 40-82.3 years), which is comparable to that in the

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literature [1-16,18-27,31]. Three studies [8,11,27] were limited to a precise age range. One study [11] was limited to young patients (age < 40 years) with colon cancer. The authors reported that these patients often have a poor prognosis, and attributed this to the fact that in this age group diagnosis is often made in the late stages of disease (stages III and IV). Furthermore, histological examination showed a more unfavourable histology in younger patients, with more than 50% showing undifferentiated or mucinous adenocarcinoma. In 2 studies [8, 27], patients over 75 years of age were examined. The authors assert that age does not have to be a limiting factor when making the decision to treat surgically, whether by open or laparoscopic technique.
Table VIII Characteristics of patients with colon cancer Open surgery (n.=52) 72.8 (42-98) 25 / 27 25.2 40(76.9%) 10(19.2%) 2 (3.8 %) 4.7 52 (100%) 52 (100%) 0 12.9 1.8 2 (3.8%) 1 (1.9%) 22 (42.3%) 19 (36.5%) 8 (15.4%) Laparoscopy (n=16) 62.5 (25-83) 10 / 6 25.2 13(81.2%) 3(18.8%) 0 3.6 16 (100%) 13 (81.2%) 3 (18.8%) 13.9 0.4 0 3 (23.1%) 8 (61.6%) 2 (15.3%) 0 p 0.02 0.78 0.59 0.84 0.52 0.005 / 0.02 0.005 0.97 0.01 0.47 0.005 0.21 0.14 0.13 Statistical meaning S NS NS NS NS NS S / S S NS S NS S NS NS NS

Age (years) Sex ratio F/M BMI (kg/m2) Tumor location - right colon - transverse colon - right and transverse colon Size of tumor (cm) Save margins Histology - adenocarcinoma - carcinoid tumor Number of ganglions - examined - positive TNM - stage 0 - stage I - stage II - stage III - stage IV

BMI Body Mass Index; S significant; NS not significant

Table IX Follow-up of the patients with colon cancer Open surgery (n=52) 1 (2.2%) 11 (23.9%) 1 (2.2%) 3.5 22.5 (2-59) 6 Laparoscopy (n=16) 0 2 (15.4%) 0 0 26 (3- 67) 3 p 0.81 0.59 0.68 0.76 0.71 NA Statistical significance NS NS NS NS NS NA

Local recurrence Metachronous metastases Death Date of death (postoperative months) Total follow-up (months) Patients lost to follow-up

S significant; NS not significant; NA not available

The male to female rate in our study was similar to that reported in the literature; our patients were 47.3% male, while previous studies reported 13.5% to 57.1% male

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[1,2,4-27,31]. One publication [8] reported a 3 to 5 year survival advantage for women with colon cancer compared to men. The mean BMI of our patients was 24.9kg/m2. Rates reported in the literature range from 20.75 to 32.7kg/m2 [4,6,22,23,26,27]. One study evaluated the feasibility of laparoscopic colectomy in obese patients [26], reporting that it is possible to perform in obese patients but requires an experienced surgical team. In our study, ASA scores ranged from 1 to 4 with an average of 2.4. These figures are similar to those in the literature where ASA score scores range from 1 to 4 with an average of 1.2 to 2.6 [4,6,21-23,27]. Regarding indication for surgery, almost all authors report exclusively on resection for colon cancer. Only one study [21] lists the different diagnoses requiring a colectomy. In this report, 11.8% of patients had colon cancer and 82.4% had multiple polyps. This is markedly distinct from the distribution in our study, where 62.3% of patients were diagnosed with colon cancer, 7.3% with ischemic colitis, and 5.5% with Crohns disease. Many reports have evaluated the impact of open versus laparoscopic surgical access [1-4,7,9,13,14,19,20,22,24,25,27,31]. The majority of authors are in favor of laparoscopy owing to a lower rate of local complications, pain, and length of hospitalization. However, some authors expressed concern with the use of laparoscopy for surgical resection of the cancerous colon [28-30]. These authors associated laparoscopy with an increased risk of local tumor spread, notably to the sites of trocars insertion. In our series, the rate of conversion from laparoscopy to open surgery was 22.6%, which is slightly higher than that reported in the literature (7.4-16.9%) [4,1214,17,19,23,31]. The reasons for conversion in our series are similar to those reported by other authors, and include intra-abdominal adhesions, difficulties linked to dissection, or optimum access of the surgical zone. Inflammation and bleeding are other common causes of conversion, but were not observed in our series. Total morbidity and mortality were 32.7% and 2.7%, respectively, in our study. Morbidity rates reported in the literature range from 3 to 51.8%. Such margin of variation can be explained by variations in patient selection; studies including patients with an ASA of 4 are rare [1,11,14,27]. Moreover, many authors exclude data from patients whose surgical operation was palliative [2,9,12,13,16-21,23,25,26]. In studies that include patients with an ASA over 4 and those receiving palliative resection, total morbidity varies from 23 to 35.5% [11,15]. These results are comparable in our findings. The rate of digestive fistula in our study was 1.8%, lower than that reported in the literature (2.8-9.1%) [15,17]. Mortality rates range from 0 to 27% in the literature, but when stage IV patients and those with ASA 4 are included, the rate is 20.4-27%. [11,15]. The mean length of hospitalization in our series was 17.7 days (5-83 days). In the literature, the mean length of hospitalization ranges from 6.9 to 13.3 days regardless of surgical technology used [4,6,9,14,17,18,20,21]. There is a noticeable difference between our results and those of other authors; however, studies including patients most likely to have long-term hospitalizations do not report the mean length of the stay [11,15,27], and no study includes data on admission and stay in the intensive care unit. Histological analysis of resection specimens plays an important role in the accurate diagnosis and guidance of treatment decisions for cancer patients. In our patients, the average tumor size was 4.1cm, which is slightly lower than reports in the

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literature, where tumor size varies from 4.3 to 5.9cm [6,14]. Resection margins were negative in 100% of our patients, a value comparable to that in the literature (71.9100%) [6,8,14]. The majority of tumors in our series were adenocarcinoma. In the literature, this rate varies from 94.5% to 100% [6,14]. On average, 13.1 lymphnodes were examined histologically in our series. In the literature, the number of examined ganglions varies from 11.1 to 24 [6,15,20]. However, we observed a large difference in the rate of positive ganglions, with only 1.5% in our series compared to 33.4-37.4% in the literature [14,20]. Finally, as mentioned previously, our series included a higher percentage of patients with advanced stage disease (stage III and IV) (44.6%). In the literature, this rate varies between 25.8 and 33.3% [7,11,15,20]. Our patients were followed for an average of 25.6 months. In the literature, the mean duration of the follow-up ranges from 1 to 111 months [1,3,6-9,12,14,15,18,2022]. The rate of recurrence of our series is slightly above that in the literature (23.8% and 20.3%, respectively) but it is interesting to note that our long-term mortality rate (1.5%) is lower than that reported in the literature (18-56.3%) [8,15]. CONCLUSIONS The main indication for right or transverse colectomy is colon cancer. Open access and laparoscopic access are two surgical techniques allowing curative treatment of colon cancer, and these two methods have identical long-term postoperative morbidity, mortality, and disease progression. Nevertheless, a decreased rate of local morbidity and shorter hospital stay support the use of laparoscopic surgery in patients without contraindications.
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11. Le Nel JC, Lasserre P, Letessier E, Jurczak F, Bernard P, Mauchien C, Armstrong O Surgical treatment of colonic cancer after 75 years of age. Study of a series of 240 patients. Chirurgie. 1999; 124: 670-674. 12. Basse L, Jakobsen DH, Bardram L, Billesblle P, Lund C, Mogensen T, Rosenberg J, Kehlet H. Functional recovery after open versus laparoscopic colonic resection. Ann Surg. 2005; 241: 416423. 13. Hsu TC. Feasibility of colectomy with mini incision. Am J Surg. 2005; 190: 48-50. 14. Guillou PJ, Quirke P, Thorpe H, Walker J, Jayne DG, Smith AM, Heath RM, Brown JM. MRC CLASICC trial group. Laparoscopic surgery versus open surgery for colon cancer: short-term outcomes of a randomised trial. Lancet Oncol. 2005; 6: 477-484. 15. Rault A, Collet D, Sa Cunha A, Larroude D, Ndobo'epoy F, Masson B. Surgical management of obstructed colonic cancer. Ann Surg. 2005; 130: 331-335. 16. Hsu TC. Comparaison of one-stage resection and anastomosis of acute complete obstruction of left and right colon. Am J Surg. 2005; 189: 384-387. 17. Senagore AJ, Delaney CP, Brady KM, Fazio VW. Standardized approach to laparoscopic right colectomy: outcomes in 70 consecutives cases. J Am Coll Surg. 2004; 199: 675-679. 18. Joels CS, Mostafa G, Matthews BD, Kercher KW, Sing RF, Norton HJ, Heniford BT. Factors affecting intravenous analgesic requirements after colectomy. J Am Coll Surg. 2003; 197: 780785. 19. Lauter DM, Froines EJ. Initial experience with 150 cases of laparoscopic assisted colectomy. Am J Surg. 2001; 181: 398-403. 20. Lacy AM, Garca-Valdecasas JC, Delgado S, Castells A, Taur P, Piqu JM, Visa J. Laparoscopy-assisted colectomy versus open colectomy for treatment of non metastatic colon cancer: a randomised trial. Lancet. 2002; 359: 2224-2229. 21. Rawlings AL, Woodland JH, Crawford DL. Telerobotic surgery for right and sigmoid colectomies: 30 consecutives cases. Surg Endosc. 2006; 20: 1713-1718. 22. Schlachta CM, Mamazza J, Poulin EC. Are transverse colon cancers suitable for laparoscopic resection? Surg Endosc. 2007; 21: 396-399. 23. Belizon A, Sardinha CT, Sher ME. Converted Laparoscopic Colectomy. Surg Endosc. 2006; 20: 947-951. 24. Cermak K, Thill V, Simoens CH, Smets D, Ngongang CH, da Costa PM. Surgical resection for colon cancer: laparoscopic assisted vs. open colectomy. Hepato-Gastroenterol. 2008; 55: 412417. 25. Weeks JC, Nelson H, Gelber S, Sargent D, Schroeder G. Clinical Outcomes of Surgical Therapy (COST) Study Group. Short-term QOL outcomes following laparoscopc-assisted colectomy vs open colectomy for colon cancer. JAMA. 2002; 287: 321-328. 26. Lascano CA, Kaidar-Person O, Szomstein S, Rosenthal R, Wexner SD. Challenges of laparoscopic colectomy in the obese patient: a review. Am J Surg. 2006; 192: 357-365. 27. Vignali A, Di Palo S, Tamburini A, Radaelli G, Orsenigo E, Staudacher C. Laparoscopic vs Open Colectomies in Octogenarians: A Case-Matched Control Study. Dis Colon Rectum. 2005; 48: 2070-2075. 28. Polat AK, Yapici O, Malazgirt Z, Basoglu T. Effect of type of resection and manipulation on trocar site contamination after laparoscopic colectomy: an experimental study in rats with intraluminal radiotracer application. Surg Endosc. 2007; 22: 1398-1401. 29. Bessler M. Tumor implantation at laparoscopy. Is it a real problem? Surg Endosc. 1998; 12(11): 1288-1289. 30. Brundell SM, Tucker K, Texler M, Brown B, Chatterton B, Hewett PJ. Variables in the spread of tumor cells to trocards and port sites during operative laparoscopy. Surg Endosc. 2002; 16: 1413-1419. 31. Fukunaga Y, Higashino M, Tanimura S, Takemura M, Osugi H. Laparoscopic colorectal surgery for neoplasm. A large series by a single surgeon. Surg Endosc. 2008; 22: 1452-1458.

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CALCIUM LEVEL, A PREDICTIVE FACTOR OF HYPOCALCEMIA FOLLOWING TOTAL THYROIDECTOMY


Ancua Leahu,Vanessa Carroni, G. Biliotti Department of Clinical Physiopathology, Section of Surgery University of Florence, Italy
CALCIUM LEVEL, A PREDICTIVE FACTOR OF HYPOCALCEMIA FOLLOWING TOTAL THYROIDECTOMY (Abstract): The purpose of this research was made necessary by the progressive increase in costs for medical assistance, together with a decrease in the number of available hospital beds and therefore raising the necessity for a shorter stay in hospital and safe hospital discharge. Methods: This research is based on a study group of 206 patients, who had recently undergone total thyroidectomy surgery due to different pathologies (functional or non functional goiter, Basedow disease, differentiated carcinoma, medullar carcinoma). In order to discharge the patients safely within 24 hours after surgery, not well accepted by all the patients the serum calcium level was postoperatively measured at regular intervals, after 6, 12 and 18 hours. We used the variance analysis of the 3 samples, utilizing the p-value to verify the possibility of reducing the necessary number of blood samples to two when calculating the risk factor of hypocalcemia. Conclusion: We can consider the evaluation of the calcium level at 6 and 18 hours, sufficient to establish a calcium trend. All the patients who had registered a positive or doubt trend of calcium levels can be discharged the day after surgery, with minimum risk of subsequent hypocalcemia. The cases that registered a negative trend of calcium levels during the recovery, can not be considered as certain indicator of late hypocalcemia and therefore it is necessary to measure the PTH level, which gives highly predictive values both in scientific literature and also in our research: in 93.5% of the cases, a correlation between the PTH levels and an eventual development of hypocalcemia was noted. KEY WORDS: HYPOCALCEMIA; CALCIUM SLOPE; TOTAL THYROIDECTOMY Correspondence to: Giancarlo Biliotti, MD, PhD, Professor of Surgery, Department of Clinical Physiopathology, Section of Surgery, University of Florence, Viale Morgagni 85, 50121; Florence, Italy; e-mail: g.biliotti@dfc.unifi.it*

INTRODUCTION Total thyroidectomy, similar to hemithyroidectomy, is followed by a significant reduction in the plasmatic concentration of PTH [1]. It is associated with a parallel reduction in calcium levels, evident but transitory in a quarter of patients following surgery and permanent in 1% of patients [2]. The frequency of this phenomenon, which can occur during the successive hours after surgery, has recently been the subject of many research programmes, examining the definition of an algorithm that identifies patients with a high risk of postoperative hypocalcemia [3]. In the modern climate of increasing cost awareness, thyroid surgery has been considered for a 1 day-surgery regime with limiting factors for early discharge being postoperative bleeding (1-2%), bilateral recurrent laryngeal nerve palsy and symptomatic hypocalcemia [4,5]. Postoperative hypocalcemia after total thyroidectomy is a serious concern because it is the most frequent complication after thyroid surgery [6-8]. It is usually evident in the first 24 hours.
received date: 20.03.2009 accepted date: 1.04.2009
*

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A reliable method that could accurately identify patients who are at high risk for hypocalcemia may assist in the selection of patients suitable for early discharge [3]. The aim of the present work is to evaluate the risk of hypocalcemia following thyroid surgery and to determine whether early serial postoperative serum calcium levels after total thyroidectomy can be used to develop an algorithm identifying patients who are unlikely to develop significant hypocalcemia and can be safely discharged within 24 hours after surgery. There is an open debate in scientific literature regarding the use of early parathyroid hormone (PTH) levels as a predictor of significant hypocalcemia [9]. The cost factor is the major limitation for its wider clinical use. A purpose of this research was to verify the predictability of the post operative dosages of calcium, to reduce costs. MATERIALS AND METHODS The study was comprised of 206 patients who had undergone surgery for various thyroid diseases (goiter, cancer, Basedow disease) (Table I). The following details were recorded: age, sex, pre-operative clinical diagnosis (Table II). The mean age of the patients was 47 (range 5-79), 164 of the patients were females and 42 were males.
Table I Distribution of 206 patients who had undergone surgery according to various thyroid diseases and postoperative calcium levels Pathology Cancer Adenoma Inflammatory Goiter Patients without hypocalcemia 15 6 65 80 Patients with hypocalcemia 3 1 16 20

Table II Distribution of 206 patients who had undergone surgery according to gender and postoperative calcium levels Gender Females Males Patients without hypocalcemia 130 36 Patients with hypocalcemia 34 6

Serum calcium measurements at 6, 12 and 18 hours postoperatively were evaluated for each patient. A calcium level of 8.2 mg/dL was considered as a threshold value of hypocalcemia, defining the following: a negative trend when the straight halfway line of the 3 values had a decreasing tendency, a positive trend when the straight halfway line of the 3 values had an increasing rise and a doubt trend when there was a decrease arriving near but over the threshold value of hypocalcemia (Fig. 1). Hypocalcemia was defined as experiencing signs or symptoms of hypocalcemia perioral and digital paresthesias (Chvosteks sign and Trousseaus sign) and / or having a serum calcium level that was lower than 8.2 mg/dL. Patients were placed in a treatment algorithm based on the level of serum calcium and on the signs or symptoms of hypocalcemia (calcium gluconate 1-2 g/day and calcitrol 50-100 g/day [10,11].

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According to the change in the serum calcium level among the 3 measurements, a variant analysis was performed, using p-values in order to identify the possibility of reducing the number of measurements necessary to evaluate the risk of hypocalcemia. The entire analysis was performed utilising Stat 2 software. RESULTS Thyroid pathologies, gender and age did not show any significant correlation to the development of significant post operative hypocalcemia. From 206 patients studied, 81 (40%) showed a positive trend, only 3 of these (3.8%) successively developed hypocalcemia; from 64 patients with a negative trend 33 (51.6%) developed hypocalcemia and with a doubt trend only 4 (6.5%) of 61 patients (29%).
11

10

6h
6

12 h
5
N= 81 81 81 66 66 66 59 59 59

18 h
POSITIVE NEGATIVE DOUBT

TREND

Fig. 1 Distribution of calcium levels according to dose and trend

Table III Distribution of 206 patients according trend and postoperative calcium levels Patients with trend Positive Negative Doubt Total 81 (40%) 64 (31%) 61 (29%) 206 Normocalcemia 78 (96.2%) 31 (48.4%) 57 (93.5%) 166 (81%) Hypocalcemia 3 (3.8%) 33 (51.6%) 4 (6.5%) 40 (19%)

As expected, the incidence of hypocalcemia was moderate for patients with a doubt trend (6.5%) and maximal in patients with a negative trend (51.6%). On the other hand, the findings of a negative trend calcium level are not absolutely predictive for hypocalcemia, in fact it developed in only 33 patients (51.6%). A positive slope predicted hypocalcemia 4.92% and a negative slope predicted 51,5% of the time with a 95,18% probability of remaining within normal calcium levels

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(Table III). Patients were treated with oral calcium in the case of hypocalcemia. At three months after surgery 97.08% of patients had normal serum calcium levels. This demonstrated that by solely relying on a positive or negative rise trend, there was still a significant risk of the development of hypocalcemia. In those cases, the measurement of the PTH level with a higher predictive value revealed that in 93.5% of the cases a correlation could be observed between the PTH levels and an eventual development of hypocalcemia. We did not find any statistically significant differences in the plasma calcium level between the samples taken at 12 and 18 hours after surgery. DICUSSIONS AND CONCLUSIONS Improvement in surgical technique has led to a relevant decrease in severe postoperative complications after thyroid surgery and surgeons are considering whether one day hospital would be feasible after total thyroidectomy. In fact severe hypocalcemia continues to represent a limiting factor for such a short stay in hospital. The incidence of hypocalcemia after total thyroidectomy transient in the majority of cases in literature oscillates between extremely large limits (from 11.2% to 35%) [6-8]. Regarding our investigation, we have observed a postoperative hypocalcemia in 20% of the cases. There is no existing scoring method allowing the identification of patients who will not develop severe hypocalcemia. We used early serum calcium levels after total thyroidectomy to identify patients with a risk of developing significant hypocalcemia and allowing an early discharge. The positive rise of the calcium level after total thyroidectomy is a reliable method in 96.2% of cases allowing the patient to be discharged with a risk of hypocalcemia of only 3.8%. Otherwise, the doubt trend gives a 6.5% margin of risk, making it necessary to conduct further haematic measurements in the consequent hours. In the case of negative trend, the risk of hypocalcemia is 51.6%. In this case, the decreasing tendency of serum calcium level remains an imperfect method but anyway the hospital discharge is delayed. Regarding the serum calcium measurements used to evaluate the trend, we found no statistically significant calcium level at 12 hours after surgery. Intra and postoperative intact parathyroid hormones has been embraced with enthusiasm by many surgeons as a means to detect patients with the highest risk of severe hypocalcemia, but its major limitation for wider clinical use is the cost factor.
1. 2. 3. 4. 5. REFERENCES Miccoli P, Minuto MN, Panicucci E, Cetani F, D'Agostino J, Vignali E, Picone A, Marcocci C, Berti P. The impact of thyroidectomy on parathyroid glands: a biochemical and clinical profile. J Endocrinol Invest. 2007; 30(8): 666-671. Asari R, Passler C, Kaczirek K, Scheuba C, Niederle B. Hypoparathyroidism after total thyroidectomy: a prospective study. Arch Surg. 2008; 143(2): 132-137. Nahas ZS, Farrag TY, Lin FR, Belin RM, Tufano R. A safe and cost-effective short hospital stay protocol to identify patients at low risk for the development of significant hypocalcemia after total thyroidectomy. Laryngoscope. 2006; 116(6): 906-910. Rosato L., Avenia L, Bernante P, De Palma M, Gulino G, Nasi PG, Pelizzo MR, Pezzullo L. Complication of thyroid surgery: analysis of a multicentric study on 14934 patients operated on Italy over 5 years. World J Surg. 2004; 28: 271-276. Gac EP, Caban TP, Amat VJ, Huidobro GF, Rossi FR, Rodrguez FF, Ferrada VC, Cardemil RF. Incidence of hypocalcemia after total thyroidectomy. Rev Med Chil. 2007; 135(1): 26-30.

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Scium C, Geraci G, Pisello F, Facella T, Li Volsi F, Licata A, Modica G. Complications in thyroid surgery: symptomatic post-operative hypoparathyroidism incidence, surgical technique, and treatment. Ann Ital Chir. 2006; 77(2): 115-122. 7. Page C, Strunski V. Parathyroid risk in total thyroidectomy for bilateral, benign, multinodular goitre: report of 351 surgical cases. J Laryngol Otol. 2007; 121(3): 237-241. 8. Costanzo M, Caruso LA, Messina DC, Palumbo A, Arcerito MC, Cannizzaro MA. Postthyroidectomy hypocalcemia. Ann Ital Chir. 2004; 75(6): 623-627; discussion 627-628. 9. Australian Endocrine Surgeons Guidelines AES06/01. Postoperative parathyroid hormone measurement and early discharge after total thyroidectomy: analysis of Australian data and management recommendations. ANZ J Surg. 2007; 77(4): 199-202. 10. Tartaglia F, Giuliani A, Sgueglia M, Biancari F, Juvonen T, Campana F. Randomized study on oral administration of calcitriol to prevent symptomatic hypocalcemia after total thyroidectomy. The American Journal of Surgery. 2005; 190(3): 424-429. 11. Pisaniello D, Parmeggiani D, Piatto A, Avenia N, dAjello M, Monacelli M, Calzolari F, Sanguinetti A, Parmeggiani U, Sperlongano P. Which therapy to prevent pos-thyroidectomy hypocalcemia? G Chir. 2005; 26(10): 357-361.

6.

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SCREENING FOR COLORECTAL CANCER WITH FECAL OCCULT BLOOD TESTING AND COLONOSCOPY: CORRELATION OF CLINICAL DATA, SITE, SIZE AND DISEASES STAGE
Iuliana Tarai1, Gabriela Florena Dumitrescu2, Anca Indrei3, P. Plmdeal4, Anca Trifan5, C. Stanciu5, 1 Departament of Gastroenterology, St. Spiridon Emergency Clinical Hospital Iai 2 Department of Pathology, Prof. Dr. N. Oblu Emergency Clinical Hospital Iai 3. Department of Anatomy and Embriology, Gr.T. Popa University of Medicine and Pharmacy Iasi 4 Department of Pathology, St. Mary Emergency Clinical Hospital Iai 5 Institute of Gastroenterology Iai
SCREENING FOR COLORECTAL CANCER WITH FECAL OCCULT BLOOD TESTING AND COLONOSCOPY: CORRELATION OF CLINICAL DATA, SITE, SIZE AND DISEASES STAGE (Abstract): Aim: We present the main results from a combined screening study for colorectal cancer carried out in an asymptomatic population from Iai, Romania, during 2004-2007, adopting a combination of faecal occult blood testing (FOBT) and full colonoscopy. The primary aim of the current study was to determine the location of polyps and cancers and the prevalence of advanced histologic features in colorectal lesions removed by polipectomy followed or not by surgery. Secondary aim was to determine whether there were any risk factors for advanced histology in each patient group. Material and methods: Overall, 1291 asymptomatic subjects were screened. Patients were divided into groups, based on age: 50-59 yr, 60-69 yr, and 70 years, which were statistically analyzed. Results: Using FOBT and full colonoscopy with polypectomy as combined screening tools we were able to identified 38 cases (2.94%) of polypoid lesions (non-neoplastic and neoplastic) and colorectal cancers. 1.85% subjects from all eligible subjects were found to have advanced neoplasia and 43.75% of them had advanced histology. Taking into consideration colorectal adenomas, there were a predominance of male subjects in 50-59 age group (31.25%), but their histology was not an advanced one. As age increases to 70 years old, the tendency is for women subjects with villous architecture with high-grade dysplasia to predominate (18.5%). Proximal site was associated with smaller size of neoplastic polyps (<40 mm), and tubular architecture with or without non-invasive low-grade dysplasia. Distal colon expressed all histopathological types with all kind of grades of dysplasia, but 12.5% of cases were associated with greatest sizes (40mm), villous architecture with non-invasive high-grade dysplasia. We detected 8 (21.05%) cancers from all positive FOBT and colonoscopic detected lesions. The mean age of subjects with colorectal cancers was greater than that of subjects with colorectal adenomas (64.125 vs 61.125 years old). We found a male predominance and a predominant 50-59 years age group affected by the disease. There was an equal distribution on the left and right sided cancers. Most subjects, especially those in 50-59 group age were in stage II (87.5%), but there was a stage I colorectal cancer detected in a 60-69 years age group male. On histopathological examination adenocarcinoma was the commonest type (87.5%). Conclusions: Some aspects like the older age at presentation (mean age 64.125 years), equal right to left site location, and 12.5% cancers showing early stage (I) can be consider similar to that reported in Western countries. Some others epidemiological features like delayed presentation of the disease in an advanced stage (87.5%) make our population similar to that from developing countries. Our study prove that colonoscopy can be a useful screening tool when is applied to average-risk people who had a positive FBOT. We support the urgent need to screen asymptomatic subjects as high percentage of locally advanced tumors was detected. KEY WORDS: POLYP, CANCER, COLORECTAL, COLONOSCOPY, FBOT Correspondence to: Iuliana Tarai, MD; e-mail: iulianatarasi@yahoo.com*

received date: 30.11.2008 accepted date: 10.03.2009

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INTRODUCTION Colorectal carcinoma is one of the most common types of cancer throughout Europe, with about 250,000 cases annually in Europe, about half of whom die [1,2]. While colon cancer in an advanced and incurable stage often produces clinical findings, premalignant adenomatous polyps and early, highly curable, colon cancer are often asymptomatic. This phenomenon renders adenomas or early cancers difficult to detect by clinical presentation and provides the rationale for mass screening of asymptomatic adults over 50 years old for early detection and prevention of colon cancer [2,3]. It is believed that more than 50% of colorectal deaths may have been prevented through the use of screening tests [3,4]. Screening of asymptomatic individuals for colon malignancy has been advocated for the past 30 years in the hopes of reducing colon cancer mortality [5]. With technological advances in recent years it is now feasible to screen asymptomatic individuals so that, with early diagnosis through screening and appropriate follow-up and treatment, both morbidity and mortality from colorectal cancer may be decreased. Fecal occult blood tests (FBOT) and flexible sigmoidoscopy were used in many screening programs, but in the last years colonoscopy has become the primary screening test because of its high sensitivity and specificity, and the ability to perform polypectomy [2,4,6-9]. In the present study a combined screening investigation (FOBT and full colonoscopy) of 1291 asymptomatic subjects was conducted in a three years period (2004-2007) for identification of the distribution of colorectal adenomas and carcinomas by age at diagnosis, gender, and sub-site of the tumor. These factors also are evaluated in conjunction with size and grade of dysplasia in case of adenomas, or with disease stage and tumor differentiation at the time of diagnosis in case of colorectal cancers. MATERIAL AND METODS Participants - 1291 participants (702 males, and 589 females), from metropolitan area of Iai, a city of about 500,000 inhabitants, were enrolled in a prospective colorectal cancer screening at Ambulatory of St. Spiridon Clinical Emergency Hospital Iai from February 1-st, 2004 until December 31-st, 2007. Participants were recruited by random selection on the basis of age ( 50 years old) and were eligible for screening if they had none of the following: history of inflammatory bowel disease, active rectal bleeding or positive FOBT in the past 12 months, history of colon polyps or colon cancer, colonoscopy or sigmoidoscopy within the past 5 years, family history of colon cancer with either a single affected first-degree relative aged 55 years or older or at least two affected first-degree relatives of any age. Study protocol - Asymptomatic subjects provided stool specimens from three consecutive days for fecal occult-blood testing (Hemoccult Sensa). The two stool samples for FOBT were collected from two different parts from the same stool. The participants were instructed to abstain from red meat, poultry, fish, and certain raw vegetables and fruits and to stop taking vitamin C tablets and aspirin for 24 hours before and during the collection of the samples; adherence to this regimen was not verified. The slides were tested at the Clinical Laboratory of the St. Spiridon Clinical Hospital Iai according to a standardized, controlled procedure. The FOBT test was judged to be positive if one of the 3 samples per patient yielded a positive test reaction. 89 subjects (48 males, and 34 females) with a positive result detected were referred for a full colonoscopy.

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A complete video colonoscopic examination was performed by experienced gastroenterologists from Institute of Gastroenterology Iai. During the examination, the location and size of all polypoid lesions were noted on a standardized report form. Unless medically contraindicated, any tumoral mass was resected or biopsied and sent to the Department of Pathology for analysis. When the histopathological report identified a cancer, the patient was sent to surgical department. Tumoral masses were considered to be located in the right colon (proximal location) when arising in the cecum, ascending colon, hepatic flexure, and transverse colon. Distal location included lesions found in the left colon (splenic flexure, descending colon and sigmoid) and rectum (intestinal portion located no more than 15 cm from the anal verge).
Table I Vienna Classification of gastrointestinal epithelial neoplasia [12] Category 1 Category 2 Category 3 Category 4 Negative for neoplasia / dysplasia (normal, reactive, regenerative, hyperplastic, atrophic, and metaplastic epithelium) Indefinite for neoplasia / dysplasia Non-invasive low-grade neoplasia (low-grade adenoma / dysplasia) Non-invasive high grade neoplasia 4.1. High grade adenoma / dysplasia 4.2. Non-invasive carcinoma (carcinoma in situ) 4.3. Suspicion of invasive carcinoma Invasive neoplasia 5.1. Intramucosal carcinoma 5.2. Invasive carcinoma

Category 5

Histologic evaluation - All the retrieved colonic lesions were sent to Pathology Department for histologic evaluation. Polypoid lesions and carcinomas were fixed in buffered 10% formaldehyde solution. Multiple semiserial sections were cut to assess questionable examples of microinvasive carcinoma. The pathologist noted the histological type and grades of epithelial dysplasia for adenomas using the World Health Organization International Classification of Intestinal Tumors criteria. Colorectal adenomas can be defined as well demarcated, circumscribed lumps of epithelial dysplasia (atypia) with or without a stalk, usually polypoid but occasionally flat, which can be classified into three histological types: tubular, tubulovillous and villous. If the tubular pattern occupied more than 80% of the tumor it was classified as tubular; with a villous pattern of more than 80% it was classified as villous; the remainder were classified as tubulovillous. Subjects were assigned to groups based on the histology of polyp(s) and of the stage of the carcinoma found at colonoscopy. A lot of studies defined advanced colonic neoplasia as two entities: invasive cancer and advanced adenoma. Advanced adenoma was defined as a lesion of adenomatous histology that meets at least one of the following criteria: a size of 10 mm or more, the presence of a villous component of at least 25%, or the presence of highgrade dysplasia [10,11]. Non-invasive indicates absence of evident invasion. Intramucosal indicates invasion into the lamina propria or muscularis mucosae [12]. As all resected tumoral polyps in our study had a size of more than 20 mm, the pathologist wanted to avoid confusion concerning the terms adenoma, dysplasia, and carcinoma, and used The Vienna classification of gastrointestinal epithelial neoplasia which graded the intestinal

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epithelial neoplasia into five categories (Table I). Carcinomas were histopathologically characterized by tumoral type, grade of cell diferention, blood vessels infiltration, lymphatic vessels infiltration, and extent of tumor penetration and then were grouped in stages according to tumor-node-metastasis (TNM) classification of the Union Internationale Contra le Cancer (UICC) and the American Joint Committee on Cancer (AJCC). The histologic grade of the pure adenocarcinomas was based on a survey of the tumor architecture and cytologic features, and tumors were categorized according to the predominant growth pattern. The well differentiated tumors were characterized by wellformed glands composed of relatively uniform cells distributed in an orderly manner abut a central lumen. The moderately differentiated tumors were characterized by less orderly, more complex gland formation with foci of cribriform and papillary growth patterns. Adenocarcinoma with colloid features (AD/CF) was defined as adenocarcinoma with an intermediate morphology (both ordinary gland-forming and colloid growth patterns, the former predominating) and less than 15% of the colloid pattern present. Colloid carcinoma was defined as an adenocarcinoma growing largely (more than two-thirds) in a colloid pattern. The TNM system compartmentalizes carcinomas according to the depth of invasion of the primary tumor, the absence or presence of regional lymph node metastases, and the absence or presence of distant metastases.
Table II Characteristics of subjects enrolled in screening study Subjects enrolled Positive FOBT Negative FOBT Asymptomatic (Total) Number (percents) 89 (6.89%) 1202 (93.10%) 1291 (100%) Male 48 (53.93%) 654 (50.65%) 702 (54.37%) Female 41 (46.06%) 548 (49.34%) 589 (45.62%)

RESULTS During 2004-2007, 1291 asymptomatic subjects 50 years old had three FOBT; 89 (6.89%) FOBT screened patients (48 males and 41 female) had at least one positive Hemoccult Sensa test and 82 (92.13%) positive FOBT-subjects (46 males and 36 females) received full colonoscopy (Table II). The overall rate of any colonic neoplasia (adenoma or carcinoma) was 1.85% (24 of 1.291 subjects) and the overall rate of colorectal lesion with advanced histology (category 4 and 5 in Vienna Classification) was 1.16% (15 of 1291 subjects) (Table III). FOBT detected 17.07% cases of reactive and hyperplasic epithelium (polyps 10mm) and 29.26% cases of adenomas with advanced neoplasia (polyps 20mm) and cancers (Table IV). Combined screening using colonoscopy in positive FOBT subjects revealed reactive and hyperplasic epithelium (polyps 10mm) in 36.84% participants and adenomas with advanced neoplasia (polyps 20mm) and cancers in 63.16%. Adenomas with advanced histology were detected in 7 cases (18.42%) and colorectal cancer in 8 (21.05%) subjects (Table IV). The histopathological diagnosis of the colorectal lesion detected in the 38 subjects with positive FOBT and positive full colonoscopy revealed 14 (17.07%) negative cases for neoplasia / dysplasia (Category 1) as there were 6 cases of reactive

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epithelium and 8 cases of hyperplastic epithelium. 46.33% of the 82 positive FOBT subjects were diagnosed during colonoscopy as having either polypous lesion or cancer (Table IV). There were 16 (42.10%) adenomas 20 mm or larger in diameter and 8 (21.05%) colorectal cancers (Category 5). 39.47% (15 cases) of all detected lesions were advanced neoplasia (Category 3, 4 and 5) (Table IV).
Table III The overall rate of colonic neoplasia correlated with screening tools Asymptomatic subjects Subjects with positive FOBT Subjects with positive FOBT and positive full colonoscopy Subjects with advanced neoplasia detected by FOBT and full colonoscopy Subjects with advanced histology detected by FOBT and full colonoscopy 1291 (100%) 89 (6.89%) 38 (2.94%) 24 (1.85%) 15 (1.16%)

Table IV Colonoscopic and histological results of subjects with at least one positive FOBT Histologic results Patients with positive FBOT followed by colonoscopy (n=82) 38 Positive colonoscopy (46.34%) 44 Negative colonoscopy (53.65%) Category 1 14 (36.84%) Category 2 9 (23.68%) Category 3, 4 7 (18.42%) Category 5 8 (21.05%) -

Table V The cumulative age, sex and histology distribution of colorectal adenomas Tubular adenoma 50-59 60-69 70 Male Female Male Female Male Female Total 4 2 1 2 9 (56.25%) Tubular adenoma with low-grade dysplasia 1 1 2 (12.5%) Villous adenoma 1 1 1 3 (18.75%) Villous adenoma with high-grade dysplasia 1 1 2 (12.5%) Total 5 (31.25%) 3 (18.75%) 2 (12.5%) 3 (18.5%) 3 (18.75%) 16 (100%)

The most affected asymptomatic subjects by any colorectal adenoma were those included in 50-59 years-age-group (56.25%). Mean age was 61.125 years (range 50-75). Tubular adenomas were the most frequently encountered 68.75% (11 cases), the dysplasic subtype representing 12.5% (2 cases). Villous adenoma was diagnosed in 5 cases (31.25%) the dysplasic subtype representing 2 cases (12.5%) from all the colonoscopic detected adenomas (Table V). We examined risk factors associated with advanced histology (Category 3 and 4) within each age group, location and size of adenomas. 50-59 yearsage group was strongly associated with tubular adenoma without dysplasia (37.5%). Only 12.5% (2

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cases) of adenomas were detected in 70-75 years age group, but correspond to villous adenomas with or without dysplasia (Table V). The majority of polyps detected by colonoscopy (56.25%) was 20-29 mm in size and had a tubular architecture. There is an overlap between tubular adenoma with lowgrade dysplasia and villous adenoma at 30-39 mm sized polyps. As polyp sizes increased to 40 mm all the lesions were villous adenoma with high-grade dysplasia, but there were only a minority of cases (12.5%) (Table VI).
Table VI Correlations between histological types of adenomas and their sizes Size of adenomas 20-29 mm 30-39mm 40mm Total Tubular adenoma 9 (56.25%) 9 (56.25%) Tubular adenoma & dysplasia 2 (12.5%) 2 (12.5%) Villous adenoma 3 (18.75%) 3 (18.75%) Villous adenoma & dysplasia 2 (12.5%) 2 (12.5%) Total 9 (56.25%) 5 (31.25%) 2 (12.5%) 16 (100%)

Table VII Correlations between site and histological type of colorectal adenomas Tubular adenoma Proximal Colon Distal Colon Total 1 (6.25%) 8 (50.00%) 9 (56.25%) Tubular adenoma with non-invasive low grade dysplasia 1 (6.25%) 1 (6.25%) 2 (12.5%) Villous adenoma Villous adenoma with non-invasive high grade dysplasia 2 (12.5%) 2 (12.5%) Total 2 (12.5%) 3 (18.75%) 3 (18.75%) 14 (87.5%) 16 (100%)

Proximal location was identified as the site for development of colorectal adenomas in 12.5% of the subjects and was associated only with tubular adenomas with or without non-invasive low-grade dysplasia (Category 3). 87.5% of total adenomas were in the distal colon (14 out of 16) and expressed all histopathological types with all kind of grades of dysplasia, but 31.25% of cases were associated with villous adenomas with or without non-invasive high-grade dysplasia (Table VII). Colorectal carcinomas represented 21.05% (8 cases) of all colonoscopic detected lesions in asymptomatic subjects with positive FOBT. Mean age was 64.125 years (53 years to 78 years). 6 cases (75%) were found to be pure adenocarcinomas, with welldifferentiated tumors constituting the largest group (4 cases). Adenocarcinoma with colloid features (AD/CF) occurred in 1 case (12.5%). Colloid carcinoma was seen in 1 subject (12.5%) (Table VIII). The distribution of tumors by site for the entire group was: proximal colon - 4 cases (50%) and distal colon - 4 cases (50%). Pure adenocarcinomas were distributed

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equally in proximal and distal colon. Colloid carcinoma encountered in proximal colon, and adenocarcinoma with colloid features appeared in distal colon (Table VIII). There were 5 males and 3 females subjects. The age was not a differentiating factor but more frequent colorectal cancer appear in equal percentage (37.5%) in 50-59 age group and 60-69 age group. The distribution of all 8 invasive carcinomas by stage (S) showed a larger number of S II colonoscopic detected colorectal cancers (75%), most of them developing in males, 50-59 age group (Table IX). Colorectal cancers detected by colonoscopy were situated in equal percentages in proximal colon (50%) and distal colon (50%). Half of the colonoscopic derected proximal colon cancers developed in 60-69 years group, but 50% of distal colon cancers was associated with 50-59 years group. 70 group presented the same distribution of cancers in both colonic segments.
Table VIII Degree of differentiation of colorectal carcinoma (histological grading) Degree of differentiation Well differentiated (G1) Moderately differentiated (G2) Poorly differentiated (G3) with colloid areas Colloid carcinoma (G3) Total Proximal colon 2 1 Distal colon 2 1 1 1 4 (50%) 4 (50%) No. subjects 4 (50%) 2 (25%) 1 (12.5%) 1 (12.5%) 8 (100%)

TableIX The cumulative age, sex and colorectal cancer stage distribution Demographic characteristics Male Female 50-59 60-69 70 Total Number (%) 5 (62.5%) 3 (37.5%) 3 (37.5%) 3 (37.5%) 2 (25%) 8(100%) Stage I 1 1 1 (12.5%) Stage II 4 2 3 2 1 6 (75%) Stage III 1 1 1 (12.5%) Stage IV -

DISCUSSIONS Colorectal cancer is the second leading cause of cancer death in the United States. In women, it ranks third after lung and breast cancer, and in men, it ranks third after lung and prostate cancer. Incidence and mortality from colorectal cancer are similar in both men and women [3]. Death from colorectal cancer can be prevented by the detection of early-stage disease that has not metastasized. The concept of the early detection of colorectal cancer appear in the late 1960s, but technical means by which this concept could be implemented clinically developed in 1970s [5]. The American Cancer Society, The US Preventive Services Task Force, and a number of surgical and gastroenterological associations have established guidelines for colorectal cancer screening and

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surveillance. A variety of screening options are recommended for average-risk, asymptomatic individuals beginning at about age 50 years. These include FOBT, flexible sigmoidoscopy, doublecontrast barium enema, or colonoscopy and are associated with a decrease in colorectal mortality. Each of these tests has different features and none clearly emerges as the "gold standard." FOBT is the least invasive test, whereas colonoscopy is the most accurate. Colonoscopy is routinely used to follow-up positive results obtained from other less invasive tests and also used for surveillance after the detection of polyps or cancer [13-18]. Recently, there has been increasing interest in using colonoscopy as a screening test because of its sensitivity in detecting precancerous polyps or lesions and its ability to remove such lesions as part of the same procedure. Several expert panels have recommended combined screening with sigmoidoscopy and a fecal occult-blood test as they argue that advanced neoplasia could be detected in more patients by both tests than by one [16,17,19]. American Cancer Society, for instance, recommends that average-risk individuals obtain an annual take-home multiple-sample fecal occult blood test (FOBT), a flexible sigmoidoscopy every 5 years (or both FOBT and flexible sigmoidoscopy), double-contrast barium enema every 5 years, or a colonoscopy every 10 years (13). Annual and biennial serial FOBT screening reduces colorectal cancer incidence by 17% to 20% [20], but also produces a 33 percent decline in mortality in the annually screened group as compared with the control group [21]. The reduction in mortality demonstrated in the FOBT screening studies is attributable to the performance of follow-up colonoscopy. Recent cross-sectional colonoscopy screening studies indicate that colonoscopy is more sensitive than flexible sigmoidoscopy or sigmoidoscopy plus FOBT for the detection of large adenomas and cancers [13]. Using FOBT and full colonoscopy with polypectomy as combined screening tools we were able to identified 38 cases (2.94%) of polypoid lesions (non-neoplastic and neoplastic) and colorectal cancers in 1291 asymptomatic subjects ( 50 years old). 1.85% subjects from all eligible subjects were found to have large colorectal lesions (greater than 20 mm in diameter), the so-called advanced neoplasia, and this percentage corresponds with those from other studies [5,17,22-24]. On the other hand, FOBT and full colonoscopy identified advanced histology in 43.75% of these large polyps that is two-three times higher than the percentage reported by Regula et al [24] and Fukami and Lee [25]. We observe that the endoscopic description of a lesion as a tumor may not necessarily reflect the presence of cancer. Although most patients (64.8%) had lesions with advanced histology including cancer (21.05%), we note that 35.7% did not have such features. In our study, bleeding polyps of 10-20 mm werent neoplasic and polyps of 2029 mm were tubular adenomas without any sign of malignity, but all the colonoscopic detected lesions greater than 30 mm showed advanced histology. Anyway, we can conclude that the larger the size of the colorectal lesion, the more likely it is to harbor advanced histology. The number of male subjects predominates in 50-59 group age (31.25%), but the histology of their adenomas was not an advanced one. As age increases to 70 years old, the tendency is for women subjects to predominate (18.5%). Their detected adenomas expressed a villous architecture with or without high-grade dysplasia. By the contrary, Konishi and Morson found in their study that the number of younger women patients slightly predominates, or is about the same as that of younger men patients but

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as age increases from 50 years old to over 80 years old, the tendency is for men patients to predominate [26]. Our results show that the most frequent detected type was the tubular one (68.75%) while villous adenomas appear more rarely (31.25%) but frequently was associated with high-grade dysplasia. Though our study is a small one (38 positive FOBT and full colonoscopic colorectal lesions), the histopathological results are similar with those of Liebermann et al (949 patients whose largest polyp was 10 mm) [10] and Konishi and Morson (1118 adenomas) [26]. In our study, more than a half of colonoscopic detected polyps expressed advanced neoplasia ( 20 mm) and 64.8% of them harbored advanced histology. It is worth worthy to specify that polyps < 30 mm didnt present any dysplastic features. Our results confirm a progressive increase in the proportion of advanced histologic features with increasing polyp size above 30 mm as all polyps greater than 40 mm harbour highgrade dysplasia. So, we can conclude that as the size of adenomas increases so does the grade of dysplasia. The influence of the size of adenomas on grade of dysplasia shows a similar trend to that previously reported. Loeve et al reported that 10.9% of patients who had a polyp of any size with high-grade dysplasia developed an advanced neoplasm within 5 years, compared with only 0.6% of those with small polyps that did not harbor high-grade dysplasia [27]. Liebermann et al. found that polyp histology was neoplastic in 82.0%, with advanced histology in 30.6%. There was a progressive increase in the proportion of polyps with advanced histology with increasing size above 10 mm. The proportion of polyps with advanced histology was 18.9% in 10-14 mm polyps, 31.7% in polyps 15-19 mm, 42.3% in polyps 20-24 mm, and 75% in polyps 25 mm [1]. Severe dysplasia in colorectal adenomas appears to be a selective histopathological marker for increased colorectal cancer risk. It is closely linked with increasing age, with the larger adenomas and particularly those with a villous component in their histology [26]. We identified proximal colon as the site for 12.5% adenomas and distal location for 87.5%. Proximal site was associated with smaller size of neoplastic polyps ( < 40 mm), and tubular architecture with or without non-invasive low-grade dysplasia (Category 3). Distal colon expressed all histopathological types with all kind of grades of dysplasia, but 12.5% of cases were associated with greatest sizes ( 40 mm), villous architecture with non-invasive high-grade dysplasia (Category 4). Our findings corresponds with other studies [10,26] as for larger polyps, distal location was associated with a higher likelihood of advanced histology compared with proximal location. Konishi and Morson found that small adenomas (mostly with mild dysplasia) were evenly distributed throughout the colorectum but that adenomas showing severe dysplasia (mostly the larger tumours, > 10 mm diameter) were concentrated in the left colon and rectum, particularly the sigmoid, part which is also the segment with the highest risk of colorectal carcinoma in high risk populations. In the right colon and in the transverse colon, 67% of adenomas were < 5 mm diameter excluding a small number of large irremovable ones. They were intrigued about the high percentage (9.5%) of severe dysplasia of adenomas situated in the left colon and about the unexpectedly small percentage of severe dysplasia in the right colon. They consider that these percentages could be due to biased selection of patients [26]. We examined risk factors associated with advanced histology within each group. We detected strong correlation between histological types and the age of asymptomatic

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subjects enrolled in our screening study. 50-59 group age was strongly associated with tubular adenoma without dysplasia (37.5%). Only 12.5% (2 cases) of adenomas were detected in female 70-75 yr age group, but correspond to villous adenomas with or without dysplasia. Liebermann et al didnt find any risk factors associated with advanced histology within each group [10]. Age, sex, and race were not associated with advanced histology within any of the groups. Only distal location of the 10 mm polyps was associated with a higher likelihood of advanced histology compared with proximal location [10]. Konishi and Morson found also a greater percentage of villous adenomas in patients older than 70 yr compared to younger age groups, the difference being statistically significant. The percentage of severe dysplasia in patients older than 70 years old was greater than that in the younger age groups [26]. Sato et al reported that adenomas are more often found in a high colorectal cancer risk community than in a low risk community. These authors also showed that the adenomas found in the high risk community more often exhibited severe dysplasia than in the low risk community [28]. As we identified a great percentage (31.25%) of villous adenomas most of them being associated with high-grade dysplasia (40%) we can assume the hypothesis that the community of Iai is one with high risk. Our results have shown that the larger adenomas with severe dysplasia are mostly concentrated in the left colon and rectum. It is well known that there is a higher colorectal cancer risk with increasing age. We have confirmed previous reports of a relation between age and severe dysplasia which, although not statistically significant, demonstrates a trend. Persons over 70 years old are particularly prone to a high incidence of severe dysplasia and consequently can be considered to be those with the highest cancer risk. Using both screening methods, we detected 8 (21.05%) cancers from all advanced neoplasia. The mean age of subjects with colorectal cancers was greater than that of subjects with colorectal adenomas (64.125 vs 61.125 years old). We found a male predominance and a predominant 50-59 years age group affected by the disease. There was an equal distribution on the left and right sided cancers. Most subjects, especially those in 50-59 group age, were in stage II (87.5%), but there was a Stage I colorectal cancer detected in a 60-69 years age group male. Making an extensive study (1694 colorectal hungarian patients), Fuszek et al reported also that 75.7% of the colorectal cancers were in T3-T4 at diagnosis and lymph node metastases could be detected in 47.7% [29]. On histopathological examination adenocarcinoma was the commonest type (87.5%) as was found in all studies dealing with colorectal malignancies (30-34). On histological grading well differentiated adenocarcinomas were the most frequent (50%), but from distal part to proximal part of the colon there was an increase of colloid in detected cancers. This study reveal that the subjects enrolled in our screening programme shares a mixture of epidemiological features of Western countries and USA on one side and those of developing countries on the other side for colorectal carcinoma. Some aspects like the older age at presentation (mean age 64.125 years), equal right to left site location, and 12.5% cancers showing early stage (I) can be consider similar to that reported in Western countries and United States of America [24,30]. Some others epidemiological features like delayed presentation of the disease in an advanced stage (87.5%) make our population similar to that from developing countries (36). Anyway, quite a similar profile as ours seems to be that reported by Celestino et al in Peru [31].

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CONCLUSIONS Although there is now general agreement that average-risk adults aged 50 and older should be screened for colorectal cancer, in Romania few eligible adults have ever been screened for this disease. Our study prove that colonoscopy can be a useful screening tool when is applied to average-risk people who had a positive occult blood test. We support the urgent need to screen asymptomatic subjects as high percentage of locally advanced tumors were detected and it is clear that it can be obtain not only a reduction in cancer mortality but also a reduction in its incidence.
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. REFERENCES Washington MK. Colorectal carcinoma: selected issues in pathologic examination and staging and determination of prognostic factors. Arch Pathol Lab Med. 2008; 132(10): 1600-1607. Cappell MS. From colonic polyps to colon cancer: pathophysiology, clinical presentation, screening and colonoscopic therapy. Minerva Gastroenterol Dietol. 2007; 53(4): 351-373. Walsh JME, Terdiman JP. Colorectal cancer screening - scientific review. JAMA. 2003; 289: 1288-1296. Kronborg O. Colon polyps and cancer. Endoscopy. 2002; 34(1): 69-72. Winawer SJ, Schottenfeld D, Flehinger BJ, Miller DG. Screening for colorectal cancer with fecal occult blood testing and sygmoidoscopy. J Natl Cancer Inst. 1993; 85(16): 1311-1318. Bond JH. Colon polyps and cancer. Endoscopy. 2001; 33(1): 46-54. Cappell MS. Reducing the incidence and mortality of colon cancer: mass screening and colonoscopic polypectomy. Gastroenterol Clin North Am. 2008; 37(1): 129-160. Lieberman DA, Smith FW. Screening for colon malignancy with colonoscopy. Am J Gastroenterol. 1991; 86(8): 946-951. Jass JR, Sobin LH. Histological typing of intestinal tumors. 2-nd ed. Heidelberg: SpringerVerlag. 1989. Lieberman DA, Moravec M, Holub J, Michaels L, Eisen G. Polyp size and advanced histology in patients undergoing colonoscopy screening: implications for CT-colonography. Gastroenterology. 2008; 135(4): 1100-1105. Lieberman DA, Weiss DG, Bond JH, Ahnen DJ, Garewal H, Chejfec G. Use of colonoscopy to screen asymptomatic adults for colorectal cancer: Veterans Affairs Cooperative Study 380. N Engl J Med. 2000; 343: 162-168. Schlemper RJ, Riddell RH, Kato Y, Borchard F, Cooper HS, Dawsey SM, Dixon MF, FenoglioPreiser CM, Fljou JF, Geboes K, Hattori T, Hirota T, Itabashi M, Iwafuchi M, Iwashita A, Kim YI, Kirchner T, Klimpfinger M, Koike M, Lauwers GY, Lewin KJ, Oberhuber G, Offner F, Price AB, Rubio CA, Shimizu M, Shimoda T, Sipponen P, Solcia E, Stolte M, Watanabe H, Yamabe H. The Vienna classification of gastrointestinal epithelial neoplasia. Gut. 2000; 47(2): 251-255. Winawer SJ, Fletcher RH, Miller L, Godlee F, Stolar MH, Mulrow CD, Woolf SH, Glick SN, Ganiats TG, Bond JH, Rosen L, Zapka JG, Olsen SJ, Giardiello FM, Sisk JE, Van Antwerp R, Brown-Davis C, Marciniak DA, Mayer RJ. Colorectal cancer screening: clinical guidelines and rationale. Gastroenterology. 1997; 112(2): 594-642. Subramanian S, Amonkar MM, Hunt TL. Use of colonoscopy for colorectal cancer screening: evidence from the 2000 National Health Interview Survey. Cancer Epidemiology Biomarkers & Prevention. 2005; 14; 409-416. Lieberman DA, Harford WV, Ahnen DJ et al. for the Veterans Affairs Cooperative Study Group 380. One-tTime screening for colorectal cancer with combined fecal occult-blood testing and examination of the distal colon. N Engl J Med. 2001; 345(8): 555-560. Berry DP, Clarke P, Hardcastle JD, Vellacott KD. Randomized trial of the addition of flexible sigmoidoscopy to faecal occult blood testing for colorectal neoplasia population screening. Br J Surg. 1997; 84: 1274-1276. Cheng TI, Wong JM, Hong CF, Cheng SH, Cheng TJ, Shieh MJ, Lin YM, Tso CY, Huang AT. Colorectal cancer screening in asymptomatic adults: comparison of colonoscopy, sigmoidoscopy and fecal occult blood tests. J Formos Med Assoc. 2002; 101(10): 685-690.

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14. 15. 16. 17.

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18. Winawer SJ, Zauber AG, Ho MN, O'Brien MJ, Gottlieb LS, Sternberg SS, Waye JD, Schapiro M, Bond JH, Panish JF, et al. Prevention of colorectal cancer by polypectomy. N Engl J Med. 1993; 329(27): 1977-1981. 19. Brooks DD, Winawer SJ, Rex DK, Zauber AG, Kahi CJ, Smith RA, Levin B, Wender R; U.S. Multi-Society Task Force on Coloretal Cancer; American Cancer Society. Colonoscopy surveillance after polypectomy and colorectal cancer resection. Am Fam Physician. 2008; 77(7): 995-1002. 20. Mandel JS, Church TR, Bond JH, Ederer F, Geisser MS, Mongin SJ, Snover DC, Schuman LM. The effect of fecal occult-blood screening on the incidence of colorectal cancer. N Engl J Med. 2000; 343(22): 1603-1607. 21. Mandel JS, Bond JH, Church TR, Snover DC, Bradley GM, Schuman LM, Ederer F. Reducing mortality from colorectal cancer by screening for fecal occult blood. Minnesota Colon Cancer Control Study. N Engl J Med. 1993; 328(19): 1365-1371. 22. Iishi H, Tatsuta M, Iseki K, Narahara H, Uedo N, Sakai N, Ishikawa H, Otani T, Ishiguro S. Endoscopic piecemeal resection with submucosal saline injection of large sessile colorectal polyps. Gastrointest Endosc. 2000; 51(6): 697-700. 23. Kudo SE, Kashida H. Flat and depressed lesions of the colorectum. Clin Gastroenterol Hepatol. 2005; 3: S33-S36. 24. Regula J, Wronska E, Polkowski M, Nasierowska-Guttmejer A, Pachlewski J, Rupinski M, Butruk E. Argon plasma coagulation after piecemeal polypectomy of sessile colorectal adenomas: long-term follow-up study. Endoscopy. 2003; 35(3): 212-218. 25. Fukami N, Lee JF. Endoscopic Treatment of Large Sessile and Flat Colorectal Lesions. Curr Opin Gastroenterol. 2006; 22 (1) : 54-59. 26. Konishi F, Morson BC. Pathology of colorectal adenomas: a colonoscopic survey. J Clin Pathol. 1982; 35: 830-841. 27. Loeve F, van Ballegooijen M, Boer R, Kuipers EJ, Habbema JD. Colorectal cancer risk in adenoma patients: a nation-wide study. Int J Cancer. 2004; 111: 147-151. 28. Sato E, Ouchi A, Sassano N, Ishidate T. Polyps and diverticulosis of large bowel in autopsy population of Akita prefecture compared with Miyagi: high risk for colorectal cancer in Japan. Cancer. 1976; 37: 1316-1321. 29. Fuszek P, Horvath HC, Speer G, Papp J, Haller P, Fischer S, Halasz J, Jaray B, Szekely E, Schaff Z, Papp A, Bursics A, Harsanyi L, Lukovich P, Kupcsulik P, Hitre E, Lakatos PL. Location and age at onset of colorectal cancer in Hungarian patients between 1993 and 2004. The high number of advanced cases supports the need for a colorectal cancer screening program in Hungary. Anticancer Res. 2006; 26(1B): 527-531. 30. Fazeli MS, Adel MG, Lebaschi AH. Colorectal carcinoma: a retrospective, descriptive study of age, gender, subsite, stage, and differentiation in Iran from 1995 to 2001 as observed in Tehran University. Dis Colon Rectum. 2007; 50(7): 990-995. 31. Celestino A, Castillo T, Frisancho O, Contardo C, Espejo H, Tomioka C, Navarrete J. Colorectal cancer: study on 365 cases. Rev Gastroenterol Peru. 1996; 16(3): 187-196.

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TRANSFERUL LIBER DE MARE EPIPLOON SOLUIE TERAPEUTIC N CHIRURGIA DEFECTELOR DE PRI MOI
Camelia Tama1, S. Shaukat1, C. Moroanu2, Dana Turliuc3, L. Popa1, R. Ni1, Cristina Stnescu1, P. Srbu4, Snziana Volocaru1 Universitatea de Medicin i Farmacie Gr.T. Popa Iai 1 Clinica de Chirurgie Plastic i Reconstructiv, Spitalul Clinic de Urgene Sf. Ioan Iai 2 Compartimentul de Chirurgie Vascular, Spitalul Clinic de Urgene Sf. Ioan, Iai 3 Clinica de Neurochirurgie, Spitalul Clinic Sf. Treime, Iai 4 Clinica de Ortopedie, Spitalul Clinic de Urgene Sf. Ioan, Iai
THE OMENTUM FREE FLAP, A THERAPEUTICAL OPTION FOR THE SURGERY OF LARGE SOFT TISSUE DEFECTS (Abstract): The omentum is malleable, can fit into any defect and provides a large amount of soft tissue that obliterates the deadspaces. We used this tissue with high vascularisation and special properties to reconstruct many posttraumatic and posttumoral soft tissue defects and the results were very good, both esthetic and functional. We performed free omentum flaps in 23 patients (1998 2008 ) to reconstruct forearm and hand (5 cases), legs defects (14 cases), scalp (3 cases) and orbital region (one case). This flap was sellected in order to cover large anterior and posterior defects, passing through the interossouse membrane (3 cases), to obliterate dead spaces (6 cases) or to bring high vascular soft tissue in crushed, contaminated wounds (17 cases). Many patients (16) presented complex injuries, with bone interested; some of them (16) arrived to the moment of reconstruction with infected posttraumatic wounds, bones or tendons exposed and bad general status due the infection. We performed free omentum flaps because we are convinced of its high plasticity; it is ideally suited to cover postdebridement defects, although it has a major disadvantage: it requires laparatomy. KEY WORDS: OMENTUM, FREE FLAP, RECONSTRUCTION Coresponden: Dr. Camelia Tama, Clinica de Chirurgie Plastic i Reconstructiv, Spitalul Clinic de Urgene Sf. Ioan, Str. Gen. Berthelot nr. 2, Iai; e-mail: camelia6ta@yahoo.com*

INTRODUCERE Primele publicaii cu privire la utilizarea marelui oment aparin secolului al XIX-lea [1]. Aceast afirmaie ne introduce n lucrarea de doctorat a lui H. PenetLambert (1973) cu subiectul: Transferul pediculat i liber de mare epiploon n chirurgia plastic, realizat sub ndrumarea Prof. Cl. Dofourmentel [1]. Principiile omentoplastiei au fost descrise, pentru prima dat, de Jobert i Lambelle (1826) [2]; ei propuneau reconstrucia intestinului perforat prin aplicarea, n defect, a unui segment de epiploon, fr a-l detaa de pediculii si vasculari. n 1956 Chiricu [3] publica primele date cu privire la utilizarea omentului pentru nchiderea fistulelor vezico-vaginale datorate iradierii posttumorale, iar n 1963 [4] propune scoaterea omentului din cavitatea abdominal i utilizarea acestuia ca lambou pediculat pentru reconstrucia defectelor toracice rezultate prin radionecroz, dup terapia cancerului de sn.

received date: 10.01.2009 accepted date: 3.03.2009

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Dezvoltarea microchirurgiei a fcut posibil transplantarea marelui oment n orice segment al corpului; McLeon (1972) descrie utilizarea acestui esut pentru reconstrucia defectelor de scalp [5]. Marele oment (Fig. 1), organ cu o bogat reea vascular, are ca surse arteriale principale cele dou artere gastro-epiploice dreapt i stng; ramurile acestora se dispun n dou planuri [6]: anterior, ramurile din artera gastro-epiploic dreapt i posterior, ramurile gastro-epiploicei stngi. Cele dou reele vasculare sunt explicate de dezvoltarea embriologic a epiploonului, din cele patru foie peritoneale. ntre cele dou reele vasculare exist numeroase anastomoze. Funciile acestui organ abdominal au fost studiate experimental nc din anii 1908 [7] i 1931 [8] de Cantacuzino I. i Soru E. S-a demonstrat c marele oment are rol antibacterian i antineoplazic, rol plastic (poate fi acoperi cu grefe de piele) i poate contribui la revascularizarea esuturilor ischemice; n copilarie contribuie la reglarea dezvoltrii somatice. Are de asemenea capacitate de absorbie i contribuie la reglarea circulaiei n tubul digestiv. Desigur utilitatea sa n chirurgia plastic decurge din bogata reea vascular, dar i din funciile sale antibacterian i antineoplazic.

Fig. 1 Marele epiploon prelevat

MATERIAL I METOD Am analizat o cazuistic format din 23 pacieni cu defecte de pri moi posttraumatice (19 cazuri) i posttumorale (4 cazuri) operai n perioada 1998-2008. Pacienii aveau vrsta cuprins n intervalul 17-78 ani, cu prevalena sexului masculin (20 cazuri) precum i a etiologiei posttraumatice (19 cazuri). Defectele acoperite cu mare oment aveau localizri diferite: membrul toracic (5 cazuri), membrul pelvin (14 cazuri gamba 10, glezna i picior 4), scalp (2 cazuri), scalp i fa (1 caz), orbita (1 caz). Toi pacienii cu defecte de pri moi ale scalpului sau feei aveau vrste cuprinse n intervalul 45-78 ani (o pacient cu vrsta de 45 ani, 3 pacieni > 65 ani) iar leziunea excizat era de origine tumoral (1 carcinom bazocelular

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recidivat, multiplu operat, 3 carcinoame spinocelulare invazive (n groapa zigomatic 1 caz, n sinusul frontal stng 1 caz i n orbit, cu enucleerea globului ocular 1 caz). Defectele de pri moi cu localizare la membrul toracic erau rezultatul unor traumatisme complexe prin: strivire / avulsie (2 cazuri muctur de cal), calandru (pres fierbinte, deci strivire i ardere 1 caz) i electrocuie (2 cazuri), traume n urma crora au rezultat distrugeri tisulare pe suprafee ntinse, cu afectare anterioar i posterioar la nivelul antebraului i pumnului cu interesarea membranei interosoase (3 cazuri), cu denudarea tendoanelor flexoare i a elementelor vasculo-nervoase la pumn (2 cazuri), a tendoanelor extensoare i metacarpienelor (1 caz mna calandrat) sau distrugeri ale tendoanelor, maselor musculare i nervilor median i ulnar pe aproximativ 20-25 cm lungime (2 cazuri electrocuie). Pacienii cu plgi mucate de cal prezentau esuturi strivite, intens contaminate bacterian nc de la internare (n urgen), iar n cele 2 cazuri cu electrocuie i a minii calandrate, pregtirea defectului pentru transferul de epiplon a necesitat cteva edine de excizie i toalet chirugical seriate, la intervale de 24-48 ore. Fiind vorba de membrul toracic, n special antebra, pumn i mn dar i de leziuni multiple i complexe (traumatisme prin strivire, distrugeri osoase, musculare, tendinoase, vasculo-nervoase) tratamentul complet a cuprins mai multe intervenii chirurgicale reconstructive, secundare acoperirii defectului (reconstrucie de nerv i tendon), precum i includerea pacienilor ntr-un program intens de recuperare motorie (kinetoterapie) pentru perioade de 6-12 luni.

Fig. 2 Defect de pri moi dup muctur de cal: nainte i dup transferul liber de mare epiploon

Un pacient din cei 14 cu defecte de pri moi la membrul pelvin avea vrsta de 17 ani, restul prezentau vrste cuprinse n intervalul 29-50 ani; 13 pacieni au victime ale unor accidente (rutiere 9, de munc 2, casnice 2), iar tnrul de 17 ani a fost internat cu diagnosticul de artrit dubl (glezna dreapt i genunchiul stng) de origine iatrogen (posibil artrit tip RAA tratat prin puncionarea articulaiilor afectate i injectare de antibiotic, suprainfectat cu germeni de spital, multiplu rezisteni la antibioterapie). Doisprezece defecte de pri moi la membrul pelvin se situau n 1/3 distal a gambei, cu densitate maxim de tendoane, vase i nervi, fr mase musculare importante sau la nivelul gleznei i pe faa dorsal a piciorului, segmente recunoscute ca dificil de reconstruit prin utilizarea unor lambouri de vecintate; n 2 cazuri, leziunile

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erau localizate n vecintatea genunchiului (1/3 proximal gamb) dar erau suprainfectate cu germeni multiplu rezisteni la antibiotice, iar tentativele anterioare de excizie i reconstrucie cu utilizarea unor lambouri locale (musculare, de gemen lateral sau fasciocutane) euaser datorit agresivitii infeciei combinate cu afectarea vascular mecanismul traumatismului iniial fiind strivirea. Doisprezece din cei 14 pacieni au prezentat fracturi tip III B (de tibie 9 cazuri, ambele oase ale gambei 3 cazuri) i au necesitat osteosintez: fixator extern 7 cazuri, Ilizarov 5 cazuri. n toate cele 12 situaii cu fracturi deschise, plgile erau intens contaminate cu pmnt, uleiuri minerale, fragmente de esturi, sticla etc. impunnd ca atitudine terapeutic n urgen, principiul urgenei amnate active (intervenii chirurgicale seriate la intervale de 24-48 ore, n vederea reexciziei i reevalurii viabilitii structurilor interesate). Mecanismul principal fiind strivirea, au rezultat n toate cazurilor contuzii ale pediculilor vasculari precum i hematoame compresive, care au impus practicarea n urgen a fasciotomiei, lucru care s-a realizat la 10 dintre cele 12 cazuri (pacieni internai iniial n spitalul nostru). Interveniile chirurgicale premergtoare transferului de mare oment au fost realizate n echip mixt, ortoped plastician, iar dup rezolvarea defectului mobilizarea precoce a pacientului s-a putut realiza n 7 cazuri (cei 5 pacieni cu fixare tip Ilizarov i cei 2 pacieni cu expunere articular sau osoas fr fracturi asociate). Interveniile chirurgicale reconstructive s-au desfurat sub anestezie general i au avut o durat medie de 5-6 ore; poziia pacientului pe masa de operaie decubit dorsal n toate cazurile, cu dou cmpuri operatorii simultane i dou echipe chirurgicale formate, dup caz, din neurochirug sau ortoped, chirurg specialist n chirurgie vascular i chirurg plastician. S-au utilizat instrumente specficie chirurgiei vasculare i plastice (bisturiu electric, pensa de coagulare bipolar, microscop operator, lupe, materiale de sutur microchirurgicale). Excizia formaiunii tumorale sau a defectului, precum i pregtirea vaselor receptoare s-au desfurat n paralel cu recoltarea epiplonului din cavitatea abdominal; nu s-a recoltat niciodat marele oment n ntregime, acest lucru nefiind necesar la niciunul dintre cazurile operate. S-au realizat anastomoze termino-terminale arteriale i respectiv venoase n 16 din cele 23 de cazuri, iar n 7 situaii anastomoze termino-laterale (2 la artera carotid extern i respectiv vena jugular extern, 2 la artera i vena poplitee, 3 la vasele tibiale posterioare). n funcie de localizarea defectului am realizat 2 anastomoze la vasele temporale superficiale, 5 anastomoze la artera radial, respectiv vena cefalic, 7 anastomoze la vasele tibiale anterioare i 2, la vasele pedioase. n dou cazuri au fost necesare grefoane venoase interpuse, recoltate de la membrul pelvin controlateral. Postoperator, pacienii au primit antibioterapie conform cu rezultatul de la examenul bacteriologic i s-a efectuat profilaxia bolii trombembolice. n toate cazurile cu defecte localizate la membre s-a utilizat imobilizare pe atel ghipsat; viabilitatea lamboului, acoperit cu grefe de piele despicat, a fost urmrit prin ferestre practicate n pansament, iar n primele ore postoperator, acesta a fost a fost meninut n mediu cu temperatur controlat n toate cele 19 cazuri cu localizare la membre. Am nregistrat 5 cazuri de tromboz venoas n primele 48 de ore postoperator (2 la membrul toracic cele 2 cazuri cu defecte postelectrocuie i 3 la membrul pelvin fracturi tip III B i contuzii vasculare etajate) la care a fost necesar reintervenia cu refacerea anastomozei venoase. Un pacient a decedat la 21 zile postoperator prin embolie carotidian, (posibil de etiologie tumoral). Nu am nregistrat nicio complicaie postoperatorie precoce la plaga abdominal; 8 pacieni s-au mobilizat normal la 4-5 zile de la operaie, 22 s-au

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alimentat normal la 6-7 zile postoperator, excepie fcnd pacientul cu tumora de scalp cu invazia gropii zigomatice care a suferit embolia carotidian. Durata minim de spitalizare a fost 7 zile (cele 2 cazuri cu internare n clinica noastr imediat dup producerea traumatismului), iar cea maxim, 73 zile (cazul tnrului de 17 ani cu artrit dubl de glezn i genunchi). DISCUII Urmrind separat defectele posttumorale vom constata urmatoarele: - numrul de pacieni cu tumori ale scalpului care au necesitat ca material de reconstrucie marele oment este de aproximativ 5 ori mai redus dect al pacienilor cu traume ale membrelor, fapt explicat de particularitile anatomice ale acestei regiuni; vascularizaia bogat a scalpului ct i nvecinarea cu regiunea cervical i extremitatea cranial a trunchiului, ce ofer chirurgului mai multe tipuri de lambouri (axiale sau pediculate), deci mai multe soluii terapeutice posibile dect n cazul extremitii distale a unui membru traumatizat - vrsta pacienilor cu leziuni de tip tumoral depete 45 ani spre deosebire de traumatisme care sunt apanajul vrstelor mai tinere; - tipul tumorii au fost carcinoame n toate cele 4 cazuri, fapt explicabil prin caracterul inavziv i recidivant al acestor formaiuni, ceea ce conduce, ntr-un interval de 2-3 ani, la epuizarea resurselor reconstructive locale sau de vecinatate i impune realizarea unui aport de esut prin transfer liber microchirurgical; - toi pacienii au prezentat tumori invazive (invazia osului (n=2), invazie n groapa zigomatic (n=1), invazia orbitei i globului ocular (n=1)) i suprainfectate, toate dezvoltate secundar unor traumatisme cu leziuni de pri moi (3 cazuri) sau pri moi i os (1 caz), de regul, neglijate. n cazul pacientului care a dezvoltat embolia carotidian, leziunea iniiala s-a produs la vrsta de 8 ani (la momentul operaiei pacientul avea 65 de ani): arsur de scalp, probabil de grad IV, cu vindecare spontan, lent, cu dezvoltarea unei cicatrice instabile, cu ulcerri numeroase. A fost singurul pacient care a necesitat excizia unui fragment din duramater parietal i reconstrucia cu un lambou de fascia lata; - datorita vrstei ( > 65 ani n 3 cazuri) i procesului de ateroscleroz asociat, anastomoza la vasele temporale superficiale nu a fost posibil dect n dou cazuri, fapt care a determinat o cretere a complexitii i duratei interveniei chirurgicale prin disecia arterei carotide externe. Se constat c am apelat la aceast tehnic pentru reconstrucia scalpului i feei din urmtoarele considerente: epuizarea altor tehnici de vecinatate (pacienta de 45 ani a suferit 11 interventii chirurgicale pentru excizia tumorii occipitale in 12 ani), acoperirea unor defecte particulare cu aspect neregulat, cu expuneri osoase sau de dura mater i umplerea unor caviti (2 cazuri), situaii particulare cu vascularizaie precar a scalpului (asociat cu alopecie i o afeciune dermatologic cu expresie general) care fcea nesigur orice alt lambou, i, n toate cazurile prezentate, pentru proprietile antibacteriene ale omentului. n cazul defectelor posttraumatice cu localizare la membre constatm c aceste leziuni sunt mai frecvente la vrste tinere i la sexul masculin. Existena leziunilor osoase (12 cazuri) sau a celor articulare (2 cazuri) a fost constatat la toi pacienii cu defecte localizate la membrul pelvin, fa de doar un singur caz la membrul superior (mna calandrat). Acest tip de patologie se explic prin mecanismul complex i cantitatea mare de energie descrcat traumelor membrului

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pelvin, dar i prin selecia atent a cazurilor candidate pentru transfer liber la acest membru, avnd n vedere particularitile anatomo-funcionale ale vascularizaiei (numai 3 axe vasculare principale la gamb, comparativ cu 4 la antebra, retur venos antigravitaional care face necesar existena valvelor etc.) [9]. S-a utilizat osteosinteza extern n cele 12 cazuri cu fracturi ale gambei, metod care permite conservarea reelelor vasculare, evit contaminarea suplimentar a focarului de fractur i ofer, n cazul aparatului Ilizarov, posibilitatea mobilizrii precoce a pacientului. Aceast tehnic presupune, ns, o pregtire preoperatorie n echip, ortoped - plastician, pentru a stabili cu exactitate amplasarea materialului de osteosintez, poziia pacientului i a gambei n timpul interveniei i cile de acces la vasele receptoare. Am nregistrat tromboza anastomozei venoase n ambele cazuri victime ale electrocuiei, fapt explicat de leziunile vasculare nedecelabile preoperator, dar i n 3 cazuri cu leziuni prin strivire, cu afectare vascular etajat; amendarea acestor complicaii n timp util face posibil reuita interveniei chirurgicale. Am utilizat marele oment ca material pentru reconstrucia defectelor de pri moi cu localizare n 1/3 distal a antebraului sau gambei pentru proprietile sale plastice (era necesar nchiderea unor caviti sau pasajul prin membrana interoasoas), pentru suprafaa sa ntins ce permite acoperirea de defecte mari, dar i pentru asemnarea sa din punct de vedere anatomic i funcional (membran fin, bogat vascularizat) cu sinoviala ce acoper tendoanele i le permite glisarea normal [10]. Reconstrucia cu mare oment s-a impus n cele 2 situaii cu infecii articulare (glezn, respectiv genunchi) datorit capacitii deosebite a acestui esut de a localiza i distruge focarele de infecie. CONCLUZII Marele epiploon este cunoscut pentru plasticitate, funcia imun i antitumoral, generate de structura sa particular: membran bogat vascularizat. Defectele de pri moi, posttraumatice sau posttumorale, suprainfectate reprezint indicaii pentru utilizarea omentului ca material de reconstrucie. Selecia cazurilor trebuie s fie foarte atent avnd n vedere morbiditatea zonei donatoare, riscurile i complexitatea interveniei chirurgicale. Lucrul n echip complex, neurochirurg, ortoped, chirurg vascular, plastician, este esenial pentru reuita interveniei. Transferul liber de mare epiploon poate fi unica soluie n cazurile dificile, cu infecii oasoase sau articulare grave i poate salva pacientul de la amputaia membrului. Atitudinea terapeutic corect n urgen n cazul traumatismelor complexe ale membrelor se reflect n: spitalizare de scurt durat (7 vs 73 zile), costuri de spitalizare reduse, rezultate estetice i funcionale bune i foarte bune.
1. 2. 3. 4. BIBLIOGRAFIE Penet-Lambert H. Transferts epiploiques libres et pedicules dans le comblement des pertes de substance en chirurgie plastique. M.D. thesis Faculty of Medicine, Laviboisiere, Saint Louis, 1973. Micouleau P. Le grand epiploon, material plastique en chirurgie, M.D. thesis Faculty of Medicine, Tolouse, 1975. Chiricu I, Goldstein AMB. Omentoplasty of the bladder. A method for curative treatment of vesico-vaginal fistulae following the radio-surgical treatment of the cervix cancers. Obstetrica i Ginecologie. 1956; 2: 163. Chiricu I. Lemploi du grand epiploon pedicule. Presse Medicale (Paris). 1963; 1: 16-17.

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5. 6.

Chiricu I. Use of omentum in Plastic Surgery. Bucureti: Editura Medical; 1998. p. 13. Bourgeon A, Tram DK, Abbes M, Clemmont C, Lebreton E, Richelme H. Etude de la vascularisation du grand epiploon. Aplication chirurgicale. Bulletin Ass Anat. 1973; 57: 159-163. 7. Cantacuzino I. Recherches sur lorigine des precipitines. Ann de lInst Pasteur. 1908; 22: 54-57. 8. Cantacuzino I, Soru Eugenia. Recherches sur le mecanisme de laccolement de lepiploon; intervention de phenomenes dordre electrostatique. Arch Roum Pathol Exper Microbiol. 1931; 4: 173-176. 9. Williams LP, Warwick R. Angiology In: Grays Anatomy, 37th Edition; Churchill Livingstone; 1989. p. 685. 10. Van Son JAA, Smedts FM, Cheng-Qin Yang, Falk V, Mohr WF, Guo-Wei He. Morphometric study of the right gastro-epiploic and inferior epigastric arteries. Ann Thorac Surg. 1997; 63: 709-715.

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SUPERIOR MESENTERIC ARTERY SYNDROME: AN UNUSUAL CAUSE OF DUODENAL OBSTRUCTION A CASE REPORT AND LITERATURE REVIEW
S.B. Saha, A. Mandal, D. Deoghuria Department of Surgery and Radiodiagnosis. Bankura Sammilani Medical College, Bankura, West Bengal, India
SUPERIOR MESENTERIC ARTERY SYNDROME: AN UNUSUAL CAUSE OF DUODENAL OBSTRUCTION A CASE REPORT AND LITERATURE REVIEW (Abstract): Superior mesenteric artery syndrome is a rare form of obstruction of horizontal part of duodenum entrapped between superior mesenteric artery and abdominal aorta. A case of a young male presented with longstanding abdominal pain, vomiting, and weight loss. Barium series, endoscopy, computed tomography scan, and doppler ultrasound made the diagnosis. The patient successfully underwent duodenojejunal anastomosis with a favourable outcome. It should be considered as a cause of vomiting and weight loss in children and young adults. KEY WORDS: ARTERIO-MESENTERIC COMPRESSION, CHRONIC DUODENAL ILEUS, WILKIES SYNDROME, CAST SYNDROME, DOPPLER ULTRASOUND, DUODENOJEJUNOSTOMY Correspondance to: Dr. Subhendu Bikas Saha, Pranabananda Palli, Kenduadihi, Bankura, West Bengal, India. Pin: 722102. Phone: 03242-257672 (R); + 919434183233 (M); e-mail: sbsaha@sancharnet.in; sunsubg@gmail.com*

INTRODUCTION Superior mesenteric artery syndrome (SMAS) is an atypical clinical disorder of vascular compression affecting third part of duodenum (D3); first described by Von Rokitanski in 1800s [1,2]. Later, Wilkie coined the term chronic duodenal ileus and published a detail description of seven cases in 1927 [3]. Since then, although several cases are reported so far [1-4],4 the disease remained a subject of controversy, and many have doubted its actual incidence [3]. Modern imaging techniques nevertheless have restricted the trend of over diagnosis. The young age, nonspecific symptoms often lead to a delay in diagnosis. This entity, over the years, acquired different names, such as chronic duodenal ileus, arteriomesenteric duodenal compression, Wilkies syndrome and Cast syndrome [2,3]. CASE HISTORY A 19 years old male was referred to our hospital with progressively worsening intermittent, postprandial colicky upper abdominal pain with recurrent episodes of profuse bilious vomiting of partially digested food for last six years. Vomiting generally relieved his abdominal pain. He had usually one or two episodes of pain and vomiting every week for last six months and had lost about ten kilograms of weight during this period. He was treated for peptic ulcer disease by some local practitioner without any relief. The remainder of the history was non-contributory.
received date: 18.03.2009 accepted date: 27.04.2009
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On examination, the patient was 168 cm tall, asthenic with body weight of 48 kg. Abdomen looked scaphoid with mild fullness in epigastrium. There was no hepatomegaly or ascites. Ausculto-percussion and succusion splash test gave a clinical impression of gastric distension. Relevant laboratory values were unremarkable. Barium meal series revealed an abrupt cut-off at the level of third part of duodenum (D3) with marked proximal dilatation (Fig. 1) and incomplete gastro-duodenal emptying. Upper GI endoscopy reported gastro duodenal stasis of food particles without any demonstrable intrinsic lesion except few antral erosions.

Fig. 1 Barium meal series showing marked gastroduodenal dilatation with a vertical cut-off at the level of third part of duodenum

Contrast enhanced computed tomography (CT) scan detected narrowed segment of D3. Doppler ultrasound (USG) study of aorto-meseteric area showed Superior Mesenteric Artery (SMA) - aorta angle of 12 on sagittal image (Fig. 2) and SMA aorta distance of 4.39 mm on transverse image (Fig. 2, inset). The above imaging findings and clinical presentation correlated the diagnosis of SMAS. Conservative trial was attempted for 3 weeks with nasogastric decompression, small, frequent, high caloric feeding, postural advice and supplementation but symptoms remained refractory. Exploratory laparotomy confirmed compression of the D3. There was no evidence of any other cause of obstruction. A side-to-side retrocolic duodenojejunostomy bypass was done. The patient recovered uneventfully. During nine months follow up, he was symptom free and attained a body weight of 59.5 kg.

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DISCUSSION SMA usually takes an angular downward course from ventral surface of aorta. It is through this vascular angle that the D3 passes. Normally fat and lymphatics around SMA maintains this angle and provide protection for duodenal compression. In SMAS, SMA-aorta angle in narrowed down to 7 to 22 (normal range 25to 60) and SMAaorta distance is reduced to 2 -8 mm ( normal range 10 to 28 mm) [1,2,4].

Fig. 2 Sagittal ultrasonography image shows SMA-aortic angle of 12 (white constructed angle); [inset - Transverse ultrasonography image showing SMA aorta distance of 4.39 mm.]

Some etiological factors include dramatic weight loss resulting in loss of fat cushion (in extensive cancer and burns, malabsorption, eating disorders), high insertion and shortness of ligament of Treitz, low origin of SMA, peritoneal adhesion, duodenal malrotation, rapid linear growth without compensatory weight gain, scoliosis and body casting [1-5]. SMAS should be differentiated from SMA-like-syndrome (mega duodenum) found in several neuropathic and connective tissue disorders [1,3]. SMAS can be presented as chronic intermittent or acute duodenal obstruction in children and young adults, more often in females. Postprandial upper abdominal pain and fullness, bilious vomiting and rapid weight loss are the most characteristic symptoms. Food aggravates while certain postural adjustments like left lateral, kneechest or prone position may relieve abdominal symptoms. As obstruction is usually incomplete, diagnosis is challenging, often made by process of exclusion [2,4]. Conventional barium study findings although characteristic but not specific for SMAS [1,5]. Non-invasive modalities like colour doppler ultrasonography, CT or magnetic resonance (MR) angiography are currently useful tools for diagnosis [1,2,4,5].

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Unal et al [4], observed high clinical correlation with CT or doppler ultrasoundmeasured values of 8 mm for SMA-aorta distance (100% sensitive and specific) and 22 for SMA-aorta angle (42.8% sensitive and 100% specific). The initial treatment of this condition is generally conservative. Surgery is indicated in longstanding and unresponsive cases or in massive duodenal dilatation and stasis [2,5]. Duodenojejunostomy, open or laparoscopic, is the most accepted procedure with success rate of 90% [1,2,5]. ACKNOWLEDGEMENT We would like to thank Dr. M. Chaudhury, Principal, B. S. Medical College for his support in submission of this manuscript to this journal
1. 2. 3. 4. 5. REFERENCES Shukla RC, Pathak R. Superior mesenteric artery syndrome: case report. Nepal Med Coll J. 2008; 10(2): 144-145. Baltazar U, Dunn J, Floresguerra C, Schimidt L, Browder W. Superior mesenteric artery syndrome: an uncommon cause of intestinal obstruction. South Med J. 2000; 93(6): 606-608. Ahmed AR, Taylor I. Superior mesenteric artery syndrome. Postgrad Med J. 1997; 73: 766-768. Unal B, Akta A, Kemal G, Bilgili Y, Gliter S, Daphan C, Aydinuraz K. Superior mesenteric artery syndrome: CT and ultrasonography findings. Diagn Interv Radiol. 2005; 11(2): 90-95. Makam R, Chamany T, Potluri VK, Varadaraju PJ, Murthy R. Laparoscopic management of superior mesenteric artery syndrome: a case report and review of literature. J Min Acess Surg. 2008; 3: 80-82.

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INTESTINUL SUBIRE, POSIBILITATE RAR DE METASTAZ DIGESTIV, SECUNDAR NEOPLASMULUI OVARIAN


Maria-Gabriela Roca1, D.C. Mariciuc1, I. Radu1, D. Ferariu2, V. Scripcariu1

1 Clinica a III-a Chirurgie, Centrul de Cercetare n Chirurgie Oncologic i Training n Chirurgie General, Universitatea de Medicin i Farmacie Gr.T. Popa Iai 2 Laboratorul de anatomie patologica, Spitalul Sf. Spiridon Iai
SMALL BOWEL A RARE METASTASIS FROM OVARIAN CANCER (Abstract): Small bowel obstruction in an oncology patient is a common and serios medical problem, associated with diagnostic and therapeutic dilemmas. We report a case of small bowel obstruction caused by a metastatic tumor secondary to bilateral recurrent ovarian cancer. The clinical diagnosis is difficult because of lack of specific signs and simptoms. The computed tomography becomes essential in the preoperative diagnostic. The treatment has two targets: to solve the obstruction and to control the metastatic desease. The case is particular because of the presence of a jejuno-colic intratumoral fistula. The anatomopathological examination reveals the character of metastatic tumor secondary to ovarian cancer. Good general status, with no severe comorbidities and the significant response to anti-cancer chemotherapy, make a good prognosis after radical resection of the metastasis. The posibility of a metastasis in the bowel wall as a potential cause of an obstruction requires a high level of suspipicion and sould be considered as a differential diagnosis in any patient with a history of cancer. KEY WORDS: METASTASIS, SMALL BOWEL, OVARIAN CANCER Coresponden: Prof. Dr. Viorel Scripcariu, Clinica a III-a Chirurgie, Spitalul Sf. Spiridon Iai, Bd. Independenei nr 1, Iai, Romnia, 700111; e-mail: vscripcariu@gmail.com*

INTRODUCERE Metastazele intestinului subire la un pacient cu antecedente oncologice sunt o entitate rar, care ridic importante probleme de diagnostic i tratament. Are o inciden variabil pentru diverse localizri ale tumorii primare [1]. Dac afectarea intestinului subire n cadrul carcinomatozei peritoneale este relativ frecvent, 10% n neoplasmul de sn i melanomul malign [2-4], post necropsie cu o frecven i mai mare [5], metastazele izolate ale intestinului subire reprezint o condiie rar. Intervalul de timp de la depistarea tumorii primare pn la depistarea metastazei izolate a intestinului subire variaz n limite largi, ajungnd pan la 30 de ani ntr-un caz de melanom malign [3] . CAZ CLINIC Pacienta P.E., n vrst de 48 de ani, a fost diagnosticat n anul 2003 cu neoplasm ovarian bilateral, pentru care s-a intervenit chirurgical, practicndu-se histerectomie total cu anexectomie bilateral si omentectomie. Examenul anatomo-patologic a evideniat aspectul de adenocarcinom ovarian cu celule clare. Postoperator s-a iniiat tratamentul chimioterapic adjuvant cu Carboplatin.

received date: 10.01.2009 accepted date: 15.02.2009

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n februarie 2007, pacienta acuz dispnee i dureri abdominale, motiv pentru care este reevaluata clinic si paraclinic. Examenul computer tomografic (CT) toracoabdominal evideniaz la nivelul plmnului drept cel puin 2 noduli infracentimetrici, juxtapleurali, n segmentul lateral al lobului mijlociu drept, iar la nivelul plmnului stng, cel puin un nodul infracentimetric juxtapleural n segmentul anterior al culmenului. Se evideniaz de asemenea, o formaiune chistic cu dimensiuni de 8 x 11 x 9 cm, cu localizare pelvi-abdominal. Se stabilete diagnosticul de recidiv tumoral loco-regional i determinri metastatice pulmonare multiple. n perioada februarie-iunie 2007, pacienta urmeaz tratament chimioterapic sistemic (3 cure Sindaxel + Carboplatin; 8 cure Sindaxel + Farmorubicin), obinndu-se dispariia imaginilor pulmonare i ameliorarea strii generale. n iulie 2007, se intervine chirurgical i se practic rezecia recidivei tumorale pelvine, fr a se evidenia diseminri secundare macroscopice intraabdominale. Pacienta se prezint dup 8 luni de la reintervenia pentru cancerul ovarian, cu dureri abdominale difuze, tulburri de tranzit i prezena unei formaiuni tumorale abdominale, cu diametrul de aproximativ 10 cm, palpabil n mezogastru, la dreapta liniei mediane. Debutul simptomatologiei fiind insidios, n urm cu 4 luni, cu agravare i apariia simptomatologiei sugestive pentru sindrom subocluziv n ultimele 2 saptmni. Examenul clinic general evideniaz o pacient obez cu stare general relativ bun i tegumente palide. Examenul abdominal constat prezena cicatricilor postoperatorii abdominale, eventraie pe cicatricea postoperatorie median subombilical. La palpare se descoper un nodul cu diametrul de 2 cm pe cicatricea postoperatorie n regiunea subombilical i o formaiune tumoral localizat n mezogastru, la dreapta liniei mediane, dureroas, cu diametru de 10 cm, de consisten elastic. Percuia abdomenului evideniaz matitate n aria de proiecie a tumorii i hipersonoritate n flancul stng. Tranzitul intestinal este accelerat, cu scaune de consisten scazut. Dintre examenele de laborator menionm ca semnificativ existena unui sindrom anemic feripriv: eritrocite = 2,81x106 /mmc, Hb = 8,7 g/dL, Ht = 26,4%. Prezena unei formaiuni tumorale abdominale voluminoase n contextul antecedentelor neoplazice ale pacientei constituie premisele solicitrii unui examen CT care evideniaz: 1) formaiune chistic localizat paraombilical drept, intraperitoneal, n contact cu peritoneul parietal, cu diametrul de 62 x 46 x 35 mm (diametrul anteroposterior x transversal x craniocaudal), cu perete avnd o grosime de 20 mm, neregulat pe faa intern, care i crete moderat i tardiv densitatea dup administrarea substanei de contrast; formaiunea este descris n contact, la polul superior, cu colonul transvers, medial cu ansele de intestin subire, lateral cu colonul ascendent, fa de care pare a avea plan de separaie; 2) eventraie pe cicatricea postoperatorie median, cu anse de intestin subire; 3) absena adenopatiilor i a formaiunilor tumorale n pelvis. Pe radiografia toracic, nu se evideniaz determinri secundare. Starea general bun a pacientei n condiiile prezenei unei formaiuni tumorale abdominale voluminoase cu simptomatologie frust, intermitent, de subocluzie intestinal, i a antecedentelor personale de neoplasm ovarian constituie indicaie de laparotomie exploratorie. Dup reechilibrarea biologic a pacientei, se intervine chirurgical. Dup liza aderenelor intraperitoneale, explorarea intraoperatorie constat absena diseminrilor secundare intraperitoneale, absena recidivei locale pelvine, absena determinrilor

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secundare hepatice i o formaiune tumoral parietal dur cu diametrul de 2 cm. La nivelul ileonului, se evideniaz o tumor vegetant circumferenial, stenozant cu diametru de aproximativ 5 cm, localizat la 30 de cm de valvula ileo-cecal, ce invadeaz versantul transvers al unghiului hepatic al colonului i o alt formaiune tumoral ileal, polipoid, cu diametrul de 2 cm, situat la 5 cm n aval de prima. Se practic hemicolectomie dreapt extins pe ileon, n condiii de siguran oncologic precum si excizia n esut sntos a formaiunii tumorale parietale i cura chirurgical a eventraiei postoperatorii cu refacerea peretelui n plan total. Examenul macroscopic al piesei de rezecie efectuat imediat postoperator, a descoperit o fistul ileo-colic intratumoral, survenit probabil consecutiv stenozei ileonului i invaziei tumorale a unghiului hepatic al colonului (Fig. 1).

Fig. 1 Piesa operatorie hemicolectomie dreapt extins pe ileon Aspect macroscopic A Fistul ileo-colic intratumoral; B metastaz ileal cu aspect tipic ombilicat i ulcerat al tumorilor intestinale

Examenul anatomo-patologic a evideniat intestin subire i colon cu infiltraie parietal de carcinom slab difereniat, predominant cu celul clar, arhitectur solid, cu focare de difereniere tubular sau papilar (metastaz de la un cancer ovarian). Se mai remarc arii ulcerate i ntins necroz; 16 ganglioni limfatici pericolici, fr metastaz. Tumora parietal este reprezentat de esut conjunctivo-vasculo-adipos cu zone de liponecroz, cu numeroase chisturi lipidice, fara infiltraie tumoral. Evoluia postoperatorie a pacientei a fost simpl, fr complicaii, fiind externat la 7 zile postoperator. Avnd n vedere evoluia favorabil a metastazelor pulmonare sub tratament chimioterapic sistemic, pacienta a fost ndrumat spre cabinetul oncologic cu un prognostic favorabil, n vederea tratamentului adjuvant. DISCUII n general, sindromul ocluziv abdominal cauzat de o obstrucie pe intestinul subire este o condiie rar, cu att mai mult cnd acesta este determinat de o tumor secundar intestinal. Dei exist numeroase alte entiti mult mai frecvente care ar putea fi cauza unei ocluzii de intestin subire, mai mult sau mai puin facile din punct de vedere diagnostic, exist anumite situaii n care se poate ridica suspiciunea unei tumori

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secundare, metastatice pe intestinul subire. Simptomele de prezentare sunt nespecifice, tardive i nu ofer indicii asupra localizrii i cauzei ocluziei intestinului subire [6]. n literatura de specialitate sunt citate relativ puine cazuri de metastaze intestinale, de aceea, recunoaterea lor constituiind adevrate provocri diagnostice, n special cnd exist un interval liber de boal mare [2-23]. ntr-un studiu desfurat n 2005, Idelevich E et al au efectuat un review al literaturii de specialitate, al cazurilor cu metastaze intestinale raportate. Studiul conine 36 de cazuri, dintre care majoritatea (47%) au fost secundare neoplasmului mamar i 2 cazuri (5,6%) secundare neoplasmului ovarian. Cei mai muli pacieni se aflau n decada a 6-a de vrst (vrsta medie de 55 ani), cu o predominen feminin, n legatur direct cu incidena neoplasmului mamar [1]. Simptomele metastazelor intestinale sunt de obicei nespecifice i tind s fie atribuite frecvent altor etiologii mult mai comune (aderene intraperitoneale; carcinomatoza peritoneal). Tumorile intestinale secundare apar dup un interval liber variabil dup diagnosticul tumorii primare, fiind localizate la distan de acestea [3,15,16]. Toi acesti factori conduc la ntrzieri semnificative n diagnosticul tumorilor secundare n etiologia obstruciilor intestinului subire [17]. Gradul de suspiciune diagnostic este crescut ns de contextul neoplazic al pacientului, care poate fi astfel supus explorrilor imagistice n vederea depistrii determinrilor secundare abdominale. Implicarea metastazelor intestinale n simptomatologia abdominal a bolnavilor neoplazici a putut fi depistat post-mortem n 55% din cazuri [5]. Totui, cteva principii s-au dovedit utile. n primul rnd, recunoaterea simptomatologiei de tip ocluziv nalt i atribuirea acestuia unei obstrucii pe intestinul subire i n al doilea rnd, contextul n care survine aceasta simptomatologie, la un pacient cu trecut neoplazic (cel mai frecvent, secundar unui neoplasm mamar, melanom malign, neoplasm pulmonar, neoplasm ovarian). Dei la aceti pacieni sindromul ocluziv este determinat cel mai frecvent de alte entiti (aderene intraperitoneale, carcinomatoza peritoneal), se impune diagnosticul diferenial cu o metastaz intestinal, n relaie de cauzalitate cu tumora primar. Rolul explorrilor imagistice devine evident, examenul CT ocupnd locul cel mai important. Nu se exclud beneficiile laparotomiei exploratorii i diagnosticul intraoperator. Tumorile secundare intestinale ridic, de asemenea, probleme terapeutice complexe. Dei datele din literatura de specialitate sunt limitate, anumite studii au reuit totui s stabileasc principii care ghideaz tratamentul. Tratamentul chirurgical are dou scopuri: rezolvarea obstruciei intestinale i controlul bolii metastatice. Acesta este condiionat de starea general a pacientului i capacitatea sa de a suporta o intervenie de amploare. Laparotomia exploratorie este indicat de semnele clinice abdominale de alarm. Agresivitatea interveniei cu viz terapeutic este condiionat de starea general a pacientului, de stadiul local al metastazei, de agresivitatea tumorii primare i de rspunsul la tratamentul adjuvant, putnd opta pentru o intervenie radical sau o derivaie paliativ [16]. S-a raportat o supravieuire de durat dup rezecia tumorilor secundare intestinale, chiar n cazul unor entiti considerate agresive (neoplasm mamar, melanom malign, neoplasm ovarian) [20]. Astfel, chirurgia radical poate fi luat n considerare la toi pacienii la care situaia local o permite, i n special, la pacienii cu antecedente de tratament antineoplazic sistemic cu efecte favorabile, la acetia ateptndu-se o evoluie favorabil n continuare.

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Un loc important ocup tratamentul sistemic adjuvant ce poate include chimioterapia i hormonoterapia ntr-un protocol individualizat pentru fiecare pacient. Examenul anatomo-patologic al piesei de rezecie devine astfel esenial, fiind singurul care face diagnosticul diferenial ntre o tumor intestinal primar i una secundar. La pacienii vrstnici, cu multiple comorbiditi sau cu forme neoplazice agresive, cu rspuns slab la chimioterapie n antecedente, pot fi luate n considerare procedurile derivative. CONCLUZII Tumorile metastatice n intestinul subire fac parte din diagnosticul diferenial la pacienii cu antecedente personale de cancer care prezint tulburri de tranzit. Rezecia segmentului de intestin implicat i terapia sistemic postoperatorie trebuie adecvat fiecrui caz n parte. Diagnosticul histopatologic poate fi uneori dificil dar antecedentele bolnavului, n aceste cazuri, pot fi benefice pentru interpretarea leziunilor.
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. BIBLIOGRAFIE Idelevich, Hanoch Kashtan, Eli Mavor, Baruch Brenner. Small bowel obstruction caused by secundary tumors . Surgical Oncology. 2006; 15(1): 29-32. Clavien PA, Laffer U, Torhost J, Harder F. Gastrointestinal metastases as first clinical manifestation of the dissemination of a breast cancer. Eur J Surg Oncol. 1990; 16(2): 121-126. Bender GN, Maglinte DD, McLarney JH, Rex D, Kelvin FM. Malignant melanoma: patterns of metastasis to the small bowel, reliability of imaging studies, and clinical relevance. Am J Gastroenterol. 2001; 96(8): 2392-2400. Schwarz RE, Klimstra DS, Turnbull AD. Metastatic breast cancer masquerading as gastrointestinal primary. Am J Gastroenterol. 1998; 93(1): 111-114. Washington K, McDonagh D. Secondary tumors of the gastrointestinal tract: surgical pathologic findings and comparison with autopsy survey. Modern Pathology. 1995; 8(4): 427433. Liaw CC, Wang CS, Ng KK, Lin PY. Enteric intussusception due to metastatic intestinal tumors. Journal of Formosan Medical Association. 1997; 96(2): 125-128. Cormier WJ, Gaffey TA, Welch JM, Welch JS, Edmonson JH. Linitis plastica caused by metastatic lobular carcinoma of the breast. Mayo Clin Proc. 1980; 55(12): 747-753. Gatsoulis N, Roukounakis N, Kafetzis I, Gasteratos S, Mavrakis G. Small bowel intussusception due to metastatic malignant melanoma. A case report. Technical Coloproctology. 2004; 8(Suppl 1): s141-s143. Hung GY, Chiou T, Hsieh YL, Yang MH, Chen WY. Intestinal metastasis causing intussusception in a patient treated for osteosarcoma with history of multiple metastases: a case report. Japanese Journal of Clinical Oncology. 2001; 31(4): 165-171. Chen TF, Eardley I, Doyle PT, Bullock KN. Rectal obstruction secondary to carcinoma of the prostate treated by transanal resection of the prostate. British Journal of Urology 1992; 70(6): 643-647. Kamal HS, Farah RE, Hamzi HA, Cohen HI, Kristal BI. Unusual presentation of rectal adenocarcinoma. Roman Journal of Gastroenterology. 2003; 12(1): 47-50. Hofflander R, Beckes D, Kapre S, Matolo N, Liu S. A case of jejunal intussusception with gastrointestinal bleeding caused by metastatic testicular germ cell cancer. Digestive Surgery. 1999; 16(5): 439-440. Catino A, Lorusso V, Gargano G, Pellecchia A, Marzullo F, Berardi F, De Lena M. Metastatic involvement of the stomach secondary to breast carcinoma. A case report. Eur J Gynaecol Oncol. 1992; 13(1 Suppl): 85-88. Taal BG, den Hartog Jager FCA, Steinmetz R, Peterse H. The spectrum of gastrointestinal metastases of breast carcinoma: II. The colon and rectum. Gastrointestinal Endoscopy. 1992; 38(2): 136-141. Daniels IR, Layer GT, Chisholm EM. Bowel obstruction due to extrinsic compression by metastatic lobular carcinoma of the breast. Journal of Royal Society of Health 2002; 122(1): 61-62.

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16. 17. 18. 19. 20. 21. 22. 23.

Van Trappen P, Serreyn R, Elewaut AE, Cocquyt V, Van Belle S. Abdominal pain with anorexia in patients with breast carcinoma. Annals of Oncology. 1998; 9: 1243-1245. Lisa R, Gunilla C, Jonsson PI. Small bowel obstruction caused by intestinal metastases from undiagnosed breast cancer: report of two cases. European Journal of Surgery 2002; 168: 648650. Capasso L, Iarrobino G, D Ambrosio R, et al. Surgical complications for gastric and small bowel metastases due to primary lung carcinoma. Minerva Chirurgica. 2004; 59(4): 397-403. Pavlakis GM, Sakorafas GH, Anagnostopoulos GK. Intestinal metastases from renal cell carcinoma: a rare cause of intestinal obstruction and bleeding Mt Sinai. Journal of Medicine. 2004; 71(2): 127-130. Heymann AD, Vieta JO. Recurrent renal carcinoma causing intestinal hemorrhage. American Journal of Gastroenterology. 1978; 69(5): 582-585. Nahhas WA. Ovarian cancer. Current outlook on this deadly disease. Postgraduate Medical Journal. 1997; 102(3): 112-120. van der Poel HG, Roukema JA, Horenblas S, van Geel AN, Debruyne FM. Metastasectomy in renal cell carcinoma: a multicenter retrospective analysis. European Urology. 1999; 35: 197203. Deguchi R, Takagi A, Igarashi M, Shirai T, Shiba T, Watanabe S, Kurumada T, Miwa T, Sadahiro S, Yasuda M. A case of ileocolic intussusception from renal cell carcinoma. Endoscopy. 2000; 32(8): 658-660.

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CERVICAL NECROTIZING FASCIITIS


G. Dimofte1, Gabriela Lozneanu1, D. Pieptu2, R. Moldovanu1, M. Danciu3, E. Trcoveanu1 Gr.T. Popa University of Medicine and Pharmacy Iai, Romania 1 First Surgical Unit, St. Spiridon Hospital Iai 2 Department of Plastic Surgery, St. John Emergency Hospital Iai 3 Department of Pathology, St. Spiridon Hospital Iai
CERVICAL NECROTIZING FASCIITIS (Abstract): Cervical necrotizing fasciitis is an unusual encounter in the general surgical practice, but is a life-threatening condition requiring early recognition and adequate surgical treatment. We present the case of a 65 year old male patient referred to our department from a General Hospital. Large excisions of both superficial and deep cervical fascia were required together with necrotic skin on a very large surface. Rapid recovery with early sterilization allowed adequate skin grafting with good results. We advocate for aggressive debridment with excision in viable healthy tissue, with no concern for the future reconstruction followe by early grafting of the skin defect. KEY WORDS: CERVICAL FASCIITIS NECROTIZING Corespondence to: Gabriel Dimofte, MD, PhD, Assoc. Professor of Surgery, First Surgical Unit, St. Spiridon Hospital Iai; 700111, Independenei Street, No. 1, Iai, Romania; e-mail: gdimofte@yahoo.com*

INTRODUCTION Necrotizing fasciitis is a life threatening infection first described by Mehler with a recognized pattern of subcutaneous necrosis and progression [1]. Early diagnosis and early operation are accepted key points in successful treatment. Cervical origin of this subcutaneous spreading infection is infrequent and its development is determined by the complexity of anatomical planes of the neck and continuity with fascial planes of adjacent anatomical regions, notably thorax and mediastinum [2-6]. Most cases have a recognized odontogenic or pharyngeal origin. Idiopathic cases are not rare as aggressive broad spectrum antibiotic therapy may mask the primary site [5]. CASE PRESENTATION Patient CA, a 65 years old farmer, was referred to our emergency department from a General Hospital with a suspicion of cervical gangrenous infection. The onset of the condition was sudden, 2 weeks before arrival in our department, with excruciating pain in the right cervical area accompanied by fever, chills and non-painful dysphagia that did not respond to oral antibiotics. As the general status and local symptoms progressed the patient was referred to a General Hospital for surgical evaluation. Marked edema developed on the right cervical area followed in 72 hours by a limited necrotic lesion in the suprasternal notch that spontaneously drained a foul aerated discharge. Necrotic tissue was excised and patient was referred to our hospital with suspicion of a cervical fasciitis.
received date: 10.03.2009 accepted date: 25.04.2009
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On presentation the patient had major pain in the right cervical area, subcutaneous edema and a skin defect in the suprasternal notch extending to the right supraclavicular region 10 cm x 6 cm. The wound appeared necrotic with a dark base and foul, aerated, frothy discharge. Skin over the entire cervical area and right thoracic wall appeared purple discolored, with marked edema. Palpation did not reveal gas in the subcutaneous tissue. General status of the patient was not influenced but was obviously distressed. No other abnormalities could be identified either in clinical examination as well as lab work with the exception of a high WBC 15.8 x103/dL. Urinary function was normal and a slight transient increase in glycemia (153 mg/dL) was not considered significant and subsequent values returned to normal.

Fig. 1 Cervical wound with patches of necrotic fascia and viable muscles exposed. Skin borders with vascular thrombosis; deep cervical structures are exposed both medial as well as in the supraclavicular region. Puss is still visible emerging from deep fascial planes.

Emergency surgical debridment was indicated with a high suspicion of infection with gas producing bacteria. Initial evaluation proved to underestimate the extension of necrotic lesions which spread following fascial spaces in all neck compartments as well as most of the right thoracic wall. All structures components of the superficial and deep neck fascial planes were necrotic, but with viable pink muscular structures benetah. The sterno-mastoideus bundle was partially resected for a better access to the deep cervical structures. On the right side thoracic wall all structures starting with deep dermis to the fascia of the pectoralis major were affected by necrosis. Deep dermis both in the neck and thorax presented vascular thrombosis and did not bleed. Surgical strategy consisted in aggressive debridment of as much as possible of necrotic fascial structures and resection of all affected skin down to viable tissue. Muscular tissue was in general preserved. No attention was paid to cosmetic results and future reconstruction. Figure 1 depict the general aspect of the wound after debridment and gives a general idea regarding the extent of infection and skin defect created surgically. Soft gauges impregnated with betadine were placed in all spaces that have been developed and the whole wound was covered in betadine soaked dresses. Patient could be extubated immediately and was supervised in ICU for hemodynamic stability and parenteral nutrition.

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Bacterial cultures from the wound showed a mixed flora with Gram positive cocci and diplococci, Gram negative sporulated bacilli. Penumococcus and Stpahylococcus could be isolated and tested for antibiotic sensibility. Broad spectrum antibiotherapy was commenced with Teicoplanin as empirical therapy, followed by high dose Penicillin associated with Ciprofloxacin and Metronidazole for 5 days. Pathological examination confirmed inflammation with tendency to abscess formation (Fig. 2A) that extended between viable muscular fibres (Fig. 2B). Fat tissue from the anterior thoracic wall shows massive lyponecrosis (Fig. 2C) with recent thrombosis of small vessels associated to inflammatory infiltrate (Fig. 2D).

D
Fig. 2 Pathological examination A Inflammatory infiltrate with abscess formation (HE x 4); B Inflammatory infiltrate dissecting viable striated muscle bundles (HE x 4); C Massive lyponecrosis (HE x 4); D Recent thrombosis surrounded by inflammation and fibrosis (HE x 4)

First two dressings were done under general anesthesia and limited excisions were required to ensure a complete debridment and offer conditions for rapid granulation. Nine days after the surgical debridment the wound was clean, with granulation tissue developing and feeling empty spaces and negative bacterial cultures. Early grafting was decided and split thickness skin grafts were used to cover the major skin defects. All skin grafts survived and patient had a swift recovery being discharged after an additional postoperative week. Early postoperative functional results are very good with no limitations in movements, while cosmetic aspects are acceptable (Fig. 3).

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DISCUSSIONS Necrotizing fasciitis is an insidiously advancing soft tissue infection characterized by widespread fascial necrosis. Organisms spread from the subcutaneous tissue along the superficial and deep fascial planes, presumably facilitated by bacterial enzymes and toxins. This deep infection causes vascular occlusion, ischemia, and tissue necrosis. Superficial nerves are damaged, producing the characteristic localized anesthesia. Septicemia ensues with systemic toxicity [7]. In most cases aetiology is plurimycrobial (Type I necrotizing fasciitis) and this form may initially be mistaken for wound celulitis more so when toxicity is not obvious [7,8]. Type II is a streptococcal infection also called flesh eating infection and type III is a gas gangrene with myonecrosis. The case presented in this paper was a typical type I infection with infection spreading on fascial planes and association with vascular thrombosis. As this situation almost always develops in a surgical wound it is a possible scenario that superinfection followed in an initial surgical wound.

Fig. 3 Cosmetic results one month after first surgical debridment

The key in management is early recognition and early debridment. Of course resuscitation is to be started immediately and empirical antibiotics commenced even before the first surgical gesture, with later tailoring according to in vitro testings. Aggressive surgery implies incisions to the deep fascia, that can reveal the presence of murky dishwater fluid in the wound [7,8]. It is essential to remove all non-viable tissue including fascia, without concern for further reconstruction. Repeated debridment is required as lesion may progress away from apparent viable limits of resection. Bleeding can be a problem mostly if associated with intravascular coagulation, but in most cases bleeding from small vessels is a sign of adequate resection. We wish to stress the significance of aggressive surgical approach of this cases that certainly contributed to an early recovery, although our initial evaluation of life prognostic was poor. If non-recognition of the condition is by far the most damaging mistake,

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preserving non-viable structures for a future cosmetic result is responsible for continuous toxicity and infection progression beyond the healthy margins. Non surgical management of deep cervical fascial infection emerges as a novel alternative but requires a close supervision and drainage of all abscesses [9]. As there is limited experience and no clear cut indications for such a conservative treatment we do advocate against such management except for well documented cases with limited extension. Cervical fasciitis is particularly difficult as it hits on the border of surgical specialties. Complex anatomy of the neck allows progression along superficial as well as deep fascial structures. Continuity of the neck fascia with mediastinum and thoracic wall structures favors progression towards this anatomic areas [4,9,10]. Appropriate surgical management of deep neck infections is predicated on a comprehensive understanding of the anatomy of the head and neck [10]. All infected spaces should be readily opened and drained. Fascial planes are defined, anatomical, potential spaces dictated by the connective tissue and surrounding musculature within the neck and mediastinum. Anatomical spaces within the neck include the sublingual, submental, submandibular, submasseteric, pterygomandibular/masticator, infratemporal/temporal, lateral and retropharyngeal, and prevertebral spaces, all of these interconnected [10]. One should take into account possible spreading to this spaces and the pictures we present clearly demonstrate the importance of adequately debridement fascia in this spaces. Reconstruction should be decided together by the surgeon in charge and the plastic surgeon but early grafting should be delayed until bacteriological eradication [8]. A good level of trust and communication between the two specialties will speed up the procedure. CONCLUSIONS The management of necrotizing fasciitis affecting cervical spaces continues to be a challenge and results depend a great deal on surgical skills and courage to insure an early aggressive debridment. Clinical examination, correct empiric antibiotic selection, and appropriate surgical intervention are the cornerstones of proper management of deep cervical infections.
REFERENCES Meleney FL. Hemolytic Streptococcus Gangrene: Importance of early diagnosis and early operation. J Am Med Assoc. 1929; 92: 2009-2012. 2. Beck HJ, Salassa JK, MeCaifrey TV, Hermans PE. Life-threatening soft-tissue infections of the neck. Laryngoscope. 1984; 94: 354-362. 3. Krespi YP, Lawson W, Blaugrund SM, Biller HF. Massive necrotizing infection of the neck. Head Neck Surg. 1981; 3: 475-481. 4. Morrow JS, Gianoli GJ. Craniocervical necrotizing fasciitis. J La State Med Soc. 1993; 145: 297-300. 5. Helmy AS, Salah MA, Nawara HA, Khataba A, Khalaf HA, El-Maguid N. Abd. Life-threatening cervical necrotizing fasciitis. J R Coll Surg Edinb. 1997; 42: 410-413. 6. Diaz Manzano JA, Cegarra Navarro MF, Medina Banegas A, Lopez Meseguer E. Diagnostico y tratamiento de la fascitis necrotizante cervical. Evolucion tras una angina de Ludwig. An Otorrinolaringol Ibero Am. 2006; 33(3): 317-322. 7. Schwartz RA, Kapila R. Necrotizing fasciitis. E-Medicine. 2009; [available online at http://emedicine.medscape.com/article/1054438-overview ] 8. Hasham S, Mateucci P, Stanley PRW, Hart NB. Necrotizing fasciitis - Clinical review. BMJ. 2005; 330: 830-833. 9. Islam A, Oko M. Cervical necrotising fasciitis and descending mediastinitis secondary to unilateral tonsillitis: a case report. Journal of Medical Case Reports. 2008; 2: 368. 10. Miles BA, Myers L. Management of Deep Space Cervical Infection. The University of Texas Southwestern Medical Center at Dallas, 2009; [available online at http://www8.utsouthwestern.edu/utsw/cda/dept28151/files/308663.html] 1.

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HERNIA RETROSTERNALA (HERNIA MORGAGNI) LA COPIL CONSIDERAII ASUPRA A 2 CAZURI


Dana Mndrescu, G. Aprodu, V. Munteanu Clinica de Chirurgie Pediatric Spitalul Clinic de Urgene pentru Copii Sf. Maria Iai
RETROSTERNAL HERNIA A CHILDREN REPORT OF TWO CASES (Abstract). The retrosternal hernia is a rather rare affection encountered in the pediatric population, having an incidence of 1-6% of all the diaphragmatic hernias. It is generally asymptomatic, but it may present with respiratory or gastrointestinal symptoms. We present two patients with retrosternal hernia admitted with respiratory (recurrent repiratory infections before presentation) and gastrointestinal symptoms, respectively (weight stagnation for about four months and regurgitations). The final diagnosis was established on examining the colon appearance, after performing a barium enema, which in both cases revealed the intrathoracic, transdiaphragmatic and retrosternal colon herniation. Surgery was performed immediately after diagnosis, consisting in a median laparotomy with closure of the diaphragmatic gap with separate stitches, without having the hernia sac resected. The patients were discharged on the eighth postoperative day and on the fourth one, respectively. The clinical and X-ray controls performed one month after surgery revealed good results. When dealing with retrosternal hernias in children, surgery must be performed in order to close the diaphragmatic gap as soon as the diagnosis is certain, because of the high risk of complications. Even the resection of the hernia sac was not performed in any of the two presented cases, the long-term follow-up showed a favourable course. KEY WORDS: RETROSTERNAL HERNIA, FORAMEN OF MORGAGNI, Coresponden: Dr. Gabriel Aprodu, Clinica de Chirurgie Pediatric, Spitalul Clinic de Urgene pentru Copii Sf. Maria Iai; str. Vasile Lupu nr. 62, 700309, Iai; tel: 0232 / 264266*

INTRODUCERE Hernia retrosternal (retroxifoidian) este varianta cea mai rar a herniilor diafragmatice congenitale [1]. n general este asimptomatic i descoperit ntmpltor n cursul investigaiilor pentru alte afeciuni, dar poate determina simptome variate, nespecifice, de tip respirator sau gastro-intestinal [1,2]. Prezentm dou cazuri de hernie retroxifoidian la copil, ce au fost tratate chirurgical, cu evoluie favorabil. PREZENTAREA CAZURILOR Observaia 1. Un bieel, n vrst de 8 luni, s-a internat n Departamentul de Pediatrie al Spitalului de Copii Sf . Maria Iai, pentru febr i simptomatologie de tip respirator, reprezentat de tuse n chinte i tiraj suprasternal. La examenul stetacustic pulmonar s-au notat raluri bronice i subcrepitante pe ambele cmpuri pulmonare. Pacientul a fost diagnosticat cu pneumonie interstiial, instituindu-se tratament antibiotic. S-a efectuat radiografie toracic n inciden postero-anterioar (Fig. 1A), ce a evideniat o hipertransparen localizat, neomogen, cu dimensiuni de aproximativ 5
received date: 15.02.2009 accepted date: 1.03.2009
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cm, proiectat la nivelul cmpului pulmonar mijlociu drept i n 1/3 medie a mediastinului. Pe radiografia toracic de profil (Fig. 1B) formaiunea descris ocup mediastinul anterior, mijlociu i inferior. Diagnosticul de certitudine a fost pus n urma opacifierii colonului cu substan de contrast (bariu), care a evideniat prezena unei poriuni din colon, intratoracic, retrosternal.

Fig.1 Clisma baritat Se constat prezena unui segment colic intratoracic, transdiafragmatic A inciden postero-anterioar; B. profil.

Dup tratarea pneumoniei, s-a intervenit chirurgical sub anestezie general cu intubaie oro-traheal, practicndu-se laparotomie median supraombilical. Intraoperator s-a observat hernierea unei poriuni de colon intratoracic, printr-un defect diafragmatic situat pe linia median, de aproximativ 4 cm in dimensiuni. Dup extragerea anselor colice situate intratoracic, s-a nchis defectul diafragmatic cu fire separate, fr rezecia sacului herniar. Observaia 2. O feti, n vrst de 8 luni, s-a internat n clinica de pediatrie al aceluiai spital, pentru regurgitaii i stagnare ponderal de la vrsta de 5 luni, n condiiile unei alimentaii diversificate realizat corespunztor. La examenul obiectiv sau notat: murmur vezicular nnsprit, oc apexian n spaiul IV intercostal stng, deplasat spre stnga i zgomote anormale la nivelul ariei precordiale, pe toata suprafaa, asemntoare garguimentelor. Pe radiografia toracic n inciden postero-anterioar (Fig. 2A) s-a evideniat o opacitate de intensitate medie, omogen, situat bazal paracardiac drept i multiple imagini transparente, cu perete propriu, suprapuse peste opacitatea cordului, ridicnd suspiciunea unei hernii diafragmatice. Opacifierea ansei colice cu substan de contrast (bariu), efectuat ulterior, a evideniat colonul descendent herniat n cutia toracic, transdiafragmatic, retrosternal lateral stng (Fig. 2B).

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S-a intervenit chirurgical, efectundu-se laparotomie median supraombilical i s-a nchis fanta retroxifoidian (Fig. 3) (la stnga i la dreapta apendicelui xifoid) prin apropierea marginilor drepilor abdominali i ascensionarea diafragmului, fr rezecia sacului herniar.

Fig. 2 Radiografie toracic inciden postero-anterioar A multiple imagini transparente, cu perete propriu, suprapuse peste opacitatea cordului; B ansa colic opacifiat cu bariu migrat intratoracic

Fig. 3 Hernie retrosternal aspect intraoperator

REZULTATE Cei 2 pacieni au fost tratai prin chirurgie deschis, practicndu-se laparotomie median supraombilical i nchiderea defectului diafragmatic cu fire separate, fr rezecia sacului herniar.

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Primul a fost externat a 8-a zi postoperator, iar cel de-al doilea, n a 4-a zi postoperator, cu stare general bun i tranzit intestinal normal. Controlul clinic i radiologic efectuat la o lun dup intervenia chirurgical au evideniat evoluie favorabil n ambele cazuri. DISCUII Hernia prin foramenul Morgagni este considerat a fi rar n populaia pediatric, avnd o inciden de 1-6% din herniile diafragmatice [3]. n general, pacienii sunt asimptomatici. Exist ns cazuri n care sunt prezente repetate infecii respiratorii sau simptomatologie de tip gastro-intestinal [2]. n ambele cazuri organul herniat intratoracic a fost reprezentat de poriuni din colon, dei sunt citate n literatur i alte organe ce pot hernia: poriuni din ficat, intestin subire, splin, stomac [1-2]. Diagnosticul diferenial n hernia retroxifoidian include eventraia diafragmului, hernia hiatal, hernia diafragmatic prin orificiul Bochdalek, ruptura traumatic a diafragmului, tumori diafragmatice i formaiuni situate n mediastinul anterior [1-2]. Diagnosticul de certitudine este pus de opacifierea organului herniat cu substan de contrast (intestin subire sau colon) sau prin computer tomografie. Foarte rar s-au notat n literatur complicaii ale acestei afeciuni, reprezentate de obstrucie intestinal sau perforaie colic [4]. Toi autorii recomand intervenia chirurgical n herniile diafragmatice simptomatice, fr a ine seama de vrsta pacienilor [5]. n timp ce hernia retrosternal asimptomatic la aduli nu necesit n mod imperios intervenie chirurgical, muli autori recomand corecia chirurgical la copii, datorit creterii riscului de obstrucie intestinal [6,7]. La ambii pacieni am practicat laparotomie median supraombilical pentru repararea defectului diafragmatic. Aceasta se poate efectua i prin abord toracic, dar de obicei acesta este rezervat cazurilor n care diagnosticul preoperator nu este cert sau cnd defectul diafragmatic este foarte mare i n apropierea nervului frenic [8]. Abordul minim invaziv, reprezentat de chirurgia laparoscopic, a nceput s capete amploare n repararea defectelor diafragmatice n populaia pediatric [9]. Tehnicile minim invazive necesit ns o selecie atent a pacienilor i o colaborare bun ntre chirurg i anestezist. Corecia laparoscopic a defectelor diafragmatice nu este dificil de realizat, exceptnd cazurile n care sunt prezente aderene importante [10]. Este bine tolerat de pacieni i d rezultate cosmetice excelente. La nici unul din cele dou cazuri nu am practicat rezecia sacului herniar. Unii autori susin c rezecia sacului herniar este parte component a interveniei chirurgicale n repararea defectului diafragmatic, recomandnd rezecia sau mcar plicaturarea acestuia, pentru a preveni formarea unei colecii n cavitatea restant sau recurena herniei [10]. Ali autori, ns, afirm c nu exist nicio diferen n ceea ce privete evoluia postoperatorie a pacienilor la care s-a practicat rezecia sacului herniar comparativ cu cei la care nu s-a efectuat [11]. CONCLUZII Hernia retroxifoidian este o afeciune rar. Diagnosticul pozitiv se realizeaz prin tehnici de imagiistic medical, cu evidenierea organului herniat. Intervenia chirurgical pentru defectului diafragmatic este absolut necesar, dar rezecia sacului herniar este discutabil.

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BIBLIOGRAFIE Simson JNL, Eckstein HB. Congenital diaphragmatic hernia: a 20-year experience. Br J Surg. 1985; 72: 733-736. 2. Cullen ML, Klein MD, Philippart AI. Congenital diaphragmatic hernia. Surg Clin North Am. 1985; 65(5): 1115-1138. 3. Al-Arfaj AL. Morgagnis hernia in infants and children. Eur J Surg. 1998; 164: 275-279. 4. Anthes TB, Thoongsuwan N, Karmy-Jones R. Morgagni hernia: CT findings. Curr Probl Diagn Radiol. 2003; 32: 135-136. 5. Wolloch Y, Grunebaum M, Glanz I, Dintzman M. Symptomatic retrosternal (Morgagni) hernia. Am J Surg. 1974; 127: 601-605. 6. Berman L, Stringer D, Ein SH, Shandling B. The late-presenting pediatric Morgagni hernia: a benign condition. J Pediatr Surg. 1989; 24(10): 970-972. 7. Bentley G, Lister J. Retrosternal hernia. Surgery. 1965: 57: 567-575. 8. Sarihan H, Imamoglu M, Abes M, Soylu H. Pediatric Morgagni hernia: report of two cases. J Cardiovasc Surg. 1996; 37(2): 195-197. 9. Shah AV, Shah AA: Laparoscopic approach to surgical management of congenital diaphragmatic herniain the newborn. J Pediatr Surg. 2002; 37(3): 548-550. 10. Contini S, Dalla Valle R, Bonati L, Zinicola R. Laparoscopic repair of a Morgagni hernia: Report of the cases and review of the literature. J Laparoendosc Adv Surg Tech A. 1999; 9(1): 93-99. 11. Bortul M, Calligaris L, Gheller P: Laparoscopic repair of a Morgagni-Larrey hernia. J Laparoendosc Adv Surg Tech A. 1998; 8(5): 309-313. 1.

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TEHNICA PRELEVRII FICATULUI PENTRU TRANSPLANT


C. Lupacu Clinica I Chirurgie, Spitalul Sf. Spiridon Iai Universitatea de Medicin i Farmacie Gr.T. Popa Iai
SURGICAL TECHNIQUE FOR LIVER DONOR PROCUREMENT (Abstract): Transplantation of the liver is one of the most traumatic operations yet deviced and there is a tendency for it to be offered as a possible life-saving therapy to some of the sickest patients that are submitted to surgery. The concept of vascularized liver graft resulted from the pioneering work of Moore (1959) and Starzl (1960). In the last twenty years, the concept of multiorgan donor has been accepted in most European countries and USA, and, where possible, all organs that can be used are transplanted from a given donor, provided permission is forthcoming. Procurement of the whole liver graft from a heart-beating, but brain-dead, donor remains the standard method of liver procurement and is usually carried out as part af a multiple organ retrieval that also includes the kidneys, pancreas and thoracic organs, and occasionally intestinal grafts are being recovered. The author describes the standard approach for donor hepatectomy. KEY WORDS: ORGAN PROCUREMENT, LIVER TRANSPLANTATION Coresponden: Conf. Dr. Cristian Lupacu, Clinica I Chirurgie, Spitalul Sf. Spiridon Iai, Bd. Independenei, Nr. 1, Iai, 700111; e-mail: cristianlupacu@hotmail.com*

INTRODUCERE Prelevarea ficatului se nscrie, ca regul general, n cadrul unei prelevri multiorgan care include practic ntotdeauna rinichii, adesea cordul i marile axe vasculare, mai rar plmnii i pancreasul. Organele trebuie explantate mpreun cu vascularizaia lor i trebuie corect conservate n vederea transplantrii. Starea donorului aflat n moarte cerebral (cu att mai mult a celui non heart beating), este ntotdeauna precar iar regula este de a organiza i practica prelevri rapide, cu o bun coordonare ntre echipe. Exist constant riscul unei opriri cardiace premature care poate antrena prelungirea timpului de ischemie cald i uneori, compromiterea grefonului. Tehnica transplantului hepatic, inclusiv cea de prelevare, a fost pus la punct mai nti la Universitatea Colorado n Denver i, din ianuarie 1981, la Universitatea din Pittsburgh [1]. Aceste metode chirurgicale au fost apoi preluate i perfecionate de centre chirurgicale de transplant din ntreaga lume. PRINCIPIILE TEHNCILOR CHIRURGICALE DE PRELEVARE Principiile prelevrii ficatului sunt: 1) verificarea integritii i calitii grefonului printr-o inspecie atent; 2) efectuarea unui lavaj lichidian refrigerat al organului pe cale arterial i venoas, pentru reducerea efectelor nefavorabile ale ischemiei; 3) prelevarea organului se face evitnd orice traumatism, pstrndu-i vascularizaia, pentru a permite reimplantarea i revascularizarea sa [1,2]. Tehnica de rutin a fost descris iniial de T. Starzl [1]. Ea are avantajul de a fi rapid, reproductibil i convenabil oricrei variante anatomice. Se face fr disecie
received date: 24.01.2009 accepted date: 25.04.2009
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pedicular i cu o minim disecie a ficatului, acesta fiind explantat mpreun cu un tub aortic comportnd toate ramurile arteriale cu destinaie hepatic, axele venoase precum i o larg pastil din diafragm [1,2]. Prelevarea concomitent i a pancreasului necesit ns modificarea tehnicii [2,3]. Prelevarea multi-organ ncepe prin laparotomie, efectuat n general de echipa urologic, cu abordul vaselor i prepararea cmpului abdominal; echipa cardiac apare de regul ulterior, pentru realizarea sternotomiei i pregtirea cordului. TEHNICA CHIRURGICAL PROPRIU-ZIS Instalarea Cmpul operator este larg, ncepnd de la foseta suprasternal, mergnd n jos ctre apendicele xifoid i simfiza pubian. Dac se prelev i vase, incizia se prelungete ctre membrele inferioare [3-5]. La nivelul abdomenului incizia este xifopubian sau cruciform, permind deschiderea sa larg [1]. Cele 4 cadrane-lambouri cutaneo-musculare sunt eversate i meninute cu suturi [1].

Fig. 1 Disecia i pregtirea pentru canulare a venei cave inferioare, aortei i venei mezenterice inferioare. Se remarc decolarea i reclinarea colonului i anselor intestinale.

Pregtirea canulrilor Colonul drept i cecul sunt decolate pn la rdcina mezenterului. Decolarea dodeno-pancreatic permite expunerea larg a venei cave inferioare, de la bifurcaia sa pn la venele renale, precum i a aortei, de la originea arterei mezenterice superioare pn la axele iliace [1-5]. Aorta este disecat apoi mai sus de bifurcaia sa, iar dou lauri (de cauciuc sau material textil) sunt trecute n jurul ei. n caz de prelevare concomitent vascular sau anomalie de vascularizaie renal, este de dorit s se canuleze i artera hipogastric i, ca urmare, aceasta va fi de asemenea, disecat. Se realizeaz disecia i expunerea pe lauri a venei cave inferioare, a arterei mezenterice superioare (la origine din aort) i a

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venei mezenterice inferioare la nivelul marginii inferioare a pancreasului (Fig. 1) [1-5]. Liniile de perfuzie sunt pregtite, dar nu sunt instalate imediat. Explorarea parenchimului, controlul aortei supraceliace i lavajul vezicular Ficatul este explorat vizual i printr-o atent palpare. Lobul stng este eliberat i ridicat pentru a vedea dac exist o arter hepatic stng din artera coronar gastric la nivelul micului epiploon [1]. Vezicula biliar este golit dup ce n prealabil a fost realizat o burs, apoi se realizeaz lavajul cilor biliare cu ser fiziologic (Fig. 2). Aorta este abordat la nivelul hiatusului diafragmatic, dup reclinarea esofagului, disecat i apoi pus pe un la (Fig. 2).

Fig. 2 Abordul aortei la nivelul hiatusului diaphragmatic i puncionarea i lavajul veziculei biliare

Canularea venei mezenterice inferioare pentru lavajul portal Vena mezenteric inferioar, disecat n prealabil la nivelul marginii inferioare a pancreasului, este ligaturat la cca 4 cm de marginea inferioar a pancreasului. n aceast ven se introduce apoi o canul (sau o sond de aspiraie traheal adaptat dimensiunilor venei), care se poziioneaz pn la originea trunchiului portal sub control palpator al pediculului hepatic (Fig. 3). Canularea aortei i venei cave inferioare Dac se preleveaz i cordul, acesta este momentul realizrii sternotomiei, pentru ca echipa cardiac s prepare grefonul cardiac. Cnd toate echipele sunt pregtite, se realizeaz canularea aortei, ligatura aortei deasupra bifurcaiei, amplasarea canulei aortice care este asigurat prin laul aortic superior [3]. n acelai mod, se

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ligatureaz vena cav inferioar, amplasndu-se canula de descrcare [3]. Este absolut necesar s se verifice poziionarea corect a canulei de descrcare (sub venele renale) i a celei aortice (sub emergena arterelor renale) [1-5]. Clampajul aortei toracice de ctre chirurgii cardiaci, este semnalul de declanare al purjrii aortice i mezenterice, precum i de ligatur a aortei subdiafragmatice supraceliace [1-5]. Descrcarea venei cave este imediat deschis. Cmpul operator este refrigerat prin irigarea cu o soluie de ser fiziologic rece. Se urmrete decolorarea lent a organelor.

Fig. 3 Ligatura pediculului mezenteric superior i secionarea pancreasului

Eliberarea ficatului Mna stng a chirurgului apas n jos ficatul, iar diafragmul este incizat de-a lungul ligamentului triunghiular pn la vena cav, care este secionat deasupra diafragmului, dup aplicarea prealabil a unui clamp, n cazul n care cordul nu este prelevat [1]. Incizia diafragmatic se prelungete la stnga pn la hiatusul diafragmatic, apoi marginea inferioar a ficatului este eliberat pn la vena cav subhepatic, care este secionat deasupra celor dou vene renale, pstrnd totui mcar un centimetru de securitate pentru grefoanele renale.

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Eliberarea cefalo-pancreasului din potcoava duodenal Ajutorul expune duodenul operatorului, n condiiile n care manevra Kocher a fost efectuat n debutul operaiei de prelevare. Pancreasul este separat complet de DI, DII i DIII, cu seciunea intrapancreatic a coledocului [1-4]. n jos, aceast manevr conduce la vasele mezenterice superioare, care sunt incluse n mezenter (Fig. 3). Aceste vase sunt legate n bloc la nivelul rdcinii mezenterului iar n sus, capul pancreatic este total eliberat de duoden dup secionarea arterei pilorice. Seciunea cozii pancreatice Cavitatea retrogastric este deschis prin seciunea ligamentului gastrocolic. Mna chirurgului trece posterior de splin i de coada pancreasului, permind seciunea pancreasului distal i vaselor splenice [1-3]. Se continu apoi cu eliberarea micii curburi gastrice cu seciunea arterei coronare gastrice, n partea de sus a stomacului, dup pstrarea originii unei eventuale artere hepatice stngi (Fig. 3) [1]. Seciunea aortei Aorta abdominal este secionat deasupra ligaturii subdiafragmatice. Faa ei posterioar este eliberat cu degetul, apoi se abordeaz aorta renal. Se deschide faa anterioar a aortei printr-o incizie longitudinal, ceea ce permite reperarea, endoluminal, a nivelului aburii arterelor renale i, eventual, a unor artere polare superioare [1-5]. Se incizeaz circumferenial aorta sub nivelul arterei mezenterice superioare, pentru prezervarea arterelor renale [1-5]. Tubul aortic astfel secionat este eliberat de pilierul diafragmatic, reclinnd toat masa organic ctre dreapta. Pregtirea grefonului Grefonul incluznd capul pancreasului, pediculul hepatic nedisecat i o parte din diafragm, este apoi ntr-un recipient plin cu ser fiziologic refrigerat. Apoi se pregtete un container coninnd un litru soluie de conservare, n care se introduce, n mod steril, organul de transplantat, nconjurat de ghea, n vederea transportului. DISCUII n minile unui chirurg experimentat, aceast tehnic rapid de prelevare hepatic dureaza n medie 30-45 minute. Ea este destinat n special donatorilor stabili din punct de vedere hemodinamic. Trebuie bine nsuit de chirurgii aflai la nceputul experienei de prelevare, deoarece nu necesit o disecie prelungit. Odat stpnit tehnica de prelevare ct i cea de rcire a ficatului, se poate trece la nvarea unor tehnici mai rapide, care s fie utilizate n situaii clinice particulare [6]. Cnd cordul donatorului cadaveric a ncetat s bat doar de cteva minute (cardiac arrest), la donatori non-heart beating, n situaia unor ri n care nu este permis prelevarea de organe de la pacieni aflai n moarte cerebral sau n alte circumstane legale sau religioase, se poate trece la tehnica super rapid [6,7]. Aceasta presupune canularea imediat a aortei distale i iniierea irigrii cu soluie de conservare refrigerat n condiiile n care practic nu exist o circulaie sanguin efectiv [8,9]. Ulterior se recurge la sternotomie median rapid, clamparea aortei toracice i secionarea venei cave inferioare suprahepatice pentru decompresiune hepatic; se canuleaz apoi vena mezenteric inferioar pentru irigarea refrigerat a sistemului portal. Etapele urmtoarele sunt asemntoare cu cele descrise. Oricum, pentru tehnica super rapid, este necesar un nivel de ndemnare mult mai ridicat din partea chirurgului care efectueaz procedura [7-9].

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1. 2. 3. 4. 5. 6. 7.

8. 9.

BIBLIOGRAFIE Stazl TE, Demetris AJ. Liver Transplantation. Chicago: Year Book Medical; 1990. CasavillaA, Selby R,Tzakis A, Todo S. Logistics and technique for combined hepatic-intestinal retrieval. Annals of Surgery. 1992; 216: 605-609. Starzl TE, Hakala TR. A flexible procedure for multiple for multiple cadaveric organ procurement. Surgery, Gynecology and Obstetrics. 1984; 158: 223-230. Kalayoglu M, Sollinger HW, Stratta RJ, D'Alessandro AM, Hoffmann RM, Pirsch JD, Belzer FO. Extented preservation of the human liver for clinical transplantation. Lancet. 1988; 1(8586): 617-619. Gordon R D, Van Thyel D, Starzl TE. Liver Transplantation. In: Schiff L, Sciff ER, editors. Diseases of the liver, 7-th edition, Philadelphia: Lippincott; 1993. Walia A, Schumann R. The evolution of liver transplantation practices. Curr Opin Organ Transplant. 2008; 13(3): 275-279. Detry O, Seydel B, Delbouille MH, Monard J, Hans MF, De Roover A, Coimbra C, Lauwick S, Joris J, Kaba A, Damas P, Damas F, Lamproye A, Delwaide J, Squifflet JP, Meurisse M, Honor P. Liver transplant donation after cardiac death: experience at the University of Liege. Transplant Proc. 2009; 41(2): 582-584. Muiesan P, Girlanda R, Jassem W, Melendez HV, O'Grady J, Bowles M, Rela M, Heaton N. Single-center experience with liver transplantation from controlled non-heartbeating donors: a viable source of grafts. Ann Surg. 2005; 242(5): 732-738. Moon JI, Nishida S, Butt F, Schwartz CB, Ganz S, Levi DM, Burke GW, Tzakis AG. Multiorgan procurement and successful multi-center allocation using rapid en bloc technique from a controlled non-heart-beating donor. Transplantation. 2004; 77(9): 1476-1477.

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PROTEZAREA VALVULAR AORTIC MINIM-INVAZIV


Ctlina Maria Moldovanu1, O. tiru2 1 Clinica a III-a Medical Cardiologic G. Enescu, Universitatea de Medicin i Farmacie Gr.T. Popa Iai 2 Clinica de Chirurgie Cardiovascular, Institutul de Boli Cardiovasculare Prof. Dr. C.C. Iliescu, Bucureti Universitatea de Medicin i Farmacie Carol Davila Bucureti
AORTIC VALVE REPLACEMENT BY MINIMALLY INVASIVE APPROACH (Abstract): Degenerative aortic stenosis is one of the most frequent valvular disease. About 25% from the people over 65 years old had aortic sclerosis and about 4% from the inhabitants older then 75 years old had aortic stenosis. Aortic valve replacement (AVR) is the treatment of choice. The overall postoperative mortality of this operation is under 5% especially in large volume surgical centers. For the patients older then 80 years old and with severe comorbidities the postoperative mortality rate of AVR operation is over 15%. For this category of patients the best approach is AVR using a minimally invasive approach, especially the percutaneous approach. The paper describes the different tehniques and valvular prosthesis for minimally invasive AVR. The data from the literature - actual indications, valvular prosthetic types and results of different minimally invasive tehniques - are discussed. KEY WORDS: AORTIC STENOSIS, AORTIC VALVULAR REPLACEMNT, ROBOTIC CARDIAC SURGERY, PERCUTANEOUS AORTIC VALVE IMPLANTATION Coresponden: Dr. Ctlina Maria Moldovanu, Clinica a III-a Medical, Spitalul Sf. Spiridon Iai, Bd. Independenei, Nr. 1, 700111, Iai, Romnia; e-mail: catalinamoldovanu@gmail.com*

INTRODUCERE Stenoza aortic (SAo) valvular degenerativ este cea mai frecvent afeciune valvular la adult reprezentnd 30-40% din afeciunile valvulare [1]. n S.U.A., 25% dintre pacienii peste 65 ani au scleroz aortic [2], iar cca 4% din populaia peste 75 ani are SAo [3]. Se consider c 1 din 6 pacieni cu scleroz aortic evolueaz spre SAo [4] i o jumtate din pacienii cu stenoz aortic uoar i moderat evolueaz spre stenoz aortic sever [5]. Raportarea AHA din 2006 [6] consider c afeciunile valvulare sunt rspunztoare de 19989 decese, majoritatea (12471 62,4%) datorndu-se patologiei aortice; aceeai surs menioneaz c n 2003, n S.U.A., au fost implantate 95000 de proteze valvulare. Tratamentul de elecie al SAo este protezarea valvular; indicaia de protezare i momentul interveniei se bazeaz pe prezena simptomatologiei (angin, dispnee sau sincop) [7]. n aceste situaii protezarea valvular are o rat nalt de succes i un prognostic bun pe termen lung [8,9]. Managementul formelor asimptomatice reprezint o provocare, ntruct absena simptomelor se asociaz pe de o parte cu un risc crescut de deces (moarte subit), iar pe de alt parte, protezarea valvular neselectat i prematur conduce la o rat nalt a morbiditii i mortalitii perioperatorii. Mortalitatea perioperatorie a sczut continuu n nterveniile de protezare aortic, mai ales n centrele specializate cu volum mare [7]. Dac n anii 80
received date: 22.12.2008 accepted date: 15.03.2009
*

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mortalitatea perioperatorie atingea 16% [10], actualmente AHA, citnd datele Societii Chirurgilor Toracici (Society of Thoracic Surgeons), raporteaz, n centrele specializate, o mortalitate perioperatorie de 3-4% la pacienii cu protezare valvular aortic i de 5,56,8% la pacienii cu protezare valvular aortic i by-pass coronarian [7]. Factori adiionali pot crete riscul chirurgical: chirurgia de urgen (mortalitatea poate atinge 30%) [11], disfuncia ventricular sever, hipertensiunea pulmonar secundar, boal coronarian coexistent, by-pass sau nlocuirea valvular n antecedente, boala renal cronic, vrstnici [12]. Pentru aprecierea i predicia riscului operator se folosete curent scorul EUROSCORE [7,11]. La pacienii cu multipli factori de risc, rata predictiv a mortalitii perioperatorii calculat standard este subestimat; de aceea exist posibilitatea calculrii riscului folosind formule statistice, n funcie de ponderea fiecrui parametru n determinismul mortalitii perioperatorii (www.euroscore.org). La pacienii cu risc nalt (peste 15% mortalitate predictiv) este indicat protezarea valvular percutan fie ca metod definitiv de protezare, fie ca o etap intermediar, pentru stabilizarea pacientului i pregtirea unei viitoare protezri definitive (bridge). TEHNICI DE NLOCUIRE VALVULAR MINIM-INVAZIV n prezent exist disponibile dou posibiliti de protezare valvular miniminvaziv: chirurgia robotic i protezarea valvular percutan [13]. Chirurgia robotic Prima intervenie robotic de nlocuire valvular a fost realizat n 2000, de Colvin S, de la New York University Medical Center And School Of Medicine [14], cnd s-a practicat protezare valvular mitral la un pacient de 50 ani, folosind un sistem robotic Zeus, calea de abord fiind o minitoracotomie de cca 5 cm. Pentru interveniile de by-pass coronarian i chiar de nlocuire a valvei mitrale, chirurgia robotic a fost deja folosit existnd raportri n literatur [15,16]. Primele date despre protezarea valvular aortic robotic aparin lui Folliguet TA et al [17], care, n 2005, public primele 5 cazuri; au fost 4 pacieni cu SAo calcificat i un pacient cu insuficien aortic, avnd o vrst medie de 59 ani. A folosit un sistem robotic daVinci, calea de abord fiind dou porturi pentru trocare i o minitoracotomie de cca 6 cm. Durata medie a by-pass-ului cardio-pulmonar a fost de 121,537,5 minute, iar spitalizarea postoperatorie de 8,63 zile, cu un necesar redus de antalgice n perioada postoperatorie. Avantajele sitemului robotic n chirurgia valvular au fost demonstrate de seriile de intervenii de protezare mitral [18]: rezoluie optic nalt, imagine tridimensional, instrumente cu 7 grade de libertate, cu micri intuitive, incizii de mici dimensiuni i, ca urmare, cu dureri postoperatorii mai reduse, spitalizare mai scurt. Pn n prezent seriile raportate n literatur sunt prea mici pentru a putea trage concluzii asupra morbiditii i mortalitii operatorii. Protezarea valvular percutan Protezarea valvular minim-invaziv, percutan, este o tehnic minim invaziv dezvoltat pentru pacienii cu SAo sever i risc nalt. Tehnicile percutane au fost dezvoltate ncepnd cu 1985, cnd Cribier a efectuat prima valvuloplastie aortic [19]. n 2000 a fost raportat primul stent valvular introdus percutan, iar n 2002 prima protezare aortic percutan [20-23]. Exist trei tehnici de abord percutan pentru protezarea valvular aortic: anterograd, retrograd i transapical, pentru fiecare fiind concepute tipuri speciale de valve (Fig. 1). Se utilizeaz curent trei tipuri de valve [20]:

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Cribier-Edwards bioprotez din pericard de cal pe structur de oel, expandabil pe balon de valvuloplastie disponibil pentru toate cele trei tipuri de abord); CoreValve ReValving System bioprotez din pericard bovin pe stent autoexpandabil din nitinol disponibil doar pentru calea retrograd; Edwards-Sapien bioprotez din pericard bovin pe structur din oel inoxidabil, expandabil pe balonul de valvuloplastie pentru abord retrograd sau transapical.

Fig. 1 Proteazarea aortic percutan posibiliti de abord

Tehnica anterograd const n abordul venei femurale, ascensionarea cateterului pn la nivelul atriului drept, traversarea septului interatrial, apoi a valvei mitrale i poziionarea la nivelul valvei aortice stenozate [22]. Avantajul major al tehnicii este reprezentat de diametrul mare i compliana crescut a femuralei care permitea folosirea unor catetere de dimensiuni generoase. Tehnica a fost abandonat datorit riscului lezrii valvei mitrale, cu dezvoltarea ulterioar a unei insuficiene, precum i a dificultilor de manipulare ale protezei [22]. Tehnica retrograd, n care calea de acces este reprezentat de artera femural, abordul valvei aortice fiind realizat retrograd. Prima protezare prin abord retrograd a fost raportat n 2005, de Paniagua D et al [23], de la Centrul de cardiologie din Caracas, la un brbat de 62 ani, cu SAo calcificat sever i multiple comorbiditi (hipertensiune pulmonar sever, insuficien cardiac congestiv, insuficien renal cronic), dar pacientul a decedat n a 5-a zi postoperator ca urmare a unei embolii pulmonare, dei proteza valvular funciona corespunztor din punct de vedere hemodinamic. Tehnica asigur actualmente rezultate bune, dezavantajele citate fiind riscul de lezare al aortei i femuralei i manipularea dificil a cateterului la nivelul crosei aortei [22].

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Tehnica transapical este o intervenie chirurgical minim-invaziv care impune anestezia general; calea de acces este o minitoracotomie de cca 1-2 cm urmat de puncionarea vrfului ventriculului stng cu un ac, catetrizarea i apoi fixarea valvei n poziie aortic. Principalul avantaj este reprezentat de accesul direct asupra valvei aortice; n schimb puncia ventricului stng poate fi sursa unor poteniale complicaii: anevrism ventricular, aritmie, lezarea coronarelor, revrsat pericardic i pleural [22]. Toate cele trei tipuri de abord necesit ghidare fluoroscopic, angiografie coronar i monitorizare transesofagian. Poziia ideal de plasare a protezei este mijlocie, la nivelul valvei aortice, astfel nct s nu influeneze ostiumurile coronare i deschiderea mitralei [22]. Protezele sunt plasate prin umflarea balonului de valvuloplastie sau deschiderea stentului, dezumflarea rapid i retragerea balonului i a cateterului n timpul unei tahicardii ventriculare de cca 10 sec, induse prin stimularea ventriculului drept, de 180-200 /min, care are drept scop scderea volumului btaie i a fluxului transaortic. Rezultatele tehnicilor percutane Rata de succes raportat n literatur pentru proteza Cribier-Edwards, prin tehnica anterograd a fost de 85%, constatndu-se o mbuntire a ariei valvulare aortice (de la 0,60,11 cm2 vs 1,70,1 cm2), creterea fraciei de ejecie (4518% vs 5314%), reducerea gradientului transvalvular (3713 mmHg vs 92 mmHg), i mbuntirea statusului funcional (90% dintre pacieni au trecut din NYHA IV n NYHA I sau II), rezultate meninute la peste 26 luni [24]. Mortalitatea perioperatorie a fost variabil 8-16% n funcie de experiena echipei [25]. Pn n prezent au fost implantate peste 500 bioproteze Cribier, utilizarea valvelor cu diametre mari (26 mm) fiind asociat cu un risc mai mic de migrare valvular i regurgitare aortic paravalvular [22]. Sistemul CoreValve Revalving este o bioprotez valvular autoexpandabil folosit numai pentru abordul retrograd i are un diametru de 21-22 mm. Prima protez de acest tip a fost implantat n 2005 [26]. Rata de succes a protezei este de 84-94%, gradientul transvalvular i mbuntirea statusului funcional fiind rapide i durabile. Sistemul nregistreaz un grad redus de regurgitare aortic perivalvular i a fost folosit i la pacieni cu bioproteze degenerate i comorbiditi importante [22,27,28]. Design-ul protezei i asigur cteva avantaje: autocentrarea la nivelul orificiului valvular, posibilitatea ancorrii adecvate la nivelul orificiului aortic, posibilitatea schimbrii implantrii dup o poziionare parial, proprietate deosebit de util n timpul curbei de nvare [27]. Proteza Edwards-Sapien reprezint o evoluie a protezei Cribier i este disponibil n dou dimensiuni 21 i 26 mm [22]. Rata de succes este de 91-96%, toi parametrii hemodinamicii cardiace mbuntindu-se semnificativ [22]. Mortalitatea perioperatorie a fost de 15% supravieuirea la 6 luni fiind de 78%, iar la 2 ani de 60% (pacieni vrstnici avnd comorbiditi importante) [29]. Protezarea valvular percutan pare a fi metoda de elecie pentru pacienii vrstnici (peste 80 ani) ce au comorbiditi importante i SAo sever asimptomatic. La aceast categorie de pacieni rata mortalitii perioperatorii este 15-18%; prin comparaie rata mortalitii n protezarea valvular percutan este de cca 12% i se mbuntete continuu pe msur ce experiena se acumuleaz [22,30]. Dezavantajele protezrii valvulare aortice percutane sunt reprezentate posibilitatea apariiei unor complicaii grave, de multe ori letale: dislocarea protezei i embolizarea aortei, ruptur sau disecie acut de aort, obstrucia ostiumurilor coronare.

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Rata exact a aacestor complicaii nu este cunoscut; de asemenea, nici rata i nici severitatea insuficienei aortice perivalvulare [31]. CONCLUZII Tehnicile minim-invazive de protezare valvular aortic ctig teren. Chirurgia robotic pare a oferi rezultate favorbile dar costul prohibitiv al tehnologiei i limiteaz aplicarea. Protezarea valvular aortic percutan este indficat la pacienii cu risc operator nalt (vrstnici peste 80 ani, comorbiditi). Indicaiile protezrii valvulare aortice minim-invazive trebuie nuanate deoarece riscul unor complicaii potenial letale este relativ ridicat. Sunt necesare studii randomizate, eventual multicentrice pentru a stabili indicaiile protezrii valvulare percutane. BIBLIOGRAFIE
ung B, Baron G, Butchart EG, Delahaye F, Gohlke-Brwolf C, Levang OW, Tornos P, Vanoverschelde JL, Vermeer F, Boersma E, Ravaud P, Vahanian A. A prospective survey of patients with valvular heart disease in Europe: the Euro Heart Survey on Valvular Heart Disease Eur Heart J. 2003; 24(13): 1231-1243. 2. Dal-Bianco JP, Khanheria BK, Mookadam F, Gentile F, Sengupta PP. Management of asymptomatic severe aortic stenosis. J Am Coll of Cardiol. 2008; 52(16): 1279-1292. 3. Nkomo VT, Gardin JM, Skelton TN, Gottdiener JS, Scott CG, Enriquez-Sarano M. Burden of valvular heart diseases: a populationbased study. Lancet. 2006; 368: 1005-1011. 4. Cosmi JE, Kort S, Tunick PA, Rosenzweig BP, Freedberg RS, Katz ES, Applebaum RM, Kronzon I. The risk of the development of aortic stenosis in patients with benign aortic valve thickening. Arch Intern Med. 2002; 162(20): 2345-2347. 5. Rosenhek R, Klaar U, Schemper M, Scholten C, Heger M, Gabriel H, Binder T, Maurer G, Baumgartner H. Mild and moderate aortic stenosis. Natural history and risk stratification by echocardiography. Eur Heart J. 2004; 25(3): 199-205. 6. Thom T, Haase N, Rosamond W, Howard VJ, Rumsfeld J, Manolio T, Zheng ZJ, Flegal K, O'Donnell C, Kittner S, Lloyd-Jones D, Goff DC Jr, Hong Y, Adams R, Friday G, Furie K, Gorelick P, Kissela B, Marler J, Meigs J, Roger V, Sidney S, Sorlie P, Steinberger J, Wasserthiel-Smoller S, Wilson M, Wolf P. Heart disease and stroke statistics-2006 update: A Report From the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2006; 113(6): e85-e151. 7. Bonow RO, Carabello BA, Chatterjee K, de Leon AC Jr, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah PM, Shanewise JS. 2008 Focused update incorporated into the ACC/AHA 2008 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 guidelines for the management of patients with valvular heart disease) developed in collaboration with the Society of Cardiovascular Anesthesiologists endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. Circulation. 2008; 118(15): e523-e661. 8. Rosenhek R, Binder T, Porenta G, Lang I, Christ G, Schemper M, Maurer G, Baumgartner H. Predictors of outcome in severe, asymptomatic aortic stenosis. N Engl J Med. 2000; 343(9): 611617. 9. Pai RG, Kapoor N, Bansal RC, Varadarajan P. Malignant natural history of asymptomatic severe aortic stenosis: benefit of aortic valve replacement. Ann Thorac Surg. 2006; 82: 2116-2122. 10. Murphy ES, Lawson RM, Starr A, Rahimtoola SH. Severe aortic stenosis in patients 60 years of age or older: left ventricular function and 10-year survival after valve replacement. Circulation. 1981; 64: II184-II188. 11. Chikwe J, Walther A, Pepper J. The surgical management of aortic valve disease. Br J Cardiol. 2003; 10(6): 453-461. 12. Vahanian A, Baumgartner H, Bax J, Butchart E, Dion R, Filippatos G, Flachskampf F, Hall R, Iung B, Kasprzak J, Nataf P, Tornos P, Torracca L, Wenink A. Guidelines on the management of 1.

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valvular heart disease: The Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology. Eur Heart J. 2007; 28(2): 230-268. Gulbins H, Pritisanac A, Hannekum A. Minimally invasive heart valve surgery: already established in clinical routine? Expert Rev Cardiovasc Ther. 2004; 2(6): 837-843. New York University Medical Center And School Of Medicine (2000, May 3). A First In Robotic Heart Valve Surgery. ScienceDaily. Available online at http://www.sciencedaily.com- / releases / 2000 / 05 / 000502185715.htm. Bonatti J, Schacher T, Bernecker O, Chevtnik O, Bonaros N, Ott H, Friedrich G, Weidinger F, Laufer G. Robotically totally endoscopic coronary bypass: program development and learning curve issues. J Thorac Surg. 2004; 127(2): 504-510. Woo YJ, Nacke EA. Robotic minimally invasive mitral valve reconstruction yields less blood product transfusion and shorter length of stay. Surgery. 2006; 140(2): 263-267. Folliguet TA, Vanhuyse F, Konstantinos Z, Laborde F. Early experience with robotic aortic valve replacement. European Journal of Cardio-Thoracic Surgery. 2005; 28: 172-173. Jones BA, Krueger S, Howell D, Meinecke B, Dunn S. Robotic mitral valve repair: a community hospital experience. Tex Heart Inst J. 2005; 32(2): 143-146. Cribier A, Savin T, Saoudi N, Rocha P, Berland J, Letac B. Percutaneous transluminal valvuloplasty of acquired aortic stenosis in elderly patients: an alternative to valve replacement? Lancet. 1986; 1: 63-67. Andersen HR, Knudsen LL, Hasenkam JM. Transluminal implantation of artificial heart valves. Description of a new expandable aortic valve and initial results with implantation by catheter technique in closed chest pigs. Eur Heart J. 1992; 13: 704-708. Cribier A, Eltchaninoff H, Bash A, Borenstein N, Tron C, Bauer F, Derumeaux G, Anselme F, Laborde F, Leon MB. Percutaneous transcatheter implantation of an aortic valve prosthesis for calcific aortic stenosis: first human case description. Circulation. 2002; 106(24): 3006-3008. Singh IM, Tuzcu ME, Shishehbor MH, Kapadia SR, Christofferson RD. Percutaneous treatment of aortic valve stenosis. Cleveland Clinic Journal of Medicine. 2008; 75(11): 805-812. Paniagua D, Condado JA, Besso J, Velez M, Burger B, Bibbo S, Cedeno D, Acquatella H, Mejia C, Induni E, Fish RD. First human case of retrograde transcatheter implantation. Tex Heart Inst J. 2005; 32: 393-398. Cribier A, Eltchaninoff H, Tron C, Bauer F, Agatiello C, Nercolini D, Tapiero S, Litzler PY, Bessou JP, Babaliaros V. Treatment of calcific aortic stenosis with the percutaneous heart valve: mid-term follow-up from the initial feasibility studies: the French experience. J Am Coll Cardiol. 2006; 47(6): 1214-1223. Webb JG, Pasupati S, Humphries K, Thompson C, Altwegg L, Moss R, Sinhal A, Carere RG, Munt B, Ricci D, Ye J, Cheung A, Lichtenstein SV. Percutaneous transarterial aortic valve replacement in selected high-risk patients with aortic stenosis. Circulation. 2007; 116(7): 755763 Grube E, Laborde JC, Zickmann B, Gerckens U, Felderhoff T, Sauren B, Bootsveld A, Buellesfeld L, Iversen S. First report on a human percutaneous transluminal implantation of a self-expanding valve prosthesis for interventional treatment of aortic valve stenosis. Catheter Cardiovasc Interv 2005; 66(4): 465-469. Grube E, Schuler G, Buellesfeld L, Gerckens U, Linke A, Wenaweser P, Sauren B, Mohr FW, Walther T, Zickmann B, Iversen S, Felderhoff T, Cartier R, Bonan R. Percutaneous aortic valve replacement for severe aortic stenosis in high-risk patients using the second- and current thirdgeneration self-expanding CoreValve prosthesis: device success and 30-day clinical outcome. J Am Coll Cardiol. 2007; 50(1): 69-76. Wenaweser P, Buellesfeld L, Gerckens U, Grube E. Percutaneous aortic valve replacement for severe aortic regurgitation in degenerated bioprosthesis: the first valve in valve procedure using the CoreValve ReValving system. Catheter Cardiovasc Interv. 2007; 70: 760-764. Pasupati S, Humphries K, Al Ali A, Altwegg L, Lichtenstein S, Ye J, Cheung A, Thompson CR, Carere R, Moss R, Munt B, Lee M, Webb J. Balloon expandable aortic valve (BEAV) implantation. The first 100 Canadian patients. Circulation. 2007; 116(suppl): 357. Caroll JD. The evolving treatment of aortic stenosis Do new procedures provide new treatment options for the highest risk patients? Circulation. 2006; 114: 533-535. Kallenbach K, Karck M. Percutaneous aortic valve implantation - contra. Herz. 2009; 34(2): 130-139.

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CAROTID ARTERY DISEASE


H. Van Damme

University Hospital of Li Lige, ge, Belgium Abstract:

H Van Damme
University Hospital of Li Lige Belgium

Carotid artery disease (CAD) become a commonly seen disease in general general medical practice, due to the general population aging. Stroke, one of the the most frequent complications of CAD and represents the third cause of death in Western countries. The leading cause of stroke in CAD is atheroembolism rather than flowflow-reduction. This paper reviewed imaging techniques, medical treatment and esepecially carotid endarterectomy (from point of view of indications, surgical technique and results) and carotid artery stenting for the correct management of CAD. KEY WORDS: CAROTID ARTERY DISEASE, STROKE, CAROTD ENDARTERECTOMY, ENDARTERECTOMY, CAROTID STENTING

International Course of the EAcSS : Iai, Romania October 25-th, 2007

Carotid Artery Disease

APPROPIATE CAROTID SURGERY Introduction


prevalence of > 50% carotid artery stenosis 50 - 59 y 0.5% > 80 y 10% PAOD 20% stroke is 3rd cause of death stroke and TIA are heterogenous conditions with various etiologies and difficult to classify subsequent stroke risk after TIA = 7% per year annual risk of unheralded stroke for an asymptomatic > 80% stenosis = < 3% per year 20% of subsequent strokes in the territory of a symptomatic ICA are unrelated to the ICA stenosis

1. 2. 3. 4. 5. 6.

prevalence and ethiopathogeny of stroke imaging techniques medical treatment carotid endarterectomy : randomised trials carotid endarterectomy : surgical technique carotid artery stenting

The leading cause of stroke in carotid artery disease is atheroembolism rather than flowflow-reduction. reduction.

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giant ulceration left internal carotid artery

Diagram of plaque with intraplaque hemorrhage. hemorrhage.

Intraplaque hemorrhage broken through the surface, allowing egress of the hemorrhage material up the internal carotid artery to the brain.

Carotid Artery Disease


1. 2. 3. 4. 5. 6.

prevalence and ethiopathogency of stroke imaging techniques medical treatment carotid endarterectomy : randomised trials carotid endarterectomy : surgical technique carotid artery stenting

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spectral window

continuous systolosystolodiastolic flow

correlation between flow velocity and % stenosis


% stenosis peak systolic velocity 25 - 100 cm/sec 100 - 120 cm/sec > 130 cm/sec > 250 cm/sec end diastolic velocity < 40 cm/sec < 40 cm/sec > 40 cm/sec > 80 cm/sec PSV CCA ratio < 1.5 < 1.8 > 1.8 > 4.0
ICA ICA

50%

60%

70%

0 - 40% 40 - 60% 60 - 80% 80 - 99%

80%

95%

99%

velocity measurements : an indirect method for stenosis evaluation

diameter and surface area stenosis

50% 50%
* spectral broadening * high peakpeak-systolic flowflow-velocity

70% 70%
* aliaising aliaising * turbulent flow

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color doppler flow (acoustic shadow)

power doppler

calcified plaque 90% stenosis

advantages :

analysis of plaque structure analysis of flow disturbances carotid angiography neurologic morbidity : AVC 0.1% AIT 1.0% mortality : 0.02% renal toxicity puncture site complications : 0.5 to 1%

limitations :

limited to cervical portion of carotid artery operator dependent


interference interfernece with with cardiac cardiac disease disease obscuring obscuring calcified calcified lesions lesions

the surgeon as "clinician-sonographer"

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DEFINITION DEFINITION
784 carotid angiograms with intracranial views 6% siphon stenosis 2% intracranial aneurysm 0.01% cerebral tumor from Akers, Akers, Am J Surg 1988;156:871988;156:87-90 1000 carotid angiograms with aortic arch view 0.6% intrathoracic stenosis 0.3% tandem lesions from Akers, Akers, Am J Surg 1987;154:2201987;154:220-23
50% NASCET ~ 70% ECST stenosis

carotid artery imaging multimulti-slice helicoidal angioangio-CTCT-scan

carotid artery imaging angioangio-magnetic resonance imaging (MRI)

MIP

VRT
arterio Angio-CT Angio-MRI

Carotid Artery Disease


1. 2. 3. 4. 5. 6.

best medical treatment for carotid artery disease


anti100 mg anti-platelet drugs : aspirine clopidogrel 75 mg lipid lowering drugs : statins* statins* antianti-hypertensive drugs : ACEACE-inhibitors Triple therapy allows to stabilise and heal the atheromatous plaque
* MetaMeta-analysis of randomised trials with statins Br J Pharmacol 2004;57:6402004;57:640-669 * SPARCL (Stroke Prevention by Aggressive Reduction in Cholesterol Levels) NEJM 2006;355:5492006;355:549-559

prevalence and ethiopathogeny of stroke imaging techniques medical treatment carotid endarterectomy : randomised trials carotid endarterectomy : surgical technique carotid artery stenting

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Carotid Artery Disease


1. 2. 3. 4. 5. 6.

benefit of CEA for symptomatic ICA stenosis


ipsilateral stroke rate med. NASCET trial 70 - 99% ECST trial 70 - 99% pooled data 3 y FU 5 y FU 17% 10.3% 6.5% 15 2 y FU 26% 9% 17.0% 6 surg. surg. ARR NNT (5 y)

prevalence and ethiopathogeny of stroke imaging techniques medical treatment carotid endarterectomy : randomised trials carotid endarterectomy : surgical technique carotid artery stenting

adjusted NASCET criteria

24%
25%

8%
9%

18.7%
16.0%

5
7

Rothwell, Rothwell, Pooled data of NASCET, ECST and VAVA-309 Trials, Lancet 2003 ; 36 : 107107-116

benefit from surgery in terms of stroke prevention in patients with symptomatic 70 - 99% stenosis (NASCET criteria) criteria)
* absolute risk reduction of ipsilateral stroke at 5 y = 16% ipsilateral stroke rate p < 0.00001 medical treatment
18.7%

> 70% stenoses : benefit from CEA


treatment effect modifiers Absolute Risk Reduction at 5 y for ipsilateral stroke or periop strokestroke-death
16% 23%

NNT

time since last ischemic event sex age

<2 weeks 2-4 weeks 4-12 weeks >12 weeks men women <65y 65-74 y >75 y AF TIA stroke ulcerated smooth 70-79% 80-89% 90-99% overall benefit

7.9% 7.4% 9.9%

4.0 6.0 12.0 12.0 6.6 10.0 10.0 7.4 3.0 20.0 7.4 6.0 6.0 12.0 6.6 6.0 3.0 6.0

15%

*
6.5%

carotid endarterectomy ischemic event plaque surface degree stenosis

9.8% 13.5% 5.5%

37%

13.5% 17.7% 17.1% 15.2% 17.7% 15.9%

7.8%

5 years

10

32.4%

Rothwell, Rothwell, Pooled data of NASCET, VA and ECST Trials, Lancet 2003 ; 36 : 107107-116

Rothwell, Rothwell, (Pooled (Pooled data from ECST and NASCET), Lancet 2004 ; 363 : 915915-924

stroke prevention by carotid TEA for a recently symptomatic stenosis in function of % of stenosis
risk reduction for ipsilateral stroke at 5 year FF-U NASCET/ECST/VANASCET/ECST/VA-309
pooled data

benefit of carotid endarterectomy in function of time delay between CEA and presenting symptom
presenting symptom
(TIA, AF, minor stroke)

5050-69% 7070-79% 8080-89% 9090-99%

absolute risk reduction 4.6% 15.2% 17.7% 32.4%

N.N.T. 22.0 6.6 6.0 3.0

risk reduction for MAJOR ipsilateral stroke at 5 year FF-U 502.3% 43 (125 for F) 50-69% 707.0% 14 70-99%
Rothwell, Rothwell, pooled data of NASCET, ECST and VAVA-309 Lancet 2004;363 :915:915-924

< 2 weeks 2 - 4 weeks 4 - 12 weeks > 12 weeks

(ipsilateral stroke at 5 y) 23.0% 16.0% 8.0% 7.5%

absolute risk reduction

N.N.T.

4 6 12 12

The marginal benefit of CEA for 5050-69% stenoses is nullified once perioperative strokestroke-death rate exceeds 3% !

Patients with recently symptomatic stenosis (70(70-99%) are at highest risk of subsequent stroke. The efficacy of CEA falls with time.
MetaMeta-analysis of pooled data of NASCET/ECST, Lancet 2004;363:9152004;363:915-924

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benefit of CEA in elderly


natural history of a 7070-99% symptomatic stenosis : > 75 y 36.5% ipsilateral stroke risk at 2 y < 75 y 20.0% ipsilateral stroke risk at 2 y number needed to treat to prevent one ipsilateral stroke at 5 years : < 65 years 65 - 75 years > 75 years NNT = 10 NNT = 7 NNT = 3

benefit of CEA for asymptomatic carotid stenosis (60(60-99%)


prevention of ipsilateral stroke at 5 years followfollow-up absolute risk reduction ACAS ACST 5.5% 5.4% N.N.T. 17 18

pooled NASCET/ECST data

ACAS, JAMA 1995;273:14211995;273:1421-1428 ACST, Lancet 2004;363:14942004;363:1494-1502

benefit of surgery in terms of prevention of ipsilateral stroke in patients with an asymptomatic > 60% stenosis (ACST - Trial)
100

carotid endarterectomy for asymptomatic carotid stenosis


limited benefit for 60 - 99% (RRR = 53%, ARR = 5.9% at 5 y)

stenosis

stroke-free survival % stroke

95

carotid endarterectomy: endarterectomy: 6,42% medical treatment : 11,78%

less

benefit for retinal event (AF)

no benefit for women (17% RRR vs 66% for men) men) no no

90

85 0 p < 0.0001 1 2 3 4 5

benefit if controlateral occlusion benefit for octogenarians no benefit for near occlusion linear relation between degree of stenosis and stroke risk (1.8% for 7070-80%, 3.5% for > 80% stenosis) stenosis)
Rigorous selection of patients and low (<3%) periperi-operative strokestroke-death rate are required to justify carotid TEA for asymptomatic stenosis. stenosis.

years

ACST - Trial, Lancet 2004 ; 363 : 14911491-1502

Operative outcome of CEA

Carotid Artery Disease


1. 2. 3.

for symptomatic stenosis (*) 3030-day mortality 3030-day strokestroke-death rate 1.1% 7.1%

prevalence and ethiopathogeny of stroke imaging techniques medical treatment carotid endarterectomy : randomised trials carotid endarterectomy : surgical technique carotid artery stenting

for asymptomatic stenosis (**) 3030-day strokestroke-death rate 2.9%

4. 5.

(*) from Rothwell : Pooled data of NASCET, ECST and VAVA-309. Lancet 2003;361:1072003;361:107-116 (**) from Chambers : CEA for asymptomatic carotid stenosis. stenosis. COCHRANE data base 2005, (CD 00 1923)

6.

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open carotid endarterectomy (CEA) : operative technique

open carotid endarterectomy (CEA) : operative technique

open carotid endarterectomy (CEA) : operative technique

open carotid endarterectomy (CEA) : operative technique inlay shunt (Javid ) (Javid)

open carotid endarterectomy (CEA) : operative technique

kinking kinking of ICA

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carotid endarterectomy 5 controversial points : open CEA vs eversion shunt or no shunt patch or no patch cerebral monitoring general vs local anaesthesia

carotid endarterectomy
patch closure : 4.0% restenosis (> 50%) rate at 1 year 0.5% early thrombosis 17% restenosis rate at 1 year
(24% in women)

direct closure :

3% early thrombosis
- < 0.1% risk of venous patch blow out out - < 0.5% risk of prosthetic patch infection

from Tenholter, Tenholter, Eikelboom, Eikelboom, J Cardiovasc Surg 1990;31:581990;31:58-65.

carotid endarterectomy
routine shunt or no shunt or elective shunt ?
1.

Carotid Artery Disease


prevalence and ethiopathogeny of stroke imaging techniques medical treatment carotid endarterectomy : randomised trials carotid endarterectomy : surgical technique carotid artery stenting

almost all patients tolerate a 20 to 30 min period of carotid clamping selection of shunting, based on transtranscranial doppler or intraoperative EEG is intra questionable routine shunting is safest and gives the best exposure of the distal ICA

2. 3. 4. 5. 6.

CAS (Carotid Artery Stenting) Stenting)

Endovascular angioplasty : Controlled injury

catheter based intervention is trendy industry pushed attractive, less invasive

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Carotid Stent

Angio before and after stenting

Different stenting strategies


Carotid Wallstent 9 For treating carotid bifurcation lesions 9 For treating long and/or and/or softsoftdishomogeneous lesion

Nitinol stents 9For treating short and/or and/or hard hard-calcified lesions 9For maintaining original anatomy

AngioGuard XP (AngioGuard, AngioGuard, Inc., Cordis, Cordis, Warren, N) distal filter device in the deployed and undeployed states

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embolic protection device (filter)

CAS (Carotid Artery Stenting) Stenting)


Global Carotid Artery Stent Registry (12392 CASCAS-procedures, 19971997-2002)

3030-day TIA 3030-day minor stroke 3030-day major stroke 3030-day mortality 3030-day stroke death rate

3.1% 2.1% 1.2% 0.6% 4.7%

from Wholey, Wholey, Catheter Cardiovasc Interv 2003;60:2592003;60:259-266

CAS (Carotid Artery Stenting) Stenting)


Global Carotid Artery Stent Registry (12392 CASCAS-procedures, 19971997-2002)

CAS (Carotid Artery Stenting) Stenting)


randomised controlled trials (low risk, symptomatic > 60% stenoses) stenoses) 4.7% 2.8% 6.2% 4.9% 2.9% 2.5% 1.2%
trial nb of procedures 1183 527 3030-day stroke death rate CAS SPACE* (Germany(Germany-2006) EVAEVA-3S** (France(France-2006) 6.8% 9.6% CEA (ipsilateral) 3.9% (any) 6.3%

strokestroke-death rate : overall with EPD (filter) without EPD (filter) strokestroke-death rate in symptomatic pts in asymptomatic pts restenosis rate at 3 y ipsilateral stroke rate at 1 y

* Lancet 2006;368:12152006;368:1215-6 ** N Engl J Med 2006;355:17262006;355:1726-9 from Wholey, Wholey, Catheter Cardiovasc Interv 2003;60:2592003;60:259-266

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CAS (Carotid Artery Stenting) Stenting)


always

WHO WHO ARE ARE performing performing CAROTID CAROTID STENTING STENTING ? ?
Vascular Surgeon Radiologist
20% 15% 65%

embolic protection device

Cardiologist

complete coverage of the plaque (from disease free distal CCA to disease free proximal ICA) selfself-expanding nitinol stent (superior conformability and resistance to deformation) predilatation 4 30

with a 2 mm balloon for tight stenoses

days Aspirin + Clopidogrel prior to CAS days Aspirin + Clopidogrel following CAS

BASED ON THE 40 SURVEY CENTERS


International Carotid Angioplasty Registry
M.H. Wholey GET Montecarlo 1616-19 May 2003

human and technical limits

costcost-estimation of CAS
4500 4000 3500 3000 2500 2000 1500 1000 500 0 CEA CAS TOTAL health insurrance patient

20072007-Guidelines of American Heart Association


CEA

carotid endarterectomy
greatest benefit for symptomatic stenosis for TIA within 2 weeks after TIA for elderly for men for severe (> 80%) stenoses

is justified for symptomatic 5050-99% stenosis if the risk of perioperative stroke or death is less than 6% CEA is justified for asymptomatic 8080-99% stenosis if the risk of perioperative stroke or death is less than 3% CAS (carotid artery stenting) stenting) is still a procedure under investigation (only justified in controlled trials)

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ISTORICUL CHIRURGIEI PARATIROIDELOR


E. Trcoveanu1, A. Vasilescu1, R. Van Hee2 1 Clinica I Chirurgie, Spitalul Sf. Spiridon Iai Universitatea de Medicin i Farmacie Gr.T. Popa Iai 2 University of Antwerp, European Academy of Surgical Sciences (EAcSS) Glandele paratiroide au fost descrise pentru prima dat de Sir Richard Owen, chirurg britanic, pioner n anatomia comparat, care s-a nscut n 1804 n Lancaster, ntr-o familie urma a unor hughenoi francezi emigrai n Anglia. El este cel care a introdus termenul de dinozaur. De-a lungul vieii a denumit i descris numeroase specii de dinozauri, precum i Eohippus (Hyracotherium), care este un nainta al calului. A catalogat 13000 specimene anatomice umane i animale din colecia Hunterian. Dei a lucrat mpreun cu Darwin, la fosilele aduse de acesta din cltoriile sale, el nu a fost un susintor al ideilor evoluionismului. Richard Owen a disecat toat iarna 1849-1950 un rinocer indian de 2 tone, mort la grdina zoologic din Londra printr-o fractur costal care a perforat plmnul stng. Raportul su de disecie a fost fcut public n articolul On the anatomy of the Indian Rhinoceros din 1862, ntr-o revist cu circulaie limitat (Transactions of the Zoological Society of London, 1862; 4: 3158), unde se gsete prima descriere detaliat anatomic a paratiroidelor: a small compact yellow glandular body attached to the thyroid at the point where the vein emerged. Piesa de disecie poate fi vzut i astzi la Muzeul Hunterian al Royal College of Surgeons of England, are 30x14x8 cm i cuprinde laringele, traheea i o parte din lobii tiroidieni cu paratiroidele superioare ale rinocerului [1]. n 1880, un student suedez Ivar Viktor Sandstrm de la Universitatea Uppsala, descoper mici structuri anatomice adiacente tiroidei cinelui, dar incluse n capsula tiroidian i de culoare mai deschis, i cu vascularizaie important. El spune c judecnd dup aspect nu par a fi nici ganglioni limfatici, nici tiroide accesorii. El descoper aceste structuri i la pisici, iepuri i cai. Studiind peste 50 de cadavre umane, found on both sides of the inferior border of the thyroid an organ of the size of a small pea which judging from its exterior, did not appear to be a lymph gland, or an accessory thyroid gland and which upon histological examination showed a rather peculiar structure i denumete aceste structuri glandulae parathyroidae. Public aceste rezultate On a New Gland in Man and Several Mammals-Glandulae Parathyroideae n revista Upsala Liikarenforerings Forhandlingar. Descoperirea sa a rmas necunoscut n afara Suediei, singura referire despre Sandstrm aparine lui Retzius n Jahresbericht, n 1880 [2]. Articolul original a fost tradus n limba englez abia n 1938 de Seipel. Dei ajunge profesor la Institutul de Anatomie al Universitii Uppsala, el sufer de o boal psihic ereditar i moare la vrsta de 37 de ani, neputnd s-i impun descoperirea [3]. Importana descoperirii lui Sandstrm, nu a fost apreciat pn la experimentul lui Eugene Gley din 1892, un fiziolog succesor al lui Brown-Squard de la Collge de France, care a observat apariia tetaniei la cinii la care s-a practicat tiroidectomie total. Tot el a observat c tetania poate fi prevenit prin reimplantarea paratiroidelor [1,2].

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n 1879, Anton Wolfer descrie primul caz de tetanie la om aprut la un pacient la care Theodor Billroth a practicat tiroidectomie total [4]. n 1891 Friedrich Daniel von Recklinghausen a descris, cazul unui pacient cu fracturi osoase multiple aprute dup traumatisme minore i la care, la nivelul oaselor lungi a descoperit fibroz extensiv, tumori chistice i brune. Toate aceste tulburri osose le-a reunit n cadrul sindromului osteitis fibrosa cystica sau boala von Recklinghausen. El nu a corelat ns anomaliile osose cu patologia paratiroidian. La vremea respectiv se credea c hipertorfia paratiroidelor este compensatorie bolii osose [1]. Mai muli cercettori de la nceputul secolului XX, au observat c patologia neuromuscular aprut dup tiroidectomia total, poate fi prevenit prin reimplantarea paratiroidelor. Askanazy n 1903, relateaz cazul unei femei cu o boal osoas sever i cu o tumor situat lateral de glanda tiroid a crezut c boala osoas este cauza tumorii paratiroidiene. Jacob Erdheim, n 1907, consider hipertrofia glandelor paratiroide, compensatorie i secundar leziunilor scheletice asociate. n 1909, W.G. MacCallum i Carl Voegtlin demonstreaz c paratiroidectomiile produc hipocalcemii i tetanie, ameliorate prin injectarea intravenoas de calciu. Mecanismul biochimic este studiat pentru prima dat de Jacoby i Schroth n 1912, care au descoperit excreia excesiv de calciu n urin la bolnavii cu osteitis fibrosa cystica [5]. Abia n 1915, Schlagenhaufer, profesor anatomopatolog din Viena, demonstreaz c rolul central n metabolismul calciului l au glandele paratiroide, acestea putnd fi cauza osteopatiei i propune ca terapie, excizia glandei. El descrie dou cazuri de pacieni cu osteomalacie, la care, la necropsie, a gsit cte o tumor paratiroidian [1,4,5]. Abia peste 10 ani, pe 30 iulie 1925, Felix Mandl, profesor la Universitatea din Viena face prima paratiroidectomie, cu anestezie local, la un pacient cu boal Recklinghausen. El a excizat o tumor galben maro, de 25x15x12 mm, situat posteroinferior stng de glanda tiroid. Postoperator evoluia a fost favorabil, cu normalizarea valorilor serice i urinare a calciului, pacientul putnd s mearg din nou. Remisiunea bolii a fost de 6 ani, cnd a fost diagnosticat cu hipercalcemie recidivant i litiaz renal. Mandl a reintervenit, dar recidiva era cauzat de o leziune paratiroidian ectopic, el negsind cervical nicio leziune patologic. Pacientul a murit n 1936 [6]. ntre 1926-1932, Dubois i Aub, la Massachusetts General Hospital din Boston, practic 7 explorri chirurgicale la un bolnav, cpitanul Ch. Martell, cnd reuesc s evidenieze un adenom paratiroidian mediastinal. Acest caz constituie prima observaie de hiperparatiroidism diagnosticat preoperator i prima explorare chirurgical mediastinal. n 1927, Gold efectueaz o intervenie chirurgical similar cu cea practicat de ctre Mandl [7]. Termenul de hiperparatiroidism aparine lui Bar i Bulger din Saint Louis de la Barnes Hospital care au efectuat cu succes prima paratiroidectomie din S.U.A. n 1929. n 1931, Hunter i Turnbull, raportnd un caz de adenom paratiroidian, descriu tumorile osoase din hiperparatiroidism, pe care le denumesc osteoclastoame. n 1929, Russel i Wilder de la Mayo Clinic descriu pentru prima dat tumorile maligne ale paratiroidelor. Acestea sunt foarte rare i reprezint 0,5% din totalul cazurilor cu hiperparatiroidism. 1934, Hall i Chaffin comunic i ei un caz de cancer paratiroidian [4]. n 1934, Albright descrie hiperparatirodismul secundar n insuficiena renal cronic. Nivelurile sczute ale calciului din snge stimuleaz hiperplazia secundar a celulelor principale paratiroidiene i secreia de PTH. Aceste modificri paratiroidiene

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reprezint un mecanism compensator n cele mai multe cazuri, dar exist pacieni care dezvolt boli osoase severe, aceste tulburri ncadrndu-se n hiperparatiroidismul teriar, pentru care este indicat paratiroidectomia subtotal sau total cu reimplantare; tot el a descris i hiperplazia cu celule clare [3]. n 1942, Coppe descrie asocierea hiperparatiroidism pancreatit, iar ntre 19461947, Rogers descrie asocierea hiperparatiroidism ulcer [4,5]. n 1925, Collip izoleaz parathormonul (PTH) hormon regulator al calciului. Efectele hipercalcemice ale PTH au fost identificate n urma unor experimente pe animale. n 1957 Reis i Canterbury efectueaz imunodozarea parathormonului. Diagnosticul precis al hiperparatiroidismului a fost posibil abia n 1963, cnd Bearson i colaboratorii au dezvoltat radioimunodozarea (RIA) pentru cuantificarea nivelelor sanguine ale PTH. n 1959, Auerbach izoleaz hormonii paratiroidieni [4,5]. n 1954 Wermer descrie sindromul de neoplazie endocrin multipl, care ulterior se va numi MEN 1 i n care hiperparatiroidismul este cea mai frecvent manifestare [8]. n 1958, Oliver Cope a descris hiperplazia celulelor principale la 10% dintre pacieni i a dezvoltat o tehnic chirurgical pentru tratamentul acesteia. Muli chirurgi au practicat paratiroidectomia subtotal, dar Samuel A. Wells Jr. a sugerat ablaia tuturor celor patru paratiroide i transplantul de esut paratiroidian pe antebra. Astfel, esutul paratiroidian poate fi rezecat uor n caz de reapariie a hipercalcemiei. n 1973, Wells SA Jr raporteaz reuita autogrefrii paratiroidiene la cine, urmat, n 19761977, de utilizarea autogrefelor paratiroiodiene la bolnavii cu hiperparatiroidism primar, prin hiperplazia glandelor. n 1975, Wells public primele rezultate privind transplantul paratiroidian la om [9]. Tehnica clasic a paratiroidectomie, cu explorarea cervical bilateral, descris de Mandl, nu s-a modificat, dect n anii 90, odat cu apariia scintigrafiei cu Tc 99 Sestamibi, cu localizarea preoperatorie a tumorii paratiroidiene, cnd s-a dezvoltat o tehnic minim invaziv, radioghidat MIRP (Minimally invasive radio-guided parathyroidectomy). Norman J, un chirurg american, este promotorul acestei tehnici, ajungnd n 2008 la 8000 de intervenii de acest fel pe paratiroid [10]. Dup scintigrafia cu Sestamibi (glandele paratiroide normale nu devin radioactive pentru c nu absorb radiotrasorul), se efectueaz intervenia chirurgical n urmtoarele 2-4 ore. Cu o sond gamma se localizeaz leziunea care este excizat printr-o mic incizie de 11,5 cm. Durata medie a interveniei este de 17 min (14-21 min), iar pacientul poate fi externat la cteva ore postoperator [10]. n 1996, Gagner, efectueaz prima paratiroidectomie endoscopic [11]; cele mai mari statistici de paratiroidectomii realizate prin abord minim invaziv endoscopic i videosistat aparin ns lui Henry F i Miccoli P [12,13]. Literatura romneasc cuprinde lucrri valoroase, ncepnd cu I. Iacobovici, profesor la Facultatea de Medicin din Cluj i Bucureti, care comunic, n 1925, la 7 ani dup cazul princeps descris de Mandl, un caz de paratiroidectomie pentru o poliartrita ankilozant cu hipercalcemie. C.I. Parhon, autorul primei cri de endocrinologie din lume, Secreiile interne, scris n colaborare cu Goldstein n 1909, a susinut rolul glandelor paratiroide n metabolismul calciului [14]. n 1933, Parhon public la editura Al. Talek Iai monografia Les parathyroides [15]. Alte lucrri importante privind fiziopatologia i chirurgia de exerez a paratiroidelor au mai avut G. Marinescu (1939), t. Milcu (1955 - primul caz de osteoz paratiroidian vindecat, 1964), C. Caloghera i T. Bordo (1976), C. Lazr (1976), E. Proca (1983), I. Juvara

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(1983), M. Chifan (1984), V. Strat (1988), M.R. Diaconescu (1996) [4,5]. Prima monografie privind patologia chirurgical a paratiroidelor din literatura romneasc aparine Prof. dr. M.R. Diaconescu (1995) [5], dei n 1976 la Editura Facla, C. Caloghera et al. au publicat volumul Chirurgia tiroidei i paratiroidei.
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. BIBLIOGRAFIE Modarai B, Sawyer A, Ellis H. The glands of Owen. J R Soc Med. 2004; 97(10): 494-495. Taylor S. Hyperparathyroidism: retrospect and prospect. Ann R Coll Surg Engl. 1976; 58: 225265 Seipel CM. An English translation of Sandstroms glandulae parathyroideae. Bull Inst Hist Med 1938; 6: 192-222. Trcoveanu E, Vasilescu A, Epure Oana. Istoricul Chirurgiei Endocrine (I) Jurnalul de Chirurgie. 2005; 1(2): 238-242. Diaconescu MR. Patologia chirurgical a glandelor paratiroide. Iai: Ed. Junimea; 1995. p. 1516. Mandl F. Hyperparathyroidism. A review of historical developments and the present state of knowledge on the subject. Rec Adv Surg. 1947; 21: 374-439. Norton JA. History of Endocrine Surgery In: Norton JA, Randal Bollinger R, Chang AE, Lowry SF, Mulvihill SJ, Pass HI, Thompson RW, editors. Basic Science and Clinical Evidence. Philadelphia: Springer; 2001. p. 849-857. Wermer P. Genetic aspects of adenomatosis of endocrine glands. Am J Med. 1954; 16(3): 363371. Wells SA Jr, Gunnells JC, Shelburne JD, Schneider AB, Sherwood LM. Transplantation of parathyroid glands in man: clinical indications and results. Surgery. 1975; 78:.34-44. Norman J, Politz D. Measuring individual parathyroid gland hormone production in real-time during radioguided parathyroidectomy. Experience in over 8,000 operations. Minerva Endocrinol. 2008; 33(3): 147-157. Gagner M. Endoscopic subtotal parathyroidectomy in patients with primary hyperparathyroidism. Br J Surg. 1996; 83(6): 875. Henry JF, Sebag F, Tamagnini P, Forman C, Silaghi H. Endoscopic parathyroid surgery: results of 365 consecutive procedures. World J Surg. 2004; 28(12): 1219-1223. Miccoli P. Parathyroid surgery: we only need a minimal surgical approach. J Endocrinol Invest. 2005; 28(6): 570-573. Zbranca E. C.I. Parhon, In: Trcoveanu E, Romanescu C, Liu M, editors. Ctitorii prestigiului. Iai: Ed. U.M.F. Gr.T. Popa; 2004. p. 241-244. Caloghera C. Istoric, In: Caloghera C, Mogoeanu A, Bordo D, editors. Chirurgia tiroidei i a paratiroidelor. Timioara: Ed. Facla; 1976. p. 11-16.

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ACADEMICIANUL GHEORGHE GHIDIRIM LA 70 ANI


La 20 aprilie, n acest an, comunitatea chirurgical din Republica Moldova srbtorete pe Domnul Academician Gheorghe Ghidirim, om de cultur, chirurg de prestigiu, la mplinirea a apte decenii de via. Acest eveniment remarcabil capt semnificaii deosebite pentru c l gsete pe cel aniversat n condiii de sntate mintal demne de invidiat. Pentru noi, contemporanii si, este o datorie de onoare s evocm personalitatea remarcabil a academicianului Gheoghe Ghidirim pentru a lsa posteritii o imagine conform cu dimensiunile acestei personaliti. Vede lumina zilei pe 22 aprilie 1939, n comuna Palanca, plasa Olneti, judeul Cetatea Alb, Romnia. A fost elev al colii primare din comuna Palanca ntre anii 1946-1953. i-a continuat studiile la Colegiul de Medicin din Tighina ntre anii 1953-1956. Dup absolvirea cu meniune a Colegiului, activeaz ca felcer la spitalul din comuna Tudora, plasa Olneti, ceea ce i va oferi posibilitatea de a se apropia de omul bolnav. Cu energia copilului de 17 ani, dar i cu responsabilitate din cei doi ani de activitate i-a reconfirmat opiunea de a veni n sprijinul pacienilor care ateptau alinare i vindecare i i continu studiile la Institutul de Medicin (1957-1963), astzi Universitatea de Stat de Medicin i Farmacie Nicolae Testemianu, din Chiinu. Aici, sub influena marelui chirurg Nicolae Anestiade, personalitate notorie a medicinei basarabene, a decis s-i continue drumul n medicin, devenind chirurg. ntre anii 1963-1964 este asistent la catedra de anatomie topografic i chirurgie operatorie, ceea ce i-a permis fortificarea cunotinelor n materie. i pregtete doctoratul la Catedra Chirurgie, sub conducerea lui Nicolae Anestiade, i susine teza de doctorat Modificrile tensiunii venoase i altor indici hemodinamici n afeciunile chirurgicale ale pulmonilor, n care a studiat aspectele modificrilor fiziopatologice ale pacientului chirurgical pulmonar. La finalizarea doctoranturii este angajat ca asistent la Catedra Chirurgie a facultii (1966-1969). n aceeai perioad este Preedinte al Comitetului Sindical al Institutului de Medicin, promovnd o serie de proiecte pentru mbuntirea vieii i a condiiilor de trai ale colaboratorilor. Anul 1969 este un an deosebit n cariera profesional i administrativ. Doctor n tiine medicale, Gheorghe Ghidirim este ales n funcia de confereniar al Catedrei Chirugie a Facultii de Pediatrie i, concomitent, vicedecan la Facultatea Medicin General, unde a insistat asupra perfecionrii procesului didactic. Prin calitatea sa excepional de organizator, a fost printre muli ali precusori ai Universitii care au pledat pentru trecerea la predarea materiilor n limba romn. A participat activ la traducerea materialelor didactice, a manualelor, fiind ntre primii participani i promotori ai Renaterii Naionale. n anul 1978 este numit ef de Catedr Chirurgie pentru Subordinatur. Dl. Gh. Ghidirim a primit sarcina asigurrii procesului didactic pentru pregtirea practic a viitorilor chirurgi, sarcin rezolvat excelent datorit capacitilor i spiritului

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organizatoric deosebit, precum i profesionalismului excepional pe care l posed. n anul 1979 este transferat la Catedra de Chirurgie General i Semiologie la care a activat pn n 1992. Colectivul a fost reorientat spre noi tehnici didactice i, n special, pe motivarea studentului n nsuirea conceptelor fundamentale ale chirurgiei. n acelai timp, cercetarea tiinific rmne n centrul ateniei, continund investigaiile ntr-o problem controversat i dificil pancreatita acut. Aici, mpreun cu marele savant rus Vladimir Filin, Gheorghe Ghidirim a schimbat concepia despre evoluia acestei maladii i, mai ales, a pledat pentru temporizarea actului operator, ceea ce a dus la micorarea substanial a mortalitii n acest grup de pacieni. Zeci de publicaii, rapoarte la Congrese Unionale i Internaionale, ncununeaz opera savantului Gh. Ghidirim prin intermediul tezei de Doctor Habilitat n Medicin, susinut cu succes n 1983, n Centrul tiinific Unional de Chirurgie din Moscova, la Consiliul tiinific sub conducerea Academicianului B. Petrovski. n anul 1986 i se confer titlul de Profesor Universitar, pe care, de fapt, l deinea de mai mult de 10 ani. Anul 1986 devine Anul Renaterii Naionale al popoarelor din imperiul sovietic. Fiind un fiu devotat al poporului romn din Basarabia, avnd o verticalitate demn de urmat, el i-a ocupat locul bine meritat n rndul oamenilor de frunte ai neamului. Intelectul nnscut, cultura, inteligena acumulat pe parcursul vieii, au stat la baza activitii prodigioase statale i sociale a distinsului Profesor. Ales Deputat al Poporului (1989-1992), n ultimul Parlament al U.R.S.S., a desfurat o activitate important n marea oper de obinere a Independenei Statale a Moldovei. n anul 1990 este ales membru al Guvernului, Ministru al Sntii. Aceast activitate o desfoar n condiii complicate de tranziie a societii de la un sistem totalitar la unul democratic. Cu susinerea d-lui Ministru Gh.Ghidirim, n anul 1991 este organizat Congresul de fondare al Ligii Medicilor. Este elaborat i pus n discuie proiectul Legii Sntii. Se insist asupra trecerii sistemului de sntate la medicina prin asigurare. Pentru prima dat n ar este implementat rezideniatul ca form nou de pregtire postuniversitar a medicilor specialiti. Reforma asistenei medicale primare, a serviciului spitalicesc, a clinicilor universitare, a medicinei preventive, a sistemului stomatologic i farmaceutic, au fost obiectivele de baz n activitatea Ministrului Sntii Gheorghe Ghidirim. Particip activ la pregtirea Declaraiei de Independen a Republicii Moldova, adoptat la 27 august 1992 de ctre primul Parlament Democratic, a imnului, stemei i a drapelului rii, care a ncununat Micarea de Renatere Naional. n anul 1992 este numit ef catedr Chirurgie Nr.1 care, din1994, poart numele lui Nicolae Anestiadi i pe care, cu succes, o conduce pn n prezent, asigurnd procesul didactic la anul IV i VI Medicin General. La iniiativa i cu participarea sa, pentru prima dat n istoria inutului basarabean, n1993 este creat Secia Medicin a Academiei de tiine din Republica Moldova. n semn de apreciere a meritelor tiinifice, n anul 1993, profesorul Gheorghe Ghidirim este ales Membru titular al Academiei de tiine i Preedinte al Seciei Medicale nou-formate. Activitatea tiinific multilateral a condus la alegerea, n anul 1993, ca Membru de Onoare al Academiei de tiine Medicale din Romnia, iar n 1994, ca Membru de Onoare al Societii de Chirurgie din Romnia. n 1995 i se confer titlul onorific de Om Emerit al Republicii Moldova. Anul 1996 este anul recunoaterii activitii de pionerat a d-lui Gh.Ghidirim n domeniul chirurgiei laparoscopice, fiind ales Membru de Onoare al Societii de Chirurgie Laparoscopic din Romnia. n 2008 este desemnat membru al Asociaiei Internaionale de Chirurgie Endoscopic.

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La Congresul VIII al Chirurgilor din Republica Moldova, academicianul Gh. Ghidirim este ales Preedinte al ocietii de Chirurgie din Republica Moldova, activnd pn n 2007; din 1998 este Membru al Societii Internaionale de Chirurgie Hepato-bilio-pancreatic. n acelai an este ales Preedinte al Ligii Medicilor din Republica Moldova. n 1999, drept recunotin a activitii chirurgicale, este ales membru al Societii Internaionale de Chirurgie. Este membru al Consiliului Suprem pentru tiin i Dezvoltare Tehnologic, membru al Consiliului Suprem pentru Acreditare i Atestare, preedinte al Comisiei de Atestare a Chirurgilor din Republica Moldova, preedinte al Consiliului tiinific pentru susinerea tezelor tiinifice n Chirurgie. n toate aceste posturi, medicul-chirurg, profesorul, academicianul Gheorghe Ghidirim i consacr toat energia i cunotinele ntru dezvoltarea medicinei basarabene, a tiinei medicale, a sntii poporului Republicii Moldova. Activitatea sa este nalt apreciat i de stat prin conferirea, n 2000, a Ordinului Gloria Muncii, iar n 2005 este decorat cu Ordinul Republicii, laureat al medaliilor Dimitrie Cantemir (1999) i Nicolae Testemianu(2004) i 60 ani ai Academiei de iine din Republica Moldova. n acela an este ales Membru de Onoare al Societii Limba Noastr. Opera tiinific a d-lui academician Gh. Ghidirim numr peste 400 lucrri tiinifice, 35 monografii, 2 manuale, 15 brevete de invenie. Este participant la numeroase congrese internaionale. Este redactor ef al revistei Buletinul Academiei de tiine al Republicii Moldova (tiine medicale), membru al colegiului de redacie al revistelor Chirurgiadin Bucureti, Jurnalul de Chirurgie din Iai, Arta Medica i Curierul Medical din Moldova. Este membru al Consiliului Naional pentru Acreditare i Atestare. Sub conducerea Acad. Gh. Ghidirim au fost susinute 9 teze de D.H. n t. medicale i 14 de doctor n medicin. Clinica condus de dl. Academician Gh.Ghidirim a pregtit peste 20 secundari clinici i peste 130 rezideni. Astfel, putem vorbi despre COALA ACADEMICIANULUI GHEORGHE GHIDIRIM, coal cu mari realizri i perspective, cu un mare prezent, dar cu un i mai mare viitor. Paricip activ la numeroase Expoziii Internaionale ale Salonului Internaional din Geneva, este deintorul medaliei de bronz n 2006, al celei de argint din 2007 i 2008, precum i al Diplomei de Merit. La jubileul de 70 ani, academicianul Gheorghe P. Ghidirim vine n faa pacienilor, colegilor de breasl, discipolilor ncrcat de cunotine i experien chirurgical de excepie, pe care le pune necondiionat n serviciul societii i poporului basarabean. Socotim c fa de toate acestea, lumea chirurgical din Republica Moldova nu poate rosti dect cu simplitate i recunotin: La muli ani, domnule academician Gheorghe Ghidirim! Colectivul Catedrei Chirurgie Nr. 1 Nicolae Anestiadi.

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TRATAT DE CHIRURGIE, VOL. VIII


Irinel Popescu (sub redacia) Editura Academiei Romne, Bucureti 2008, ISBN 978-973-27-1679-3 n 2008, la Editura Academiei Romne a aprut al VIII-lea volum al tratatului de chirurgie, n dou pri, sub redacia prof. dr. Irinel Popescu, preedinte al Societii Romne de Chirurgie Hepatobiliopancreatic i Transplant, eveniment editorial remarcabil pentru literatura medical romneasc. Concepia, organizarea i publicarea unei serii de 10 volume care acoper toate specialitile chirurgicale demonstreaz fora comunitii chirurgicale romneti contemporane, pe care editorul a reuit s o mobilizeze. Noua ediie a tratatului de chirurgie continu o tradiie remarcabil a colii chirurgicale romneti n care prestigioi efi de coal, ca acad. N. Hortolomei, acad. I. urai, Th. Burghele, E. Proca, N. Angelescu au pus la dispoziia chirurgilor, la fiecare 10-15 ani, tratate de excepie, necesare pregtirii continue a specialitilor. Ca i celelalte ediii, lucrarea de fa, care apare doar la 5 ani de la precedentul tratat, este o oglind a realizrilor chirurgiei romneti i o sintez a progreselor pe care specialitile chirurgicale le-au nregistrat n ultimii ani. Pe parcursul a peste 1300 de pagini, tratatul, bine structurat n 44 capitole, reunete o larg colaborare naional (110 de autori), pune la dispoziia specialitilor cele mai noi date de chirurgie general i o parte din chirurgia abdominal. Dup un scurt istoric al chirurgiei, n care se menioneaz i contribuia colii romneti de chirurgie, se prezint, n capitolul 2, noiuni de medicin molecular foarte utile pentru chirurgii din zilele noastre (acad. L. M. Popescu). n capitolul 3 sunt expuse principii ale chirurgiei oncologice (L. Lazr). Dup capitolul 4 - Metode moderne de explorare n chirurgie, este prezentat endoscopia digestiv diagnostic (C. Gheorghe) i terapeutic (Fl. Turcu). Capitolul 7 descrie blocul operator (I. Georgescu), capitolul 8 echipamentul i instrumentarul laparoscopic, iar capitolul 9 chirurgia robotic (V. Tomulescu, C. Vasilescu, I. Popescu), ultima cucerire tehnic n domeniul chirurgiei. Urmtoarele trei capitole abordeaz pregtirea preoperatorie a bolnavului chirurgical (M. Angelescu), complicaiile postoperatorii (. Bancu) i, mai ales, noiuni de anestezie i terapie intensiv importante pentru chirurgi (D. Tulbure). Un capitol nou introdus aduce n atenie rspunderea juridic a chirurgului (G. Borcean). Urmeaz capitolele sunt clasice: asepsia i antisepsia (Tr. Burco), infecia chirurgical (N. Angelescu), infecii nosocomiale (D. Mogo), terapia antiinfecioas n

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chirurgie (R. Palade), patologia chirurgical a minii i degetelor (N. Angelescu), melanomul (Olga Simionescu). Dup traumatismele esuturilor moi (R. Palade), mucturi i nepturi (M. Beuran), ultimul i cel mai important capitol al volumului I A este dedicat traumatismelor abdominale (M. Beuran i colab.) care conine date actuale despre sisteme de ngrijire a traumelor, scoruri de severitate lezional, explorare paraclinic, politraumatisme, indicaiile laparotomiei i laparoscopiei, traumatismele viscerelor parenchimatoase i cavitare, traumatismele vasculare abdominale, traumatismele abdominale la gravide i vrstnici. Partea I B ncepe cu dou capitole importante n traum: concepte moderne n managementul pacientului politraumatizat i suportul nutriional n traum. Capitolul 25 se refer la patologia benign a snului (N. Jitea), iar urmtorul la cancerul de sn, abordat n viziune multidisciplinar. Capitolele 27 i 28 cuprind patologia chirurgical a tiroidelor i paratiroidelor (F. Lazr). Capitolul 29 trateaz patologia chirurgical a glandelor suprarenale (C. Copescu), iar capitolul 30 neoplaziile endocrine multiple (E. Trcoveanu). Urmtoarele trei capitole abordeaz patologia chirurgical a peretelui abdominal (D. Sabu i colab.), patologia chirurgical a spaiului retroperitoneal (Tr. Ptracu)i patologia chirurgical a mezoului i a marelui epiploon (t. Neagu). Capitolul 34 aduce n actualitate transplantul de organe i de esuturi (I. Popescu). Patologia chirurgical a venelor (capitolul 35) este semnat de J. Avram. n continuare, sunt prezentate trei capitole noi: piciorul diabetic, dializa peritoneal (Tr. Ptracu) i obezitatea morbid (N. Iordache, C. Copescu). Capitolul 39 abordeaz hemoragiile digestive (Tr. Burco), capitolul 40 ocluziile intestinale (. Bancu), capitolul 41 icterul mecanic (t. Voiculescu) i capitolul 42 peritonitele acute (I. Georgescu).Un capitol complex, care capteaz cititorul prin noutatea informaiilor oferite, se refer la patologia chirurgical a esofagului, n care autorii (S. Constantinoiu, C. Ciuce i colab.) i demonstreaz experiena.Acest volum se ncheie cu prezentarea patologiei chirurgicale a stomacului (I. Popescu, M. Beuran, C. Copotoiu, N. Angelescu). Meritul tratatului const i n abordarea unor subiecte de grani, extrem de utile chirurgului generalist. Tratatul, bazat pe o bogat experien romneasc i pe studiul unei bibliografii recente, dei voluminos, este uor de parcurs datorit stilului concis, ordonat i clar i tehnoredactrii moderne. Iconografia foarte bogat confer lucrrii un caracter academic. Condiia grafic excelent face cinste editurii care a tiprit acest tratat. Monografia se adreseaz chirurgilor generaliti, dar i rezidenilor, medicilor specialiti din domeniile nrudite, precum i tuturor acelora care vor s-i completeze cunotinele n chirurgie. Apariia acestui magistral tratat, cel mai complet i actualizat din literatura romneasc, reprezint un eveniment editorial deosebit, iar redactorul, cunoscut pentru naltul su profesionalism, pentru pasiunea i perseverena pe care le pune n tot ceea ce realizeaz, face parte din rara categorie a acelor oameni care constituie fermentul i motorul mersului nainte.

E. Trcoveanu

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AL XI-LEA SIMPOZION AL SECIUNII ROMNE A IASGO


n perioada 1-4 aprilie 2009, s-a desfurat la Bucureti, n ambiana placut a Institutului Naional de Statistic, al XI-lea Simpozion al Seciunii Romne a IASGO cu temele chirurgia hepatobilopancreatic i transplant hepatic i chirurgia oncologic digestiv, sub preedenia Prof. dr. Irinel Popescu, organizat de IASGO Seciunea Romn, Asociaia Romn de Chirurgie Hepatobiliopancreatic i Transplant Hepatic, Societatea Romn de Endoscopie Digestiv, Academia Oamenilor de tiin din Romnia, Fundaia pentru Chirurgia Ficatului. Simpozionul a reunit peste 300 participani din ar i din strintate. Succesul simpozionului a fost garantat prin participarea unor personaliti ale chirurgiei mondiale i romneti, care au prezentat conferine pe subiecte de interes de mare actualitate: A. Lerut (UKL Leuven), J. Kiss (Budapesta), S. Puntambekar (Pune, India), N.J. Lygidakis (Atena), G. Torzilli (Milano), I. Popescu, F. Lazr, S. Constantinoiu, M. Beuran, , I. Cmpeanu., D. Sabu, L. Vlad, V. Srbu, Fl. Popa, E. Brtucu, C. Gheorghe, S. Ciurea, M. Ionescu, R. Munteanu, C. Vasilescu, V. Scripcaru, L. Miron, M. Grigora, T. Ptracu, Rodica Anghel, M. Coculescu, O. Bl, R. Palade, t. Georgescu, C. Copescu, V. Tomulescu, F. Iordache. Manifestarea a reunit chirurgi, gastroenterologi i oncologi, care timp de 2 zile i-au confruntat opiniile n faa tinerilor specialiti, n condiiile n care i n ara noastr se contureaz ca supraspecializare chirurgia hepatobiliopancreatic i chirurgia oncologic. Dup ceremonia de deschidere, la care au participat reprezentani de grad nalt ai Ministerului Sntii i ai Academiei Oamenilor de tiin, i la care I. Cmpeanu a prezentat istoria chirurgiei hepatice n Romnia, n zilele urmtoare, n dou sli apropiate, n permanen arhipline, s-au susinut conferinele i lucrrile orale. Cu ocazia simpozionului s-au mai prezentat o sesiune de postere, cu 18 lucrri, o expoziie de aparatur i echipamente i o expoziie de carte. Una din seciunile de mare succes, coordonat de S. Constantinoiu, A. Lerut i J. Kiss, a fost cea destinat chirurgiei esofagiene, n care, pe lng experiena romneasc (F. Lazr, S. Constantinoiu, C. Stnescu), prestigioas n domeniu, s-au prezentat statistici impresionate, ca cea a prof. Lerut, de 2000 esofagectomii. n seciunea de chirurgie hepatic I, condus de M. Beuran i D. Sabu, s-a prezentat experiena romneasc n privina transplantului hepatic (I. Popescu), managementul traumatismelor hepatice (M. Beuran, O. Mazilu), tratamentul chirurgical actual al chistului hidatic hepatic (D. Sabu), unturile porto-cave i mezenterico-cave n hipertensiunea portal (O. Creu).

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O seciune care a suscitat numeroase comentarii a fost cea de chirurgie a pancreasului II, n care N. J .Ligydakis a prezentat aspecte actuale ale chirurgiei pancreatice, S. Puntambekar (India) a discutat despre rolul laparoscopiei n cancerul pancreatic, cu filme interesante, S. Barbu despre rezeciile pancreatice cu intenie curativ i Cr. Lupacu i T. Dumitracu despre abordul posterior n duodenopancreatectomia cefalic. De mare interes s-a bucurat sesiunea referitoare la tratamentul complex al leziunilor maligne primitive i secundare hepatice, n care au fost dezbtute diagnosticul leziunilor focale hepatice prin ecografia de contrast (L. Gheorghe), chirurgia hepatic ecoghidat (V.Srbu), abordarea multidisciplinar a metastazelor hepatice de origine colorectal (L. Vlad, S. Alexandrescu) i conferina magistral privind rezecia ecoghidat a hepatocarcinoamelor i a metastazelor hepatice susinut de prof. G. Torzilli. De asemenea, de un mare succes a fost transmiterea n direct de la Institutul Clinic Fundeni a unei intervenii complexe pentru cancer esofagian: disecie esofagian transhiatal laparoscopic i prepararea grefonului gastric cu ajutorul robotului, fapt ce a demonstrat c chirurgia robotic, prin cele 280 operaii efectuate pn n prezent n ara noastr, a fost bine implementat i n Romnia prin eforturile profesorilor I. Popescu i M. Beuran. n sala II, dup conferina magistral a prof. C. Copotoiu privind anastomoza gastro-pancreatic versus cea jejuno-pancreatic n DPC pentru cancer, s-a desfurat sesiunea chirurgia pancreasului I, dedicat pancreatitei acute, n care profesorii Fl. Popa, M. Beuran, E. Brtucu, D. Sabu, au prezentat date actuale privind aceast grav afeciune: scoruri de gravitate, sindromul de compartiment, supuraiile retropancreatice, momentul operator optim, soluii terapeutice laparoscopice. O conferin special de mare succes, susinut de S. Puntambekar, s-a referit la rolul laparoscopiei n cancerul gastric. A urmat o mas rotund dedicat managementului hepatitelor cronice virale n 2008. Sesiunea de chirurgie hepatic II, moderat de I. Popescu i L. Vlad, a captat auditoriul prin lucrrile prezentate, referitoare la rezeciile vasculare n tumorile Klatskin, tratamentul multimodal actual al hepatocarcinomului, strategii diagnostice i terapeutice n colangiocarcinomul hilar i n cel cu dubl localizare, central i periferic. Seciunea de chirurgie hepatic III a coninut lucrri importante privind pancreatectomia total n tumorile endocrine (N. J. Lygidakis), pancreatectomia central (M. Ionescu), exerezele tumorilor periampulare (D. Munteanu), tratamentul chisturilor pancreatice (S. Ciurea). n ziua urmtoare, n sala I s-a prezentat chirurgia tumorilor gastrice, care a excelat prin conferina despre chirurgia robotic a cancerului gastric (C. Vasilescu) i conferina special a prof. D. Tulbure privind tromboprofilaxia la pacienii cu chirurgie oncologic. Sesiunea chirurgie colorectal I a cuprins lucrri privind criteriile imagistice i aspecte practice n stabilirea conduitei terapeutice (M. Grigora), probleme particulare n cancerele de rect jos situate (V. Scripcariu), decizia terapeutic n cancerele local avansate opinia oncologului (L. Miron) i managementul cancerelor colorectale cu metastaze hepatice sincrone (E. Trcoveanu).

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i sesiunea urmtoare a abordat problematica cancerului colorectal avansat, relaia cancer digestiv-boal Crohn i problema prevenirii fistulei anastomotice prin colecistectomia de protecie, care s-a dovedit a nu mai fi necesar. n seciunea Tumori rare, prezidat de Rodica Anghel i M. Coculescu, s-au dezbtut diagnosticul i tratamentul metastazelor cu punct de plecare neprecizat (R. Anghel, V. Herlea), tratamentul metastazelor hepatice din cancerele non-colorectale (L. Minea), tumorile stromale gastrointestinale (A. Croitoru, O. Bl), sindroame carcinoide cu secreie endocrin paraneoplazic (M. Coculescu), tumori endocrine digestive (E. Trcoveanu). n sala II s-a dezbtut un subiect important n practica chirurgical, suportul nutriional la pacientul oncologic chirurgical i conferina Jurisprudena n practica chirurgical a prof. G. Borcean. Sesiunea chirurgie colorectal II a inclus conferine atractive rezecia anterioar de rect pe cale laparoscopic pentru cancer rectal (S. Puntambekar), cancerul de colon complicat (G. Jinescu), chirurgia colorectal asistat robotic (S. Vasile), particulariti evolutive n adenocarcinoamele colonice (D. Dinu) i indicaiile colectomiei totale n cancerul de colon stng ocluziv (V. Strmbu). n sesiunea chirurgia cilor biliare s-au prezentat colecistectomia laparoscopic analiza unui lot de 10.000 cazuri (E. Trcoveanu), posibilitile i limitele abordului minim invaziv n colecistita acut litiazic (R. Palade), colecistectomia laparoscopic pe abdomenul cicatriceal (t. Georgescu), colecistectomia fr cicatrici vizibile (C. Copescu), colecistectomia laparoscopic printr-o singur incizie (V. Tomulescu), tratamentul laparoscopic al litiazei colecisto-coledociene (B. Marian), ERCP n transplantul hepatic (C. Gheorghe). Atenia participanilor a fost atras, de asemenea, i de sesiunea video, moderat de C. Copescu i V. Tomulescu, unde au fost prezentate colectomia dreapt laparoscopic (B. Marian), abordul laparoscopic al chistadenomului mucinos pancreatic caudal (S. Pun), abordul minim invaziv robotic i laparoscopic al unui caz de carcinom esofagian mediotoracic (V. Tomulescu), ileusul biliar (V. Constantin), icterele mecanice maligne (I. Lic). Adunarea general a Asociaiei Romne de Chirurgie Hepatobiliopancreatic i Transplant Hepatic a asistat la prezentarea raportului de activitate i a ales conducerea societii. n cadrul adunrii generale au fost discutate i problemele legate de supraspecializrile n chirurgie n Romnia. Un alt punct forte al congresului a fost cel destinat cursurilor postsimpozion: endoscopia intervenional n afeciunile tubului digestiv (coordonator conf.dr. Cristian Gheorghe), ecografia intervenional n afeciunile hepatice (coordonator prof. Guido Torzilli), anatomia chirurgical a lobului caudat (coordonator prof. dr. I. Cmpeanu), cursuri care s-au bucurat de o larg audien printre tineri deoarece au rspuns nevoii de perfecionare a chirurgilor n cel puin dou domenii de interes pentru practica chirurgical, ecografia i endoscopia intervenional. Toi participanii au apreciat c acest simpozion a fost o reuit deosebit datorit numrului mare de specialiti prezeni, cursurilor postsimpozion, demonstraiilor operatorii captivante, evalurii progreselor obinute n ultimii ani, diseminrii experienelor colectivelor care practic chirurgia hepatobiliopancreatic i chirurgia oncologic digestiv i, nu n ultimul rnd, organizrii perfecte a acestui eveniment. E. Trcoveanu

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Jurnalul de Chirurgie, Iai, 2009, Vol. 5, Nr. 2 [ISSN 1584 9341]

TERAPIA ONCOLOGIC. OPIUNI BAZATE PE DOVEZI


Lucian Miron (sub redacia) Ed. Institutul European Iai, 2008, ISBN 978-973-611-538-7

n 2008, la Institutul European Iai seria Medicin, colecia Academica, a aprut tratatul intitulat Terapia oncologic. Opiuni bazate pe dovezi, sub redacia Conf. dr. Lucian Miron, cadru didactic i oncolog de prestigiu de la U.M.F. Gr.T. Popa Iai. Pe parcursul a peste 920 de pagini, tratatul este bine structurat n 14 seciuni (88 capitole) i pune la dispoziia specialitilor cele mai noi date de terapie oncologic. Majoritatea capitolelor crii sunt mprite n seciunile: tumori solide, hemopatii maligne, maligniti pediatrice, noiuni de practic oncologic. Cartea mai cuprinde localizrile specifice neoplazice, terapia acestora, urgenele oncologice i tratamentul simptomatic. Se concentreaz asupra ultimelor nouti privind abordul multidisciplinar, n echip, al tumorilor maligne. Acolo unde au fost disponibile, au fost incluse recomandrile ghidurilor clinice de referin n oncologie (ESMO, ASCO, NCCN) sau s-a cutat cea mai bun opiune bazat pe rezultatele studiilor publicate n literatur. Prima seciune abordeaz principiile de tratament i strategia terapeutic (L. Miron): tratamente loco-regionale, tratamente sistemice, alegerea tratamentului oncologic i evaluarea eficacitii terapiei. A doua seciune abordeaz cancerele pielii (L. Miron): neoplaziile cutanate nonmelanice, melanomul malign, carcinomul celulelor Merkel i sindromul Sezary. Un capitol amplu i atractiv prezentat este destinat cancerelor glandelor endocrine (L. Miron): cancerul tiroidian, paratiroidian, cancerul de corticosuprarenal, feocromocitolul, cancerele pancreasului endocrin, tumorile carcinoide, neoplaziile endocrine multiple. Seciunea IV este dedicat cancerelor capului i gtului (L. Miron): cancerele cavitii orale, cancerele faringelui i esofagului cervical, cancerul cavitilor nazale i sinusurilor feei, cancerul de laringe i cel al glandelor salivare. Cancerele toracice sunt prezentate n seciunea V (L. Miron): cancerul bronhopulmonar, al timusului i mezoteliomul pleural. Cancerele digestive sunt amplu descrise n capitolul VI (L. Miron, M. Marinca): cancerul esofagian, cancer, al intestinului subire, colo-rectal, anal, cancerul hepatic i al cilor biliare, cancerul pancreasului exocrin i tumorile gastro-intestinale stromale. Seciunea VII se refer la cancerul mamar la femei i la brbai.

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Jurnalul de Chirurgie, Iai, 2009, Vol. 5, Nr. 2 [ISSN 1584 9341]

Cancerele ginecologice (vulvar, vaginal, col uterin, corp uterin, anexe i boala trofoblastic gestaional) sunt prezentate n capitolul VIII (L. Miron). Seciunea IX cuprinde tratamentul cancerelor uro-genitale (M. Marinca, L. Miron): cancerul renal, de vezic urinar, cancerul cilor urinare superioare, cancerul penisului, cancerul de prostat i de testicul. Cancerele musculo-scheletice (L. Miron) sunt prezentate n seciunea X. O seciune particular se adreseaz altor cancere: ale sistemului nervos central, cancere cu punct de plecare neprecizat, metastaze osoase i viscerale, cancerele la pacientul imunodeficient. O alt seciune este dedicat hemopatiilor maligne (C. Dnil, A. Dsclescu): leucemiile acute i cronice, boala Hodgkin, limfoamele maligne nehodgkiniene, sindroame mieloproliferative, mielodisplazice i gamapatii monoclonale. De o deosebit valoare este capitolul acordat cancerelor pediatrice (I. Miron): leucemiile acute, boala Hodgkin, limfoame maligne nonhodgkin, tumorile sistemului nervos central, neuroblastom, retinoblastom, nefroblastom, hepatoblastom i alte tumori hepatice, rabdomiosarcom i alte sarcoame de pri moi. Ultima seciune analizeaz o problem esenial n oncologie, respectiv terapia suportiv i simptomatic: durerea n cancer, emeza, mielosupresia, complicaiile infecioase, nutriia pacienilor canceroi, urgenele oncologice, tulburrile psihologice i starea terminal. Acest veritabil ghid se caracterizeaz printr-o prezentare concis a principalelor neoplazii umane, analiznd pentru fiecare factorii de risc i prognosticul, diagnosticul, stadializarea, strategia terapeutic. Sunt prezentate protocoalele actuale i noi ageni terapeutici disponibili, pe baza informaiilor aduse la zi i recomandrile de bun practic clinic, fiind printre primele tratate romneti care aduc date medicale bazate pe dovezi. Cartea ncearc i reuete s ilustreze foarte bine problemele clinice i de management al cancerelor n toat complexitatea, incertitudinile i progresele care caracterizeaz oncologia modern. Aceasta reprezint un instrument util n mbuntirea practicii oncologice punnd la dispoziia practicienilor informaii accesibile, utile, care reflect progresele, complexitatea i limitele oncologiei moderne. Tratatul, bazat pe o bogat experien i pe studiul unei bibliografii recente, dei voluminos, este uor de parcurs datorit stilului concis, ordonat i clar i tehnoredactrii moderne. Condiia grafic deosebit face cinste editurii care a tiprit acest tratat. Monografia se adreseaz n primul rnd oncologilor dar i chirurgilor, internitilor, pediatrilor, hematologilor, imunologilor, imagitilor, tuturor celor interesai de afeciunile neoplazice. Apariia acestui tratat, complet i actualizat reprezint un eveniment editorial deosebit.

Prof. dr. Eugen Trcoveanu

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Jurnalul de Chirurgie, Iai, 2009, Vol. 5, Nr. 2 [ISSN 1584 9341]

OSTEOASINTEZA MINIM INVAZIV CU PLCI - FIXATOARE INTERNE


Paul-Dan Srbu Casa de Editur Venus, 2008 La Casa de Editur Venus, n 2008, a aprut sub redacia Dr. Paul-Dan Srbu volumul Osteosinteza minim invaziv cu plci - fixatoare interne, nsoit de DVD, rezultatul unei colaborri multinaionale prestigioase. Monografia ncepe cu un Cuvnt nainte al domnului Academician Nicolae Gorun i reprezint un recital editorial dedicat plcilor cu stabilitate angular, care au revoluionat tratamentul fracturilor complexe situate n vecintatea articulaiilor. Cartea este realizat cu contribuia mai multor specialiti din ar i strintate. Dup un capitol dedicat evoluiei plcilor blocate(P. Botez i colab.), Prof. Dr. Wilhelm Friedl din Germania i prezint experiena deosebit privind plcile cu stabilitate angular multidirecional n fracturile radiusului distal i humerusului proximal. Monografia continu cu alte capitole dedicate fixatoarelor interne, realizate de Dr. Lucian Stratan (Martinica, Frana) i Dr. Silviu Hopulele (Cluj-Napoca). Cartea se ncheie cu dou articole ale colectivului de la Iai (P. Srbu i colab.) care susin avantajele implantelor LISS sau LCP n fracturile femurului distal i tibiei proximale. Ca i la celelalte apariii editoriale, Paul Srbu ataeaz volumului un DVD educaional cu tehnici operatorii i soft de evaluare al cunotinelor acumulate. Aa cum remarca Acad. Nicolae Gorun : Dr. Paul-Dan Srbu crede i aduce n prezent viitorul medicinii i educaiei medicale, bazate incontestabil i inevitabil pe reconstrucii 3D, fotogrametrie, perfeciune chirurgical bazat pe asistarea computerizat i sisteme de navigaie, manuale video si telemedicin. Volumul are o condiie grafic deosebit ceea ce asigur o lectur agreabil. Apariia acestei cri reprezint un eveniment editorial deosebit, extrem de util studenilor, specialitilor i rezidenilor de ortopedie. E. Trcoveanu

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