NR 4 Tot

i
Jurnalul de Chirurgie (Iai), 2012, Vol. 8, Nr. 4
Jurnalul de chirurgie este o revist electronic, cu acces liber (Open

Access), se adreseaz tuturor specialitilor chirurgicale i are drept obiective
asigurarea unui mijloc de informare eficient i ncurajarea tinerilor medici i
cercettori n a-i publica rezultatele activitii clinice i de cercetare.
Revistele electronice cu acces liber reprezint platformele ideale pentru
publicarea rezultatelor cercetrilor ntruct articolele intr imediat ntr-un larg circuit
tiinific. Astfel, publicarea n Jurnalul de chirurgie asigur apariia rapid a
articolelor n format *.pdf i indexarea acestora i a rezumatului n IndexCopernicus,
DOAJ i EBSCO Academic. Jurnalul de chirurgie public urmtoarele tipuri de
articole: editoriale, articole de sintez (review), articole originale, cazuri clinice, articole de tehnic i anatomie
chirurgical, articole multimedia i de istorie a chirurgiei. Toate articolele sunt supuse unui proces de peerreview. Membrii colectivului de redacie asigur buna desfurare a procesului de recenzare, iar autorii trebuie
s respecte cerinele International Committee of Medical Journals Editors (http://www.icmje.org).
ncepnd cu 2012, Jurnalul de chirurgie apare ntr-un nou format, este patronat de Academia de tiine
Medicale i, alturi de revista Chirurgia i este agreat oficial de Societatea Romn de Chirurgie.
REDACIE
Fondator & Editor ef
Eugen Trcoveanu
Fondator & Redactor ef
Radu Moldovanu
Secretar general de redacie
Alin Vasilescu
Redactori
Dan Andronic (Iai)
Cirprian Bolca (Quebec, Canada)
Irina Cruntu (Iai)
Gabriel Dimofte (Iai)
Cristian Lupacu (Iai)
Drago Pieptu (Iai)
Nuu Vlad (Iai)
Comitet editorial naional
Monica Acalovschi (Cluj-Napoca)
Nicolae Angelescu (Bucureti)
Gabriel Aprodu (Iai)
Mircea Beuran (Bucureti)
Eugen Brtucu (Bucureti)
Ioan Coman (Cluj-Napoca)
Nicolae M. Constantinescu (Bucureti)
Silviu Constantinoiu (Bucureti)
Ctlin Copescu (Bucureti)
Constantin Copotoiu (Tg. Mure)
Nicolae Dnil (Iai)
Corneliu Dragomirescu (Bucureti)
tefan Georgescu (Iai)
Ioan Georgescu (Craiova)
Cornel Iancu (Cluj-Napoca)
Avram Jecu (Timioara)
Fulger Lazr (Timioara)
Rducu Neme (Craiova)
Alexandru Nicodin (Timioara)
Ion Poeat (Iai)
Florian Popa (Bucureti)
Irinel Popescu (Bucureti)
Paul Srbu (Iai)
Vasile Srbu (Constana)
Viorel Scripcariu (Iai)

Valeriu urlin (Craiova)
Liviu Vlad (Cluj Napoca)
Victor Tomulescu (Bucureti)
Comitet editorial internaional
Alexander Beck (Ulm, Germania)
Giancarlo Biliotti (Florena, Italia)
Hendrick Van Damme (Lige, Belgia)
Gheorghe Ghidirim (Chiinu, Rep. Moldova)
Christian Gouillat (Lyon, Frana)
Robrecht Van Hee (Antwerpen, Belgia)
Vladimir Hotineanu (Chiinu, Rep. Moldova)
Lothar Kinzl (Ulm, Germania)
Liviu Lefter (Hobart, Australia)
Adrian Loboniu (San Francisco, S.U.A.)
Jan Lerut (Louvain, Belgia)
Christian Letoublon (Grenoble, Frana)
Phillipe van der Linden (Bruxelles, Belgia)
John C. Lotz (Stafford, Marea Britanie)
Francoise Mornex (Lyon, Frana)
Richard M. Satava (Washington, S.U.A.)
Gianfranco Silecchia (Roma, Italia)
Jose Schiappa (Lisabona, Portugalia)
Adrian Stoica (Pasadena, S.U.A.)
Paul Alan Wetter (Miami, S.U.A.)
Corector
Oana Epure (Iai)
Webmaster
Andrei Stipiuc (Iai)
Adresa de coresponden
Prof. Dr. Eugen TRCOVEANU
Redacia Jurnalul de Chirurgie
Departamentul de chirurgie,
Universitatea de Medicin i Farmacie Gr.T. Popa Iai
Spitalul Sf. Spiridon Iai
Bd. Independentei nr. 1
700111, Iai, Romania
Tel. / Fax: 0040 (0) 232 21 82 72
E-mail: redactie.jurnaluldechirurgie@gmail.com
ntreaga responsabilitate a opiniilor exprimate n articolele Jurnalului de chirurgie revine autorilor.
Republicarea sau reproducerea parial sau n ntregime a articolelor prin orice form de editare cunoscut, fr permisiunea prealabil a
redaciei Jurnalului de chirurgie, este interzis. Corespondena cu privire la drepturile de a utiliza parial sau integral articolele publicate n
Jurnalul de chirurgie va fi adresat redaciei: redactie.jurnaluldechirurgie@gmail.com Copyright Jurnalul de chirurgie, Iai, 2005-2012
ii
STANDARD DE REDACTARE
Iniializare pagin: Format A4, margini de 2,54 cm (1 inch).
Pagina de titlu:
Titlul: Times New Roman, 14, aldin (bold), centrat, la un rnd; trebuie s fie ct mai scurt i elocvent pentru
coninutul articolului;
Autorii: Times New Roman, 12, normal, centrat, la un rnd; vor fi notate: prenumele i numele de familie,
gradul profesional. Trebuie precizate datele de contact ale primului autor sau ale autorului desemnat ca autor
corespondent: adresa de coresponden, telefon/fax i o adres de e-mail funcional.
Apartenena autorilor: Numele instituiei trebuie precizat n conformitate cu reglementrile instituionale.
Titlul prescurtat: titlu de 3-5 cuvinte, ct mai elocvent pentru articol.
Pagina rezumatului:
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 parantez, italic). Rezumatul trebuie s
fie structurat pe capitole: BACKGROUND, AIM, METHODS, RESULTS, CONCLUSIONS.
Cuvintele cheie (KEY WORDS) vor fi menionate la sfritul rezumatului cu majuscule; de preferat acestea
trebuie alese din baza de date MESH (MEdical Subject Headings): www.nlm.nih.gov/mesh/MBrowser.html.
Textul propriu-zis al lucrrii:
Textul: Times New Roman, 12, la un rnd, structurat pe capitole: INTRODUCERE, MATERIAL SI METODA,
DISCUTII, CONCLUZII.
Bibliografia : numerotat n ordinea apariiei n text; Times New Roman, 10, la un rnd, redactat dup cerinele
internaionale (http://www.nlm.nih.gov/bsd/uniform_requirements.html). Referina bibliografic trebuie s
includ TOI autorii dac sunt 6 sau mai puini. Peste 7 autori vor fi notai doar primii 3 urmai de et al.
Numele revistei va fi notat n conformitate cu prescurtrile PubMed, sau n ntregime cnd acestea nu sunt
disponibile; redactarea acestuia se va face cu italice.
Formate acceptate:
Articole:
1. Takaori K, Raut V, Uemoto S. Clinical significance of liver ischaemia after pancreatic resection. Br J Surg. 2011; 99(4): 597-598.
2. Iancu D, Barto A, Mocanu L et al. Rolul stentrii preoperatorii n chirurgia cancerului de pancreas. Jurnalul de chirurgie (Iai). 2011;
7(2): 188-192.
3. Diaconescu S, Barbu O, Vascu B, Moscalu C, Aprodu G, Gavrilescu S. [Hepatic and pulmonary hydatic cyst in a child]. Jurnalul de
chirurgie (Iai). 2011; 7(2): 274-278.
Cri:
1. Whitehead WE, Schuster MM. Gastrointestinal Disorders. Behavioral and Physiological Basis for Treatment. Orlando: Academic Press;
1985. p. 213-220.
2. Moldovanu R, Filip V, Vlad N. Elemente de anatomie chirurgical. Ghid pentru examenul de specialitate. Iai : Editura Tehnopress ;
2010. P. 178-179.
Capitole n cri i tratate :
1. Meltzer PS, Kallioniemi A, Trent JM. Chromosome alterations in human solid tumors. In: Vogelstein B, Kinzler KW, editors. The genetic
basis of human cancer. New York: McGraw-Hill; 2002. p. 93-113.
2. Jecu A. Patologia chirurgical a apendicelui. In : Angelescu N, editor. Tratat de patologie chirurgical vol. II. Bucureti : Editura
Medical ; 2003. P. 1595-1614.
Materiale electronice :
1. Skandalakis JE, Colborn GL, Weidman TA et al. Skandalakis' Surgical Anatomy. New York: McGraw Hill; 2004. DVD.
2. Kelly JC. Salivary Bacteria Might Reveal Pancreatic Cancer. Medscape Medical News. 2011; [available from
http://www.medscape.com/viewarticle/751552]
Tabelele vor fi inserate pe o pagin separat i nu vor depi o pagin; titlul tabelului va fi numerotat cu cifre
romane: Times New Roman, 10, aldin, la un rnd, deasupra tabelului. Formatul tabelului trebuie s fie cel
academic. Nu sunt acceptate tabelele salvate sub form de imagini.
Figurile vor fi tiprite pe o pagin separat i trimise n format *.jpg sau *.tiff. Nu sunt acceptate imaginile n
format *gif sau *png. Legenda figurilor va fi notat pe o pagin separat cu Times New Roman, 12, aldin, la un
rnd i vor fi numerotate cu cifre arabe.
Articolele multimedia:
Filmele i prezentrile Power Point vor fi nsoite de un rezumat consistent n englez (de 300-500 cuvinte);
filmele vor fi n format *wmv, *.avi sau *.mpeg. Nu sunt acceptate filmele n format quick time. Fiierele
Microsoft Power Point (cu extensia .ppt) vor avea o dimensiune < 5Mb cu un numr de slide-uri <50.
Conflict de interese i acknowledgements
Pe o pagin separat vor fi menionate eventualele conflicte de interese i acknowledgements.
Articolele vor fi adresate redaciei n forma electronic (e-mail, CD, DVD) salvate n MS Word 1997-2003
(*.doc) i eventual printate. Nu se accept articolele n format *pdf.
Articolele nu vor depi: lucrri originale - 15 pagini; referate generale - 15 pagini; cazuri clinice i note de
tehnic - 8 pagini; recenzii si nouti - 2 pagini; comentarii/scrisori ctre redacie - 1 pagin maxim 10 titluri
bibliografice; articole multimedia: Power Point 50 Mb i 50 slide-uri; fiiere video de maxim 5GB.
iii
Jurnalul de chirurgie (Iai) octombrie-decembrie 2012; vol. 8; nr. 4
CUPRINS
EDITORIAL
GEORGE EMIL PALADE - INGREDIENTELE UNUI GENIU
E. Trcoveanu , A. Vasilescu
Jurnalul de chirurgie (Iai). 2012; 8(4): 325-328.
ARTICOLE DE SINTEZ
CANCERUL DE RECT PRINCIPII DE DIAGNOSTIC I TRATAMENT MULTIDISCIPLINAR
Maria-Gabriela Aniei , V. Scripcariu
ECOGRAFIA CU SUBSTANE DE CONTRAST
CIRCUMSCRISE HEPATICE
Oana Timofte , Elena Gologan, Simona Manea, G. Blan
CARACTERIZAREA
FORMAIUNILOR
ARTICOLE ORIGINALE
ROBOTIC ASSISTED LAPAROSCOPIC MYOMECTOMY VERSUS CLASSICAL MYOMECTOMY - A
COMPARATIVE STUDY
Sidonia Maria Sceanu , V. urlin, Cristina Angelescu, t.Ptracu, I. Georgescu, A. Genazzani
TULBURRILE COGNITIVE POSTOPERATORII I NECESITATEA ANALGOSEDRII
Oana-Diana Marcoci , Maria Vrabete
PANCREATIC PSEUDOCYST ACTUAL THERAPEUTIC OPTIONS
S. Sndulescu , V. urlin, I. Busuioc, D. Cartu, E. Georgescu, I. Georgescu
PANCREATICOGASTROANASTOMOZA VERSUS PANCREATICO-JEJUNOANASTOMOZA DUP
DUODENOPANCREATECTOMIA CEFALIC STUDIU COMPARATIV
S. Verzea , V. Scripcariu
DIETARY THERAPY IMPACT FOR CIRRHOTIC PATIENTS WITH HEPATIC ENCEPHALOPATHY
Adriana Teiuanu , Mirela Ionescu, S. Gologan, Adriana Stoicescu, M. Andrei, T. Nicolaie, M. Diculescu
VALOAREA ATELEI DE RECONSTRUCIE DIN TITAN N PLASTIA PIERDERILOR DE SUBSTAN
CONSECUTIVE REZECIEI IN CONTINUITATE A MANDIBULEI
VV Costan , M Balan, Marilena Bdlu, Otilia Boiteanu, Raluca Dragomir, Eugenia Popescu
ULCERELE DE STRES - ULCERELE CUSHING: DIAGNOSTIC, TRATAMENT, PROFILAXIE
R. cerbina , G. Ghidirim, A. Dolghii, V. Lescov, V. Burunsus, I. Glavan, Liliana Florea
iv
CAZURI CLINICE
SUPERIOR MESENTERIC ARTERY SYNDROME - AN UNUSUAL CAUSE OF DUODENAL
OBSTRUCTION
Sahu SK , Singh PK, Ray J, Uniyal M, Sharma C, Sekhar C, Kapruwan H, Sachan PK
EFECTELE MEGALIPOSUCIEI CU ULTRASUNETE ASUPRA INDICELUI DE MAS CORPORAL I
CONCENTRAIEI SERICE DE LEPTIN LA FEMEILE OBEZE PREZENTARE DE CAZ
Laura Maria Curic , F. Bassetto, Carmen Vulpoi
ANATOMIE I TEHNIC CHIRURGICAL

TRAPEZUL CEFALOPANCREATIC I TRIUNGHIUL COLEDOCO-WIRSUNGIAN
S. Suman
ARC PESTE TIMP

COMENTARIU LA ARTICOLUL FISTULE CHOLCYSTO-DUODNALE
(E. Christide - Revista de Chirurgie 1938: 7-8/41: 579-585)
N.M. Constantinescu
RECENZII I NOUTI
A XXXIV-A REUNIUNE A CHIRURGILOR DIN MOLDOVA IACOMI-RZEU
E. Trcoveanu
MANAGEMENTUL SELECTIV NONOPERATOR AL LEZIUNILOR VISCERALE ABDOMINALE LA
PACIENTUL POLITRAUMATIZAT Mircea Beuran, Ionu Negoi
E. Trcoveanu
Jurnalul de chirurgie [Journal of Surgery] (Iai) October-December 2012; vol. 8; no. 4
TABLE OF CONTENT
EDITORIAL
GEORGE EMIL PALADE - INGREDIENTS OF A GENIUS
REVIEWS
RECTAL CANCER - PRINCIPLES OF DIAGNOSIS AND MULTIDISCIPLINARY MANAGEMENT
CONTRAST-ENHANCED ULTRASONOGRAPHY IN CHARACTERIZING FOCAL LIVER LESIONS
ORIGINAL PAPERS
ROBOTIC ASSISTED LAPAROSCOPIC MYOMECTOMY VERSUS CLASSICAL MYOMECTOMY - A
COMPARATIVE STUDY
Sidonia Maria Sceanu , V. urlin, Cristina Angelescu, t.Ptracu, I. Georgescu, A. Genazzani
POSTOPERATIVE COGNITIVE DISFUNCTIONS AND NECESSITY OF ANALGOSEDATION
Oana-Diana Marcoci , Maria Vrabete
PANCREATIC PSEUDOCYST ACTUAL THERAPEUTIC OPTIONS
PANCREATICOGASTROANASTOMOSIS VERSUS PANCREATICOJEJUNO-ANASTOMOSIS AFTER
PANCREATICODUODENECTOMY A COMPARATIVE STUDY
S. Verzea , V. Scripcariu
DIETARY THERAPY IMPACT FOR CIRRHOTIC PATIENTS WITH HEPATIC ENCEPHALOPATHY
Adriana Teiuanu , Mirela Ionescu, S. Gologan, Adriana Stoicescu, M. Andrei, T. Nicolaie, M. Diculescu
THE VALUE OF TITAN PLATE FOR THE PLASTY OF BONE LOSS RESULTED FROM SEGMENTAL
RESECTION OF MANDIBLE
VV Costan , M Balan, Marilena Bdlu, Otilia Boiteanu, Raluca Dragomir, Eugenia Popescu
STRESS ULCERS: CUSHING ULCERS, DIAGNOSIS, TREATMENT, PREVENTION
R. cerbina , G. Ghidirim, A. Dolghii, V. Lescov, V. Burunsus, I. Glavan, Liliana Florea
vi
CASE REPORTS
SUPERIOR MESENTERIC ARTERY SYNDROME - AN UNUSUAL CAUSE OF DUODENAL
OBSTRUCTION
Sahu SK , Singh PK, Ray J, Uniyal M, Sharma C, Sekhar C, Kapruwan H, Sachan PK
THE EFFECTS OF ULTRASOUND-ASSISTED MEGALIPOSUCTION ON BODY MASS INDEX AND
SERIC LEPTIN LEVEL IN OBESE WOMEN - CASE REPORT
Laura Maria Curic , F. Bassetto, Carmen Vulpoi
ANATOMY AND SURGICAL TECHNIQUE

TRAPEZIUS CEFALOPANCREATIC AND COLEDOCO-WIRSUNGIAN TRIANGLE
S. Suman
ARCH BEYOND TIME

COMMENTS ABOUT THE PAPER FISTULE CHOLCYSTO-DUODNALE
(E. Christide - Revista de Chirurgie 1938: 7-8/41: 579-585)
N.M. Constantinescu
NEWS AND BOOK REVIEWS

A XXXIV-A REUNIUNE A CHIRURGILOR DIN MOLDOVA IACOMI-RZEU
E. Trcoveanu
MANAGEMENTUL SELECTIV NONOPERATOR AL LEZIUNILOR VISCERALE ABDOMINALE LA
PACIENTUL POLITRAUMATIZAT Mircea Beuran, Ionu Negoi
E. Trcoveanu
EDITORIAL
325
GEORGE EMIL PALADE - INGREDIENTELE UNUI GENIU

Departamentul de chirurgie, Clinica I Chirurgie
SHORT TITLE: George Emil Palade - ingredientele unui geniu
George Emil Palade - ingredients of a genius
HOW TO CITE: Trcoveanu E, Vasilescu A. [George Emil Palade - ingredients of a genius]. Jurnalul de chirurgie (Iai).
2013; 9(1): Jurnalul de chirurgie (Iai). 2012; 8(4): 325-328.
Pe 19 noiembrie 2012 s-au mplinit

100 de ani de la naterea lui George Emil
Palade, singurul laureat romn al Premiului
Nobel pentru medicin. Pentru a marca
evenimentul, s-au fcut numeroase eforturi
n lumea medical. Am avut astfel
posibilitatea s particip la Academia de
tiine Medicale la un simpozion patronat i
organizat de Doamna Academician Maya
Simionescu,
colaborator
apropiat
al
savantului romn, simpozion ce ne-a readus
n memorie viaa i activitatea fascinant a
acestui geniu. Ca elev i absolvent al liceului
B.P. Hadeu din Buzu am crescut i mam ndreptat spre medicin sub impresia
acestei legende vii a liceului. Ca student am
rezonat deseori cnd numele su era citat
legat de diversele descoperiri, culminnd cu
acordarea Premiului Nobel pentru medicin
i fiziologie, n 1974 i a titlului de Doctor
Honoris Causa al U.M.F. Iai, n 1995.
George Emil Palade s-a nscut la Iai,
pe pmntul fertil al Moldovei, ntr-o familie
de intelectuali, institutori i preoi, rdcinile
dinspre tat aflndu-se n Moldova, iar cele
dinspre mam n ara Romneasc. Mediul
familial propice i-a insuflat de timpuriu
dragostea i respectul fa de cri, coal i
educaie [1]. Tatl su, Emil Palade, a fost
nvtor la Sboani i Avereti, n fostul
jude Roman, pn n 1921, apoi profesor de
filosofie i pedagogie la coala Normal
Spiru C. Haret, din Buzu, pn n 1933.
Adresa de coresponden: Prof. Dr. Eugen Trcoveanu
Clinica I Chirurgie, Spitalul Sf. Spiridon, Iai
Bd. Independenei nr.1, 700111, Iai, Romnia
Tel. / Fax: 0040 (0) 232 21 82 72
e-mail: etarcov@yahoo.com
Mama savantului, Constana Cantemir

Palade, a fost nvtoare [2].
George Emil Palade are dou surori,
Constana, medic pediatru, cstorit
cu doctorul Neagoe Ionescu-Matiu i
Adriana, profesoar, cstorit cu avocatul
M.D. Israil.
A nceput coala primar la Iai i s-a
mutat n clasa a II-a, mpreun cu familia, la
Buzu, unde i-a continuat studiile. A
absolvit Liceul Teoretic Al. Hadeu, fiind
ef de promoie. n 1930 s-a nscris la
Facultatea de Medicin din Bucureti, fiind
acceptat cu media 10.
De la nceputurile studiilor a artat un
interes
deosebit
pentru
tiinele
fundamentale, determinnd planul conceptual
al cercettorului de mai trziu [2].
Trei profesori i-au marcat destinul:
- Prof. Dr. Francis Rainer, care afirma
c anatomia este tiina formei vii;
- Prof. Andre Boivin, cercettor i
profesor de biochimie, care i-a
demonstrat c legturile funcionale
sunt biochimice;
- Prof. Dr. Gr.T. Popa, care descoperise
sistemul port hipofizar i care i-a
insuflat pasiunea pentru experimentul
aprofundat.
nc din aceast perioad, George Emil
Palade a neles c fenomenele vieii i
interaciunile structur-funcie nu pot fi
nelese dect studiind sistemul molecular.
326
n aceast a doua etap, pe terenul

genetic fertil, s-a sdit influena marcant a
unor profesori de geniu. Mai erau necesare
doar condiiile propice cercetrii i munca
asidu de zi cu zi, pe care destinul i le-a
oferit.
Clasificat primul la concursul de
Externat, George Emil Palade a efectuat ca
extern, apoi ca intern stagii n diverse spitale
bucuretene, remarcndu-se de fiecare dat.
A fcut parte dintr-o generaie de aur a
Facultii de Medicin din Bucureti. A fost
prieten apropiat cu Ion Juvara, Dumitru
Vereanu i Panait Srbu, care au rmas n
Romnia i au devenit n timp mari profesori
i efi de coal [4,5]. Am avut ansa s-i
ascult pe Prof. Dr. Ion Juvara i Prof. Dr.
Dumitru Vereanu povestind despre studenia
i prietenia lor, fiind colegi de grup i m-am
transpus n atmosfera academic a perioadei
interbelice, cu profesori i studeni de
excepie, o atmosfer de poveste. Prietenia
lor a durat peste timp; la concursurile dificile
i corecte din acea perioad, G.E. Palade se
clasa pe primul loc, iar I. Juvara pe al doilea.
Cele mai multe informaii despre
aceast perioad a vieii sale le avem din
descrierile lui I. Juvara: Trebuie s
mrturisesc c G.E. Palade s-a impus ca
student deosebit din primele luni i aura
care l-a marcat s-a meninut pe tot parcursul
facultii. Aprecierile i afeciunea care l-au
nsoit permanent se datorau nu numai
calitilor sale intelectuale i pregtirii
deosebite, dar n egal msur vocaiei i
comportamentului lui de bun coleg [4].
Bun psiholog, I. Juvara creioneaz
portretul colegului su astfel: era studentul
bine dispus, vesel, surztor, care participa
la ntreaga via a generaiei sale. Iubea
literatura, muzica, teatrul, sportul, excursiile
pe muni, notul, glumele, farsele i tot ceea
ce la un loc reprezint farmecul tinereii [4].
n activitatea sa spitaliceasc din
perioada internatului s-a orientat ctre
medicina intern, fiind remarcat de
profesorul neurolog Gh. Marinescu i de
Prof. Dr. Lupu, de la boli interne.
Teza de doctorat, despre tubul urinifer
al delfinului, lucrare original i de excepie,
Trcoveanu E. et al.
este realizat sub ndrumarea Prof. Dr.
Rainer, un om de vast cultur biologic,
medical, dublat de o cultur general cu
totul deosebit.
nc din anul III este admis ca
preparator la Institutul de Anatomie al
Facultii de Medicin din Bucureti,
laborator n care a lucrat nentrerupt ca
asistent, ef de lucrri i confereniar alturi
de Prof. Dr. Gr.T. Popa.
Acelai Prof. I. Juvara scrie despre
aceast perioad: Ceea ce l caracterizeaz
pe Palade este n primul rnd curiozitatea sa
nemrginit, nsuirea cunotinelor printr-o
profund nelegere a datelor i faptelor
trecute prin sistematizarea gndirii sale.
E impresionant puterea sa de percepie, de
organizare
i
de
aprofundare
a
cunotinelor, ct i de prezentarea acelor
mai abstracte probleme n forme simple i
uor de neles [4].
Om de o vast cultur, erudit, era
ndrgostit de istorie, arheologie, poezie,
pictur i art romneasc G.E. Palade era
nzestrat cu o cultur sufleteasc i un
farmec personal care te cucerea de la
nceput.
Patriot, n timpul celui de-Al Doilea
Rzboi Mondial, a servit ara n Corpul
Armatei Romne. Dup rzboi, la insistena
lui Gr.T. Popa, n 1946, a plecat, cu mari
dificulti, n S.U.A., pentru o specializare
n Laboratorul de Biologie al Prof.
R. Chambers, de la Universitatea din New
York. Aici l cunoate pe Albert Claude, care
l fascineaz prin preocuprile sale, de
spargerea celulelor, de demontare a lor n
componente pe care urma s le studieze.
ncepe o colaborare fructuoas la
Universitatea Rockefeller New York, care va
dura 27 de ani.
Deschiderea cutiei negre a reprezentat
nceputul explorrii microcosmosului celular
i a descifrat structura, biochimia i funciile
complexe ale organitelor celulare. Aici
ncepe colaborarea cu Albert Claude i Keith
Porter i pun la punct tehnici care vor
revoluiona
utilizarea
microscoapelor
electronice n cercetarea infrastructurilor
celulare.
George Emil Palade ingredientele unui geniu

Astfel, a folosit un microtom foarte
fin, perfecionat de Porter, centrifugarea ntro soluie de sucroz care meninea
mitocondriile ct mai aproape de starea din
celul i un pH apropiat de cel al celulei vii
(ph 7 neutru), metode care au revoluionat
microscopia electronic i au clarificat
peisajul celular.
Aa cum preciza Maya Simionescu,
cu aceste noi arme n mn a urmat o
perioad de activitate febril i intens ntrun climat favorabil, cci grupul de la
Universitatea Rockefeller nu avea probleme
de fonduri, avea libertate total n alegerea
proiectelor, colaboratori exceleni, n timp
ce o competiie puternic i inea aleri [3].
n 1952, a descris crestele mitocondriale,
reticulul endoplasmatic rugos, ribozomii, iar
n 1954, mpreun cu Sandy Paley,
veziculele sinaptice din neuroni. Mintea lui
genial intuiete c naterea noilor proteine
fr de care viaa nu ar exista are loc la
nivelul ribozomilor ataai reticulului
endoplasmatic. Dup 1954, cu intuiia minii
de 40 de ani, abordeaz complex structura,
biochimia
i
funcia
ribozomilor
demonstrnd c aceste organite conin
particule de ADN i c sinteza proteinelor
are loc la acelai nivel. Demonstreaz
existena transportului vectorial prin celul i
c membranele celulare au continuitate de
organizare i funcie.
Toate aceste descoperiri au indus o
nou filosofie a vieii, demonstrnd o
uniformitate de organizare la nivel
subcelular a tuturor fiinelor i modul
prin care n evoluie s-a conservat i transmis
echipamentul
necesar
supravieuirii
celulei [3]. Descoper un nou tip de celul n
rinichi, celula mesangial i apoi
desmosomii. Studiaz schimburile dintre
snge i esuturi descriind trecerea
moleculelor prin bariera de celule
endoteliale, proces vital n viaa celulelor,
esuturilor i organelor.
Dup 27 de ani de descoperiri n
cascad, Prof. Dr. G.E. Palade se mut la
Universitatea Yale.
n 1974, primete Premiul Nobel n
fiziologie i medicin, mpreun cu Albert
327
Claude i Christian de Duve pentru

descoperirile privind organizarea structural
i funcional a celulei.
Descoperirile lui Palade au creat
fundamentul pe care s-au dezvoltat biologia,
fiziologia,
virusologia,
microbiologia,
patologia modern. Palade a pus bazele unei
noi discipline, biologia celular, care a fcut
posibil analiza bolilor la nivel celular,
primul pas pentru a controla bolile secolului.
n perioada 1969-1979, Nicolae i
Maya Simionescu, doi specialiti romni
entuziati, au colaborat cercetrile privind la
studiul membranelor, transportul molecular
i al diferenierii joncionale. n urma acestei
colaborri, la sfritul anilor 1970, ntr-un
climat politic nefavorabil, s-a nscut la
Bucureti un institut de cercetare n
domeniul biologiei celulare moderne, care a
introdus Romnia n fluxul activitii
tiinifice de vrf internaionale. Institutul a
devenit cunoscut, dup cum spunea chiar
Palade,
pentru nalta calitate i
performan a activitilor de cercetare a
personalului acestuia [1]. Institutul, nscut
sub steaua norocoas a lui Emil Palade,
reprezint i astzi cea mai important
instituie de cercetare din ara noastr.
n 1989, Emil Palade s-a mutat la
Universitatea din San Diego, California,
unde organizeaz, ca decan pentru tiin,
nvmntul de biologie celular, fr a
prsi niciodat laboratorul.
n 2000, George Emil Palade s-a retras
din funcia de decan pentru tiin al
Universitii din San Diego, dar a continuat
s coordoneze tiinific grupul de cercetare.
n 2002, nchide laboratorul de cercetare.
George Emil Palade a plecat din lumea
noastr la 7 octombrie 2008, la ora 12:01, n
localitatea Del Mar, California, dorina
profesorului fiind ca cenua sa s fie
mprtiat n Munii Carpai, pe care i-a
iubit att de mult i n Rocky Mountains
Aspen (S.U.A.), ara care l-a adoptat i a
folosit geniul su.
A muncit continuu, zilnic, toat viaa,
cu proiecte, experimente, cursuri, conferine
n ntreaga lume, profesor la trei mari
universiti din S.U.A., mentor al numeroi
Trcoveanu E. et al.
328
cercettori, director de granturi, militant

pentru fonduri de cercetare n Congresul
S.U.A.
n afar de descoperirea tainelor
celulelor, profesorul era pasionat de istorie,
muzic clasic, i plcea natura, cunotea
istoria Romniei, marii scriitori i marii
poei din care adesea recita.
Iubitor de natur de frumos, captivat
de miracolele vieii, profesorul ntrunea
unica i fericita combinaie dintre caliti
personale neobinuite, poate genetice,
educaie solid, cultur general i munc
deosebit ntr-un mediu deosebit de
stimulant. Toate acestea au fcut ca
nclinaia sa nativ pentru cercetare s dea
natere unui izvor enorm de cunotine
pentru biologie i medicin.
A lsat n urm o adevrat coal, o
filiaie tiinific bogat, de aproape 80
colaboratori, cu care a publicat peste 200
lucrri n peste 50 de ani de activitate
prestigioas. Colaboratorii si din prima
generaie s-au ntors n rile lor, unde au
devenit lideri n domeniu, n Europa, Israel,
Japonia, S.U.A. i Romnia. La rndul lor,
acetia au format a doua, a treia i a patra
generaie de biologi celulari, care susin prin
munca
i
modelul
maestrului
lor
departamentele de cercetare specifice din
lumea ntreag [3].
George Emil Palade credea c cel mai
important lucru din via este motenirea pe
care o lai generaiilor viitoare. n condiii
vitrege, de izolare total a rii noastre de
lumea tiinific internaional, a contribuit
la ndeplinirea unui vis a doi romni
entuziati (Nicolae i Maya Simionescu) de
a nfiina la Bucureti Institutul de Cercetare
de Biologie i Patologie Celular.
Un romn nscut la Iai, frumos la
suflet i n gnd, a descoperit tainele celulei,
a iubit i preuit viaa n dimensiunea ei cea
mai adnc.
BIBLIOGRAFIE
1. Palade GE. Autobiography In: Anca Michaela

Israil, Palade R, Zeletin CD. editori,
Crestomanie de familie. Bucureti, Ed.
Spandugino, 2012; p. 749-805.
2. Rusu V. Nobel. Retrospectiv 1901-1995,
laureaii premiului pentru fiziologie i
medicin. In: Anca Michaela Israil, Palade R,
Zeletin CD. editori, Crestomanie de familie.
Bucureti, Ed. Spandugino, 2012; p. 923-930.
3. Simionescu M. Omagiu lui George Emil
Palade In: Anca Michaela Israil, Palade R,
4. Juvara I. Amintirile unui coleg; despre George
Palade. In: Anca Michaela Israil, Palade R,
5. Vereanu D. Din amintirile unui chirurg de
copii. In: Anca Michaela Israil, Palade R,
ARTICOLE DE SINTEZA
329
CANCERUL DE RECT PRINCIPII DE DIAGNOSTIC I

TRATAMENT MULTIDISCIPLINAR
Universitatea de Medicin i Farmacie ,,Gr.T. Popa Iai,
Departamentul de chirurgie, Clinica Chirurgie, Institutul Regional de Oncologie Iai
MULTIDISCIPLINARY DIAGNOSIS AND TREATMENT IN RECTAL CANCER (Abstract):
The management of rectal cancer requires an individualized, multidisciplinary approach, based on
careful assessment of tumor location, stage and resectability. Pretreatment staging by MRI scan is
now standard and should be repeated following preoperative chemoradiotherapy (CRT). For
locally advanced rectal cancer, preoperative CRT increases the rate of tumor response and
decrease the rate of local recurrence. Curative treatment of rectal cancer is based on surgical
excision which combines the gold standard proctectomy, total mesorectal excision (TME) with
autonomic nerve preservation and sphincter preservation, if the level of the tumor permits. The
most important factor in rectal surgery is circumferential resection margins (CRM), negative
CRM being associated with a better outcome, decreased risk of local recurrence and distant
metastases and increased survival. The quality of oncological results is influenced by the degree
of specialization of the surgeon and the center where the patient is operated.
KEY WORDS: RECTAL CANCER; CHEMORADIOTHERAPY; TOTAL MESORECTAL
EXCISION; RESECTION MARGINS
SHORT TITLE: Cancerul de rect diagnostic i tratament
Rectal cancer diagnosis & treatment
HOW TO CITE: Aniei MG, Scripcariu V. [Rectal cancer - principles of diagnosis and multidisciplinary management].
INTRODUCERE
n ultimii 15 ani, tratamentul
neoplasmului de rect a evoluat att din punct
de vedere al tratamentului chirurgical ct i
n ce privete tratamentul oncologic. Pn n
1990 rezecia chirurgical a reprezentat
singura modalitate terapeutic standard n
neoplasmul
rectal.
n
tratamentul
neoplasmului de rect au existat 3 momente
importante: conceptul exciziei totale de
mezorect (introdus de Heald RJ n 1982,
Basingstoke,
UK)
[1];
eficacitatea
radioterapiei preoperatorii n neoplasmul
rectal (trialul suedez i trialul polonez 1996,
2004) [2,3] i evaluarea anatomo-patologic
a piesei de rezecie (criteriile Quirke P.
Universitatea Leeds, UK) [4].
Managementul modern, actual al

neoplasmului de rect presupune existena
unei echipe multidisciplinare, format din
gastroenterolog, anatomopatolog, radiolog,
radioterapeut,
oncolog,
stomaterapeut,
coordonat de chirurg, n vederea aplicrii
unui tratament corect bazat pe stadializarea
preterapeutic.
DIAGNOSTIC I STADIALIZARE
PRETERAPEUTIC
Bilanul preterapeutic n neoplasmul
rectal trebuie s conin tueul rectal i
biopsia pozitiv. O rectoscopie rigid sau
recto-sigmoidoscopie
flexibil
permite
aprecierea distanei tumorii de la marginea
superioar a sfincterului anal.
Received date: 03.08.2012

Accepted date: 21.10.2012
Adresa de coresponden: Dr. Maria-Gabriela Aniei,
doctorand Universitatea de Medicin i Farmacie Gr. T. Popa Iai
U.M.F. Iai, coala Doctoral, Str. Universitii, nr.16, 700115, Iai, Romania
Tel.: 0040 (0) 232 30 16 28; 0040 (0) 232 30 16 42
e-mail: dr.mgabriela@gmail.com
330
Primul
obiectiv
important
n
diagnosticul unei neoplazii n poriunea
distal a intestinului gros este diferenierea
ntre localizarea la nivelul colonului sau a
rectului. Acest lucru este deosebit de
important pentru conduita terapeutic
ulterioar:
- intervenie chirurgical de rezecie
urmat
de
tratament
adjuvant
(chimioterapie-CHT)
n
cazul
neoplasmului de colon n funcie de
stadializarea postoperatorie;
- tratament neoadjuvant (radioterapieRXT CHT) urmat de intervenie
chirurgical pentru neoplasmul rectal
subperitoneal.
n stadializarea preterapeutic sunt
utile urmtoarele investigaii:
- ecografia endorectal - evalueaz
gradul de infiltrare parietal a tumorii,
cu o acuratee de 72-95% i invazia
ganglionilor locali cu o acuratee de
61-88% [5,6]. Este util pentru
diferenierea tumorilor T1 i T2, n
aprecierea invaziei sfincterului anal
pentru tumori jos situate i dificil de
executat pentru tumori stenozante sau
vegetante de mari dimensiuni. Nu
permite aprecierea tumorilor situate
mai sus de 7-8 cm de marginea anal i
nici aprecierea mezorectului.
- examenul CT pelvin - are rezoluie
slab pentru peretele intestinal i fascia
mezorectal, nu poate aprecia cu
acuratee invazia tumorii n peretele
rectal sau CRM precum i ganglionii
cu diametrul < 8mm [7].
- examenul IRM pelvin - difereniaz cu
acuratee tumora de peretele intestinal,
expunnd optim caracterele fasciei
mezorectului; este considerat gold
standard n aprecierea stadializrii
tumorilor rectale. Trialul MERCURY
realizat pe un numr de 311 pacieni
cu neoplasm rectal operabil a
demonstrat c examenul IRM are o
precizie ridicat, valoarea predictiv
negativ i specificitate n aprecierea
marginilor de rezecie circumfereniale
(CRM), dei sensibilitatea i valoarea
Aniei MG. et al.

predictiv pozitiv au fost mai puin
impresionante [8].
- colonoscopia pn la nivelul valvei
ileo-cecale - pentru excluderea
prezenei leziunilor sincrone de colon;
- radiografia toracic, ecografia hepatic
i CT abdominal pentru o evaluare
complex hepatic i pulmonar pentru
leziunile secundare cu aceast
localizare.
PLANIFICAREA TIPULUI DE
TRATAMENT N NEOPLASMUL
RECTAL
Mai multe studii privind radioterapia
preoperatorie au inclus pacieni cu tumori
localizate pn la 16 cm de marginea anal
[2,9]. Aceast distan nu corespunde
rectului subperitoneal i determin folosirea
n exces a tratamentului neoadjuvant pentru
tumorile intraperitoneale. n prezent, se
considera limita de 12 cm fa de marginea
anal pentru indicatia de tratament
radioterapic [10,11].
n momentul diagnosticului, 10-20%
dintre tumorile rectale sunt considerate
inoperabile sub aspectul radicalitii
oncologice, datorit invaziei sau penetrrii
fasciei mezorectului i invazia n organele
vecine. n funcie de stadializarea
preterapeutic se planific tipul de tratament
n neoplasmul rectal. Radioterapia asociat
cu chimioterapia preoperator determin
diminuarea invaziei i mrimii tumorii,
favoriznd rezecia lor chirurgical.
Elementele de prognostic negativ care
trebuiesc apreciate preoperator sunt:
- tumori T3 cu extensie extramural >
15 mm;
- invazia tumoral a fasciei mezorectului
(CRM pozitive);
- tumori T4 cu invazia structurilor
adiacente;
- tumori T4 cu perforaie peritoneal.
Evaluarea imagistic preoperatorie
trebuie s recunoasc aceste situaii, s
aprecieze relaia tumorii cu muchii
ridictori anali i sfincterul anal, n vederea
coborrii limitei de rezecie rectal i
conservrii sfincterului anal [12-14].
Adenopatia n cancerul de colon

A) Tratamentul cancerului de rect Tis T1 N0
Aproximativ 20-30% dintre tumorile
rectale sunt diagnosticate n stadiul Tis i T1
i au un prognostic bun. Ele pot beneficia de
rezecie local, fr a se realiza ns o
evidare ganglionar, existnd riscul de
recidiv local. Invazia ganglionar poate fi
prezent n cazul: tumorilor ce intereseaz
submucoasa; dac tumora este puin
difereniat; n caz de embolii tumorale
vasculare sau limfatice. Excizia local poate
fi realizat pe cale transanal sau prin
microchirurgie endoscopic (pentru tumorile
localizate la nivelul rectului ampular
mijlociu sau superior). Excizia se face n
monobloc, macroscopic complet, n zona de
esut sntos. Trebuie s intereseze n
profunzime ntreaga grosime a peretelui
rectal. Riscul de a nu se recunoate o invazie
ganglionar variaz ntre 0-15% pentru
tumori T1 [15].
Excizia local a tumorii se poate
transforma n rezecie radical de rect n
prezena urmtoarelor criterii histologice
nefavorabile:
- rezecie incomplet (R1);
- invazie tumoral n muscular (T2);
- prezena de embolii vasculare i/sau
limfatice.
n literatur, riscul de recidiv local la
5 ani variaz ntre 0-32% iar supravieuirea
fr recidiv de 66-100% [16,17].
Rezultatele imediate ale rezeciei rectale n
ce privete supravieuirea sunt superioare
celor
obinute
pentru
reintervenie
chirurgical n caz de recidiv.
B) Tratamentul neoplasmului rectal T2-T4
N0, N+
Rata de recidiv local n tratamentul
chirurgical convenional al neoplasmului
rectal local avansat a fost ntre 20 i 40%.
Odat cu introducerea conceptului de excizie
total de mezorect (TME), dezvoltat n
ultimii 10 ani, rata de recidiv local a
sczut la < 10% [1,18].
Trialul olandez [19] a analizat rolul
asocierii radioterapiei preoperatorii la TME.
Rezultatele la 5 ani au artat o reducere a
recidivei locale de la 10,9% doar cu
331
tratament chirurgical, la 5,6% n grupul

pacienilor iradiai. Nu au fost evideniate
diferene n supravieuirea pacienilor.
Exist dou modaliti de radioterapie
neoadjuvant:
- de scurt durat - 25 Gy n 5 edine n
5 zile, urmate dup 7 zile de
intervenie chirurgical cu TME
reduce riscul de recidiv local la 2 ani
ntre 8-20%, raportat la tratament
chirurgical singur [19];
- de lung durat 50 Gy n 4
sptmni, urmat de intervenie
chirurgical dup 6-8 sptmni de la
terminarea
radioterapiei,
cu
o
diminuare a efectului tratamentului
neoadjuvant dup 12 sptmni [20].
Radioterapia
preoperatorie
este
recomandat pentru neoplasmul rectal
subperitoneal (polul inferior tumoral situat la
mai puin de 10 cm de la marginea anal)
pentru tumori T3-T4 i/sau N0 sau N+.
Pentru neoplasmul rectal local avansat se
asociaz chimioterapia neoadjuvant pentru
a crete sensibilitatea celulelor tumorale la
radioterapie.
Avantajele radioterapiei neoadjuvante
asociate cu chimioterapia neoadjuvant
(RCT) sunt urmatoarele [19-21]:
- reducerea
recurenei
locale
i
mbuntirea supravieuirii;
- maximizarea
conversiei
la
operabilitate
a
tumorii
rectale
(downstage- trecerea tumorii ntr-un
stadiu inferior- i/sau downsizediminuarea dimensiunii tumorii);
- ameliorarea controlului sistemic prin
eradicarea bolii micrometastatice;
- coborrea limitei de rezecie n
cancerul rectal jos situat, aplicnd un
procedeu chirurgical de prezervare a
sfincterului (sphincter saving);
- mbuntirea rezultatului funcional.
Ghidurile actuale de tratament
precizeaz c n formele local avansate,
care sunt iniial apreciate ca fiind
nerezecabile oncologic radical (T4, unele
T3)
se
prefer
radio-chimioterapie
preoperatorie cu doz total de 50,4 Gy, 1,8
Gy/fracie, concomitent cu 5-FU, urmat de
332
chirurgia radical dup 6-8 sptmni.

Radioterapia
sau
chimio-radioterapia
postoperatorie (ex. 50,4 Gy, 1,8-2,0
Gy/fracie) concomitent cu 5-FU nu se mai
recomand actual, dar se poate utiliza la
pacienii cu CRM pozitive, cu perforaie n
aria tumoral sau n alte situaii cu risc
crescut de recidiv local, dac radioterapia
nu poate fi administrat [22].
TRATAMENTUL CHIRURGICAL
N NEOPLASMUL RECTAL
Tratamentul
chirurgical
rmne
tratamentul care poate determina vindecarea
a 45% dintre pacienii cu neoplasm rectal. n
tehnica de excizie chirurgical a tumorii
rectale au aprut schimbri radicale, ca
urmare a evidenierii celulelor tumorale n
mezorect pn la 4 cm mai jos de tumor
precum i evidenierii impactului asupra
Aniei MG. et al.

recidivei locale a CRM [23]. Scopul
rezeciei tumorilor rectale este excizia
complet a tumorii (cu margini adecvate) i
a ganglionilor limfatici, cu reducerea riscului
de recidiv local i de diseminare la
distan. n cazul pacienilor cu tratament
neoadjuvant, intervenia chirurgical este
efectuat imediat n cazul radioterapiei de
scurt durat i la 6-8 sptmni (maxim 12
sptmni) dup terminarea radioterapiei de
lung durat [24,25].
Indicaiile terapeutice depind de:
localizarea tumorii n raport cu marginea
anal (accesibil sau nu la tueul rectal),
extensia tumorii n peretele rectal (T) i
invazia ganglionar (N) (Fig.1)
Pentru tumori localizate la nivelul
rectului ampular superior tratamentul
chirurgical este de prim intenie.
Fig. 1. Arborele decizional n tratamentul cancerului de rect

T: evaluarea extensiei tumorii; N: evaluarea invaziei metastatice a limfonodulilor regionali;
RT: radioterapie; CHT: chimioterapie
Pentru tumori T1N0 este indicat

tratamentul chirurgical conservator. Dac
tumora este jos situat, cu diametrul < 3 cm,
bine difereniat, fr embolii vasculare
sau limfatice se poate tenta excizia
transanal [26].
Pentru
tumori
T2N0
(invazia
muscularis propria) exist studii care susin
indicaia de tratament chirurgical de prim
intenie [18,19,27,28]. n unele situaii, se
poate indica tratament neoadjuvant:
- pentru tumori localizate pe peretele
rectal anterior, deoarece mezorectul
este inexistent la acest nivel i exist
risc mare pentru rezecie R1;
- pentru tumori evaluate prin endoscopia

transanal ca fiind T2 N+; pentru
tumori T2 juxtasfincteriene care ar
necesita, iniial, excizie abdominoperineal de rect iar prin tratament
neoadjuvant se dorete conversie n
stadiu inferior care ar putea duce la
tratament chirurgical conservator.
Pentru tumori T3-4, N0, N+ este
indicat tratament neoadjuvant de prim
intenie (radioterapie chimioterapie) urmat
de tratament chirurgical care, pentru a se
obine rezecie R0, poate interesa excizia n
bloc a altor organe pelvine.

Conceptul de excizie total de
mezorect (Total Mesorectal Excision, TME)
a fost descris n 1982 de ctre Heald RJ [1]
ca o tehnic chirurgical cu viz de
radicalitate oncologic bazat pe anatomia
planurilor fasciei rectale i spaiilor fibroase
ale pelvisului.
TME presupune excizia n bloc a
rectului mpreun cu toate zonele limfatice
din jur, ganglionii limfatici, esutul grsos
mezorectal i fascia mezorectului cu
prezervarea nervilor hipogastrici i a
plexului hipogastric inferior. Pentru tumorile
de rect ampular superior limita de siguran
este de cel puin 5 cm de mezorect i rect iar
pentru tumorile de rect ampular mijlociu i
inferior este necesar excizia total de
mezorect.
Plexul hipogastric superior (fibre
simpatico - preaortice) este prezervat prin
ligatura arterei mezenterice inferioare la 1-2
cm de origine. Prezervarea inervaiei
simpatice se realizeaz prin disecia
mezorectului ntre fascia presacrat i fascia
recti, cu identificarea celor doi nervi
hipogastrici, localizai la 2 cm sub uretere.
Prezervarea sfincterului anal se
realizeaz atunci cand se obine pe piesa
operatorie o margine distal de cel puin 1
cm de polul inferior al tumorii [29]. Pentru
tumorile jos situate se poate realiza o
disecie intersfincterian pentru a se obine
marginea distal de siguran [30]. Atunci
cnd nu se poate obine marginea distal de
siguran de cel puin 1 cm, se practic
operaia de excizie abdomino-perineal de
rect. Aceast intervenie chirurgical
intereseaz tumorile care invadeaz planeul
pelvin i tumori extinse la canalul anal.
Dup rezecia rectului i TME se poate
realiza un rezervor colonic n J de 5-6 cm
pentru a mbunti rezultatul funcional. O
alternativ la rezervorul n J este
anastomoza latero-terminal sau coloplastia
transversal, n special pentru pacienii cu
bazin ngust, mezocolon gros sau canal anal
lung.
Datorit riscului ridicat de fistul
anastomotic pentru pacienii cu rezecie
anterioar foarte joas de rect (anastomoz
333
colo-anal) i tratament neoadjuvant se

recomand protejarea anastomozei colorectale sau colo-anale cu o ileostomie sau
colostomie temporar (care se nchide la 6
sptmni). Aceast stom scade att riscul
de fistul anastomotic dar i consecinele
sale: peritonit, abces pelvin etc. [31].
EVALUAREA
ANATOMOPATOLOGIC A INTERVENIEI
CHIRURGICALE
Calitatea actului chirurgical n
cancerul de rect este factor de prognostic
pentru recidivele locale i supravieuirea la
distan [32,33]. Pentru a aprecia calitatea
actului chirurgical este necesar colaborarea
ntre chirurg i anatomopatolog n aprecierea
urmtorilor factori:
- integritatea mezorectului pe piesa
nefixat;
- marginile circumfereniale pe piesa
fixat;
- invazia peritoneului i invazia
vascular extramural;
- numrul de ganglioni.
Pentru stadiile T1-T3 Quirke i colab.
definesc trei grade ale rezeciei cu excizia
mezorectului. Se pot ntlni mai multe
situaii n aprecierea calitii mezorectului,
difereniat pentru rezecia anterioar de rect
(RAR) i excizia abdomino-perineal de rect
(EAP) [34].
Gradul 3 - excizia mezorectului n
planul fasciei mezorectale :
- mezorect
intact,
neted,
fr
imperfeciuni ale grsimii;
- anvelopa mezorectului intact anterior
i posterior;
- marginile distale nu prezint indentri,
specimenul chirurgical nu prezint
conizaie peritumoral;
- n cazul EAP, planul chirurgical este
situat extern, la nivelul levatorilor care
sunt ridicai n bloc cu specimenul
chirurgical.
Aceast
situaie
a
calitii
specimenului chirurgical este de dorit,
tratamentul chirurgical fiind considerat n
scop oncologic.
334

planul intramezorectal:
- neregulariti minore ale anvelopei
mezorectale;
- tendina la conizaie a specimenului
chirurgical ctre marginea distal;
- muscularis propria nu este expus
dect la nivelul ariei muchilor
levatori;
- neregulariti minore ale marginii
circumfereniale, aspect de cotor de
mr al piesei operatorii n cazul EAP.
planul muscularis propria:
- arii importante fr mezorect;
- leziuni profunde ale muscularis
propria;
importante
ale
- neregulariti
marginilor
circumfereniale
de
rezecie.
n
aceast
situaie,
intervenia
chirurgical este considerat de paleaie.
Fascia mezorectului formeaz CRM
numite i margini de rezecie laterale sau
radiale. De la descrierea iniial a
importanei sale clinice n 1986, s-a pus n
eviden implicarea CRM n recidiva local
ct i n apariia metastazelor la distan, ca
factor de prognostic independent al
supravieuirii. O CRM inferioar sau egal
cu 1 mm (prin marcare cu tu de India) este
considerat invazie [4,19,45].
Aniei MG. et al.

Obinerea CRM negative postoperator
determin o rat de recidiv local de 7 %.
Numai 22 % dintre pacieni dezvolt
metastaze la distan [36].
Aprecierea invaziei ganglionare este
important n selecia pacienilor pentru
tratament adjuvant [37]. Ghidurile actuale de
tratament [22,38] recomand recoltarea a
minimum 12 ganglioni pentru a aprecia
statusul ganglionar. Pentru cazurile n care
sunt examinai mai puin de 10 ganglioni,
ghidurile recomand ncadrarea pacientului
n stadiul TNM cu risc crescut i pacientul
este eligibil pentru tratament adjuvant
[39,40]. Radioterapia neoadjuvant de scurt
sau lung durat diminu cu cel putin 20%
numrul de ganglioni gsii pe piesa de
exerez. n absena invaziei ganglionare,
chiurajul ganglionar este un factor de
prognostic important n neoplasmul rectal.
[41,42].
TRATAMENTUL ADJUVANT N
NEOPLASMUL RECTAL
Pentru tumorile localizate la nivelul
rectului ampular superior, chimioterapia
postoperatorie se aplic n cazul invaziei
ganglionare.
Pentru tumorile rectale ampular mijlociu i
inferior indicaia tratamentului adjuvant
depinde de tratamentul neoadjuvant i de
evaluarea piesei chirurgicale (Fig. 2).
Fig 2. Arbore decizional n tratamentul cancerului de rect amlar mijlociu i inferior

N: limfonoduli regionali; RXT: radioterapie; CHT: chimioterapie;
* dac numrul de limfonoduli examina i 12
335
Postoperator, rspunsul la tratamentul

neoadjuvant i eficacitatea lui este evaluat
prin examenul anatomo-patologic al piesei
operatorii care apreciaz:
- clasificarea TNM a tumorii;
- diferenierea tumoral;
- statusul CRM;
- aprecierea invaziei limfatice i venoase
a esutului examinat;
- identificarea i descrierea zonelor de
tumor i de fibroz, apreciind gradul
de regresie tumoral conform scorului
Dworak [43].
Conform sistemului Dworak pot s
existe urmtoarele situaii n aprecierea
regresiei
tumorale
dup
tratament
neoadjuvant:
- GR 0: absena regresiei tumorale;
- GR 1: raportul mas tumoral / esut
fibrotic este net n favoarea tumorii;
- GR 2 - domin modificrile de fibroz,
mas tumoral prezent;
- GR 3: esut fibrotic cu degenerescen
mucoid ce conine insule de celule
tumorale;
- GR 4: mas fibrotic cu lacuri de
mucus fr celule tumorale (complete
response).
schimbri importante. Ecografia endorectal

i examenul IRM poate evalua gradul de
invazie a tumorii n peretele rectal cu o
sensibilitate
aproape
de
95%.
Radiochimioterapia preoperatorie crete
rspunsul tumorii i reduce semnificativ
riscul de recidiv local a tumorilor
clasificate n stadiul II i III.
Pentru neoplasmul rectal jos situat
clasificat Tis-T1N0, cu tumori cu diametrul
< 3 cm, cu localizare posterioar se poate
realiza excizia local. n prezent, gold
standard-ul chirurgical n neoplasmul rectal
este reprezentat de rezecia tumorii asociat
cu excizia total de mezorect i prezervarea
sfincterului anal. Prezervarea sfincterului
anal se poate obine atunci cnd exist o
distan de siguran de cel puin 1 cm sub
polul inferior al tumorii. Calitatea piesei
operatorii este un factor de prognostic pentru
recidiva local i supravieuire.
Calitatea actului chirurgical depinde i
de urmtorii factori: specialitatea chirurgului
i a centrului, numrul pacienilor tratai,
influeneaz controlul local dar i procentul
de prezervare
a
sfincterului
anal,
complicaiile postoperatorii i supravieuirea
pacienilor.
FOLLOW-UP POSTTERAPEUTIC
Protocolul de dispensarizare postterapeutic al pacientului cu neoplasm rectal
cuprinde:
- anamnez i examen clinic la 3 luni n
primul an, anual, timp de 5 ani;
- antigen carcino-embrionar la 3 luni n
primul an, anual timp de 5 ani pentru
tumori T2;
- colonoscopie/sigmoidoscopie o dat pe
an timp de 5 ani;
- ecografie abdomen i radiografie
toracic la 3 luni n primul an, apoi
anual timp de 5 ani;
- examen CT/RMN pentru pacieni cu
risc crescut de recuren i antigen
carcino-embrionar crescut.
CONFLICT DE INTERESE
Autorii nu declar nici un conflict de
interese
CONCLUZII
n ultimile 2 decenii, diagnosticul i
tratamentul neoplasmului rectal a suferit
BIBLIOGRAFIE
1. Heald RJ, Moran BJ, Ryall RD, Sexton
R, MacFarlane JK. Rectal cancer. The
Basingstoke experience of total mesorectal
excision, 1978-1997. Arch Surg 1998; 133(8):
894-899.
2. Swedish Rectal Cancer Trial. Improved
survival with preoperative radiation in
resectable rectal cancer. N Engl J Med 1997;
336(14): 980-987.
3. Bujko
K, Nowacki
MP, Nasierowska,
Guttmejer
A, Michalski
W, Bebenek
M, Pudeko M. Sphincter preservation
following preoperative radiotherapy for rectal
cancer: Report of a randomised trial
comparing short-term radiotherapy vs.
conventionally
fractionated
radiochemotherapy. Radiother Oncol 2004; 72(1):
1524.
336
4. The Royal College of Pathologists Working

Group on Cancer Services. Minimum data set
for colorectal cancer histopathology reports.
London: Royal College of Pathologists, 1998.
5. Massari M, De Simone M, Cioffi U, Rosso
L, Chiarelli M, Gabrielli F. Value and limits of
endorectal ultrasonography for preoperative
staging of rectal carcinoma - Surg Laparosc
Endosc 1998; 8(6): 438-444.
6. Palacios Fanlo M, Ramrez Rodrguez
J, Aguilella Diago V, Arribas Del Amo
D, Martnez Dez M, Lozano Mantecn R.
Endoluminal ultrasonography for rectal
tumors: efficacy, sources of error and
limitations. Rev Esp Enferm Dig 2000; 92(4):
222- 231.
7. Pomerri F, Maretto I, Pucciarelli S, Rugge
M, Burzi S, Zandon M, Ambrosi A, Urso
E, Muzzio PC, Nitti D. Prediction of rectal
lymph node metastasis by pelvic computed
tomography. Eur J Surg Oncol 2009; 35(2):
168173.
8. MERCURY study group. Extramural depth of
tumor invasion at thin-section MR in patients
with rectal cancer: results of the MERCURY
study. Radiology 2007; 243(1): 132139.
9. Sauer R, Becker H, Hohenberger W, Rdel
C, Wittekind C, Fietkau R. Preoperative versus
postoperative chemoradiotherapy for rectal
cancer. N Engl J Med 2004; 351(17): 1731
1740.
10. Roh
MS, Colangelo
LH, O'Connell
MJ, Yothers G, Deutsch M, Allegra CJ,
Preoperative multimodality therapy improves
disease-free survival in patients with
carcinoma of the rectum: NSABP R-03. J Clin
Oncol 2009 ; 27(31): 5124-5130.
11. Cionini L, Manfredi B, Sainato A.
Randomized
study
of
postoperative
chemotherapy (CT) after preoperative
chemoradiation (CTRT) in locally advanced
rectal cancer (LARC). Preliminary results.
Proceedings of the 11st European Cancer
Conference, Eur J Cancer 2001; 37(suppl 6):
S300 (abstr1107).
12. Beets-Tan RG, Beets GL, Vliegen RF, Kessels
AG, Van Boven H, De Bruine A. Accuracy of
Magnetic resonance imaging in prediction of
tumour-free resection margin in rectal cancer
surgery. Lancet 2001; 357(9255): 497-504.
13. Brown
G, Richards
CJ, Newcombe
RG, Dallimore
NS, Radcliffe
AG, Carey
DP, Bourne MW, Williams GT. Rectal
Carcinoma- Thin section MR Imaging for
staging in 28 patients. Radiology 1999; 211(1):
215-222.
14. Thaler W, Watzka S, Martin F, La Guardia
G, Psenner K, Bonatti G, Fichtel G, EgarterVigl E, Marzoli GP. Preoperative staging of
rectal cancer by endoluminal ultrasound vs
Aniei MG. et al.

magnetic resonance imaging. Dis Colon
Rectum 1994; 37(12): 1189-1193.
15. Nascimbeni
R, Burgart
LJ, Nivatvongs
S, Larson DR Risk of lymph node metastasis
in T1 carcinoma of the colon and rectum. Dis
Colon Rectum 2002; 45(2): 200-206.
16. Nascimbeni
R, Nivatvongs
S, Larson
DR, Burgart LJ. Long-term survival after local
excision for T1 carcinoma of the rectum. Dis
Colon Rectum 2004; 47(11): 1773-1779.
17. Mellgren
A,Sirivongs
P,Rothenberger
DA, Madoff RD, Garca-Aguilar J. Is local
excision adequate therapy for early rectal
cancer? Dis Colon Rectum 2000; 43(8): 10641074.
18. Peeters
KC, Marijnen
CA, Nagtegaal
ID, Kranenbarg
EK, Putter
H, Wiggers
T, Rutten H, Pahlman L, Glimelius B, Leer
JW, van de Velde CJ; Dutch Colorectal
Cancer Group.The TME Trial After a Median
Follow-up of 6 Years: Increased Local Control
But No Survival Benefit in Irradiated Patients
With Resectable Rectal Carcinoma, Annals of
Surgery, 2007; 246(5): 693-701.
19. Kapiteijn E, Marijnen CA, Nagtegaal ID. et al.
Preoperative radiotherapy combined with total
mesorectal excision for resectable rectal
cancer. N Engl J Med 2001; 345(9): 638-646.
20. Glehen O, Chapet O,AdhamM, Nemoz JC,
Gerard JP,Lyons Oncology Group. Long-term
results of the Lyons R90-01 randomized trial
of preoperative radiotherapy with delayed
surgery and its effect on sphincter-saving
surgery in rectal cancer. Br J Surg 2003;
90(8): 996-998.
21. Van Cutsem E, Dicato M, Haustermans K.
The diagnosis and management of rectal
cancer:
expert
discussion
and
recommendations derived from the 9th World
Congress
on
Gastrointestinal
Cancer,
Barcelona, Ann Oncol. 2007; 19(Suppl 6):
vi1vi8.
22. Glimelius B, Oliveira J. ESMO Guidelines
Working Group. Rectal cancer: ESMO
Clinical Recommendations for diagnosis,
treatment and follow-up. Ann Oncol. 2007;
18(suppl.2): ii23-ii24.
23. Quirke P, Durdey P, Dixon MF, Williams NS.
Local recurrence of rectal adenocarcinoma due
to
inadequate
surgical
resection:
histopathological study of lateral tumour
spread and surgical excision. Lancet. 1986;
38(8514): 996-999.
24. Bujko K, Nowacki MP, NasierowskaGuttmejer A. Sphincter preservation following
preoperative radiotherapy for rectal cancer:
report of a randomised trial comparing shortterm
radiotherapy
vs.conventionally
fractionated radiochemotherapy. Radiother
Oncol 2004; 72(1): 1524.

25. Peeters KC, van de Velde CJ, Leer JW. Late
side effects of short-course preoperative
radiotherapy combined with total mesorectal
excision for rectal cancer: increased bowel
dysfunction in irradiated patientsa Dutch
colorectal cancer group study. J Clin Oncol.
2005; 23(25): 61996206.
26. Guerrieri M, Baldarelli M, Organetti L, Grillo
Ruggeri F, Mantello G, Bartolacci S, Lezoche
E. Transanal endoscopic microsurgery for the
treatment of selected patients with distal rectal
cancer: 15 years experience. Surg Endosc
2008; 22(9): 20302035.
27. Nagtegaal ID, van Krieken HJM. The
multidisciplinary treatment of rectal cancer:
pathology. Ann Oncol 2007; 18(suppl_9):
ix122-ix126.
28. Law WL, Chu KW. Strategies in the
management
of
mid
and distal rectal
cancer with total mesorectal excision. Asian J
Surg. 2002; 25(3): 255-264.
29. Shirouzu K, Isomoto H, Kakegawa T. Distal
spread of rectal cancer and optimal distal
margin of resection for sphincter-preserving
surgery. Cancer 1995; 76(3): 388-392.
30. Rullier E, Zerbib F, Laurent C, Bonnel
C, Caudry
M, Saric
J, Parneix
M.
Intersphincteric resection with extension of
internal anal sphincter for conservative
treatment of very low rectal cancer. Dis Colon
Rectum 1999; 42(9): 1168-1175.
31. Dehni
N, Schlegel
RD, Cunningham
C, Guiguet M, Tiret E, Parc R. Influence of a
defunctionning stoma on leakage rates after
low colorectal anastomosis and colonic J
pouch-anal anastomosis. Br J Surg 1998;
85(8): 1114-1117.
32. Nagtegaal ID, van de Velde CJ, van der Worp
E, Kapiteijn E, Quirke P, van Krieken JH.
Cooperative Clinical Investigators
of
the
Dutch Colorectal Cancer Group Macroscopic
evaluation of rectal cancer resection specimen:
clinical significance of the pathologist in
quality control. J Clin Oncol 2002; 20(7):
1729-1734.
33. Cecil TD, Sexton R, Moran BJ. Total
mesorectal excision results in low local
recurrence rates in lymph node-positive rectal
cancer. Dis Colon Rectum 2004; 47(7): 11451150.
337
34. Quirke P, Morris E. Reporting colorectal

cancer. Histopathology. 2007; 50(1): 103-112.
35. Nagtegaal ID, Van De Velde CJH, Van Der
Worp E. Macroscopic evaluation of rectal
cancer
resection
specimen:
clinical
significance of the pathologist in quality
control. J Clin Oncol 2002; 20(7): 17291734.
36. Mawdsley S, Glynne-Johns R, Grainger J. Can
histopathologic assessment of circumferential
margin after preoperative pelvic chemotherapy
for T3-T4 rectal cancer predict for 3-year
disease-free survival? Int J Radiat Oncol Biol
Phys. 2005; 63(3): 745-752.
37. Goldstein NS. Lymph node recoveries from
2427 pT3 colorectal resection specimens
spanning 45 years. Am J Surg Pathol 2002;
26(2): 179189.
38. Union for International Cancer Control,TNM
Classification of Malignant Tumours 7th ed.
disponibil pe adresa http://www.uicc.org/tnm/
accesat pe 10 martie 2011.
39. Crhange
G, Bosset
JF, Maingon
P.
Preoperative radiochemotherapy for rectal
cancer: forecasting the next steps through
ongoing
and
forthcoming
studies
Cancer Radiother. 2011; 15(6-7): 440-444.
40. Tepper JE, OConnell MJ, Niedzwiecki D.
Impact of number of nodes retrieved on
outcome in patients with rectal cancer. J Clin
Oncol 2001; 19(1): 157163.
41. Kim YS, Kim JH, Yoon SM. Lymph node
ratio as a prognostic factor in patients with
stage III rectal cancer treated with total
mesorectal
excision
followed
by
chemoradiotherapy. Int J Radiat Oncol Biol
Phys 2009; 74(3): 796802.
42. Martling A, Cedermark B, Johansson H. The
surgeon as a prognostic factor after the
introduction of total mesorectal excision in the
treatment of rectal cancer. Br J Surg 2002;
89(8): 1008-1013.
43. Dworak
O, Keilholz
L, Hoffmann
A.
Pathological features of rectal cancer after
preoperative radiochemotherapy. Int J
Colorectal Dis 1997; 12(1): 1923.
338
Aniei MG. et al.
ARTICOLE DE SINTEZ
339
ECOGRAFIA CU SUBSTANE DE CONTRAST N

CARACTERIZAREA FORMAIUNILOR CIRCUMSCRISE
HEPATICE
Centrul de Gastroenterologie i Hepatologie Iai
CONTRAST-ENHANCED ULTRASONOGRAPHY IN CHARACTERIZING FOCAL LIVER
LESIONS (Abstract): Contrast-enhanced ultrasonography (CEUS) became widely used as a
method in characterizing focal liver lesions. The extensive use of imaging techniques in
differential diagnosis of liver lesions and screening of hepatocellular carcinoma in patients with
chronic hepatic diseases, has led to an important increase in identification of focal liver lesions.
The second generation contrast agents, due to their intravascular distribution, allow a continuous
evaluation of the enhancement pattern, which is crucial in characterization of liver lesions. The
dual blood supply in the liver shows three different phases: arterial, portal and late phases. The
enhancement during portal and late phases can give information about the lesions behavior. Each
liver lesion has a different enhancement pattern that makes possible an accurate approach to their
diagnosis. In this article, the advantages, indications and technique employed during CEUS and
the different enhancement patterns of most benign and malignant focal liver lesions are discussed.
KEY WORDS: LIVER TUMORS; LIVER CIRRHOSIS; HEPATOCELLULAR CARCINOMA;
CONTRAST-ENHANCED ULTRASONOGRAPHY; CEUS
SHORT TITLE: Ecografia cu substane de contrast
Contrast-enhanced ultrasonography
HOW TO CITE: Timofte O, Gologan E, Manea S, Blan G. [Contrast-enhanced ultrasonography in characterizing focal
liver lesions]. Jurnalul de chirurgie (Iai). 2012; 8(4): 339-345.
INTRODUCERE
n ultimii ani, ecografia cu substane
de contrast (engl. contrast enhanced
ultrasound CEUS) a devenit o metod
utilizat n caracterizarea leziunilor focale
hepatice [1]. n 2004, The European
Federation of Societies of Ultrasound in
Medicine and Biology (EFSUMB) a statuat
primele reguli referitoare la folosirea CEUS,
revizuite n 2008, prin care se prezint
principalele indicaii ale metodei [2,3].
Tehnicile bazate pe ultrasunete au
captat tot mai mult interesul clinicienilor.
Ultrasonografia a devenit cea mai popular
tehnic de diagnostic imagistic datorit
preului su sczut [4], dar i faptului c este
foarte sigur i puin invaziv [5].
Metoda clasic de evaluare a

semnalului circulator bazat pe ultrasunete
este reprezentat de tehnica Doppler.
Utilizarea ecografiei optimizat cu
ageni de contrast a fost prima dat folosit
la nivelul aparatului cardio-vascular, pentru
a evalua cu o precizie mai mare starea
vaselor mari. De atunci s-a folosit cu succes
n ecografia abdominal i apoi n
endoscopie [4].
Evaluarea leziunilor focale hepatice
este o problem frecvent n practic,
datorit folosirii de rutin a metodelor
imagistice (ecografie, computer tomografie CT, imagistic prin rezonan magnetic IRM) i datorit strategiilor de screening ale
pacienilor cu ciroz hepatic.

Adresa de coresponden: Dr. Oana Timofte, doctorand Universitatea de Medicin i Farmacie Gr.T. Popa Iai
Centrul de Gastroenterologie i Hepatologie, Spitalul Sf. Spiridon Iai
Bd. Independenei nr. 1, cod 700111, Iai, Romania
Tel.: 0040 (0) 232 24 08 22
Fax: 0040 (0) 232 21 77 81
E-mail: oanatimo@yahoo.com
340
Evaluarea de rutin a leziunilor focale

hepatice includea pn nu demult doar CT
cu contrast sau IRM i uneori biopsia
hepatic [1,6].
Leziunile incidentale vizualizate n
ecografia standard trebuie evaluate prin
diferite metode imagistice, ceea ce ar putea
fi un stres pentru pacientul aflat n ateptarea
unei alte metode de evaluare (CT cu contrast
sau IMR). Ecografia cu substan de contrast
poate fi efectuat imediat dup ecografia
abdominal standard, astfel nct dup
aproximativ 5 minute (durata acestei
investigaii), un diagnostic poate fi obinut
[6,7].
Evaluarea leziunilor focale hepatice
prin metode standard crete costurile
medicale la aceti pacieni, lund n
considerare faptul c CT cu contrast i IMR
sunt metode imagistice scumpe [8].
Dei permite o cartografiere mai
rapid, mai reproductibil i mai puin
operator-dependent
a
formaiunilor
tumorale, computer tomografia [CT] are
sensibilitate (83%) i specificitate (83%)
relativ redus. Combinarea examinrii CT cu
ecografia 2D a demonstrat ntr-un studiu
sensibilitate i specificitate ceva mai mare
(87, respectiv 100%) [9]. n cazul IRM
rezultatele diagnostice s-au gsit a fi similare
cu cele ale ecografiei optimizate cu ageni de
contrast [9].
SUBSTANE DE CONTRAST
Aceti
ageni
permit
achiziia
imaginilor pe baza efectului acustic nonlinear al microbulelor. Agenii de contrast de
generaia a doua, cum ar fi Sonovue, sunt
de cteva ori mai reflectivi dect esuturile
normale n faa oscilaiilor, astfel nct se pot
achiziiona imagini att n scala gri ct i n
modul Doppler.
Microbulele sunt preluate de ficat i
ajung n patul capilar fr a fi distruse; pot
ajunge n vasele hepatice, dar nu n
parenchim, deoarece nu pot iei din vase
[10]. Cteva tehnici de ultrasonografie cu
contrast, ce opereaz cu presiune acustic
sczut, au fost introduse n practica clinic
i permit vizualizarea parenchimului hepatic
Timofte O. et al.
n timpul perfuziei. De aceea, aceast
tehnic a fost numit i angiosonografia cu
contrast de perfuzie, pentru a fi separat de
tehnicile precedente bazate pe achiziie
intermitent de imagini. Cu o imagine
permanent asupra regiunii de interes, pot fi
monitorizate vascularizaia tumoral sau a
parenchimului.
Microbulele cu nalt elasticitate sunt
capabile de pasajul transpulmonar i
transsinusoidal i sunt eliminate pe calea
plmnului aproximativ 50% din doza
injectat este eliminat n primul minut, iar
80-90% este eliminat pe parcursul a 11
minute de la injectare [11]. Pentru
diminuarea artefactelor i pierderea imaginii
tumorale, se cere ca pacientul examinat s i
in respiraia ncepnd cu 10 secunde dup
administrarea microbulelor (cnd apare
primul semnal de contrast). Leziunea-int i
parenchimul nvecinat sunt observate
continuu timp de 5 minute dup injectare,
fr a explora restul ariei hepatice. Toi
pacienii sunt monitorizai pentru posibile
efecte adverse pn la dou ore postprocedur.
Microbulele stabile pot produce
cavitaie sau microfluxuri, ceea ce crete
valoarea indexului mecanic. Date provenite
de la modele animale mici sugereaz c
efectele nocive microvasculare sunt posibile.
Necesit atenie special uzul agenilor de
contrast n ecografie n esuturile unde
leziunile microvasculare pot provoca
implicaii clinice serioase, cum ar fi creierul,
ochiul i nou-nscutul. Ca i la celelalte
proceduri de diagnostic cu ultrasunete,
indicele mecanic trebuie monitorizat i
meninut ct mai sczut. Se pot produce
extrasistole ventriculare n timpul folosirii
substanei de contrast.[5]
TEHNICA CEUS
Se practic examinarea ecografic
uzual, incluznd analiza color/power
Doppler. Se stabilete indexul mecanic
foarte sczut (IM<0,08).
Fiecare
examinare
dureaz
aproximativ 5 minute dup injectarea n
bolus a substanei de contrast.
Ecografia cu substan de contrast

Unul dintre agenii de contrast folosii
este SonoVue (Bracco, Italy), comercializat
ca pulbere liofilizat, steril. Suspensia alblptoas de microbule cu sulphur
hexafluoride (SF6) (stabilizate cu o
membran fosfolipidic, cu dimensiuni mai
mici de 8 m) se obine prin adugarea a 5
ml de ser fiziologic peste pudr (25 mg),
urmat de agitare.
Fiecare pacient examinat primete un
bolus intravenos de cu SonoVue pentru
fiecare leziune de caracterizat (de obicei 2,4
ml) printr-un cateter intravenos de 1,2 mm
(20 gauge), plasat la vena antecubital,
urmat de 10 ml de ser fiziologic injectat
rapid.
n caracterizarea leziunii se evalueaz
comportamentul
hemodinamic
al
modificrilor pe care le sufer SonoVue n
faz arterial (15-30 secunde), portal
venoas (30-120 secunde) i faza vascular
tardiv (120-300 secunde).
Toate examinrile sunt nregistrate.
Localizarea i dimensiunea leziunii se
realizeaz prin ecografie convenional i
apoi prin ecografie cu contrast.
Se evalueaz modificrile leziunii
dup injectarea contrastului n comparaie cu
parenchimul hepatic nvecinat n cele 3 faze
(arterial, portal i tardiv), precum i
aspectul particular de umplere lezional din
punct de vedere spaio-temporal.
Faza arterial folosete n aprecierea
gradului i modelului de vascularizaie, n
timp ce faza portal i cea tardiv sunt utile
n determinarea naturii leziunii, cele mai
multe dintre leziunile maligne au
hipocontrast, spre deosebire de cele benigne,
cu izo- sau hipocontrast [3].
Examinarea ecografic cu substan de
contrast permite caracterizarea unei leziuni
ca hemangiom, hiperplazie focala nodular,
adenom, carcinom hepatocelular, metastaz
hepatic, zon de steatoz focal sau
alte tipuri de leziuni, conform ghidului
EFSUMB [3,7].
GHIDUL EFSUMB
CEUS devine din ce n ce mai
popular i folosit datorit simplitii sale,
341
ceea ce o face uor de nvat i de

interpretat.
n cazul unui ecografist experimentat,
CEUS poate crete acurateea diagnosticului
de la aproximativ 50% cu ecografia clasic
pn la 88% [12].
Ghidul EFSUMB stipuleaz c n
practica clinic, CEUS are un impact net n
urmtoarele situaii [3,13]:
- caracterizarea
leziunilor
focale
detectate la pacienii fr boal cronic
hepatic deja cunoscut
- caracterizarea
leziunilor
focale
detectate n cadrul programelor de
supraveghere a pacienilor cu boli
cronice hepatice
- stadializarea i urmrirea pacienilor
cu cancer
- monitorizarea tratamentului local
ablativ.
O problem destul de comun n
practic o reprezint caracterizarea unei
leziuni hepatice, prima alegere n
investigarea imagistic fiind ecografia.
Leziunile focale hepatice sunt observate la
mai mult de 50% din autopsii,
hemangioamele fiind cele mai frecvente
(pn la 20%), urmate de hiperplazia
nodular focal (3%). Tumorile hepatice
mici descoperite la pacieni asimptomatici
sunt adesea benigne, chiar la pacieni cu
istoric de neoplasm, n special cnd leziunea
are un diametru sub 15 mm [13].
Caracterizarea leziunilor hepatice prin
CEUS se bazeaz pe comparaia ntre
parenchimul normal i leziune n timpul
celor trei faze vasculare ale contrastului.
Vascularizaia tumorilor maligne ale
ficatului este realizat aproape complet de
artere, shunturile arterio-venoase fiind
frecvente. Fenomenul de washout este mai
rapid n majoritatea tumorilor maligne
comparativ cu parenchimul hepatic normal.
Leziunile solide benigne sunt cel mai
bine detectate i caracterizate n faza
arterial a contrastului, deoarece pot
disprea n fazele tardive.
Leziunile hepatice benigne comune au
caractere unice, iar caracterizarea lor prin
CEUS deosebit de valoroas (Tabel I).
Timofte O. et al.
342
Tabel I. Principalele caractere ecografice ale leziunilor hepatice n cele trei faze de contrast)
Leziune hepatic
Faza arterial
Faza portal
Faza trzie
Steatoz focal
Iso-C
Iso-C
Iso-C
Chist
Non C
Iso-C
Iso-C
C nodular-periferic, Ccentripet rapid complet

Hiper-C, complet, arii non-C
(hemoragii)
Hiper-C, complet, umplere
centrifug, hiper/hipo-C
central
Umplere centripet
parial/complet
Iso-C, arii de hiper-C sau
non-C (hemoragii)
C-complet, non-C n
zone centrale
Iso-C, non-C n zone
centrale (hemoragii)
Hemangiom
Adenom
Hiperplazie nodular
focal
Abces
Metastaze
hipervascularizate
Metastaze
hipovascularizate
Iso/hiper-C, hipo-C
central
Non-C central, sept C

Hiper-C, complete, vase
haotice, hipo-C
Arii non-C
Hipo/non-C
Hipo-C, arii non-C
Hipo/non-C
C : contrastant
Fig. 1 Leziune tumoral hipercaptant n faza

arterial
Fig. 2 Leziune tumoral cu washout n faza portal.
Fig. 3 Nodul hipercaptant n faza arterial cu umplere

dinspre periferie spre centru
Fig. 4 Nodul hipercapatant n faza portal, aspect

sugestiv pentru hemangiom.

Ecografia convenional nu poate
caracteriza cu precizie nicio leziune benign
la orice pacient, chiar i un henagiom; aceste
leziuni pot fi apreciate cu precizie doar la
pacieni asimptomatici, fr boal hepatic
cronic, dar la pacienii cu risc de carcinom
hepatocelular, poate eua n aproximativ
50% din cazuri [13].
Principala diferen ntre tumorile
maligne i benigne, nafara chistelor, care nu
au contrast, i a hemangioamelor
trombozate, este aceea c n timpul fazei
trzii toate leziunile benigne au uor contrast
fa de parenchimul nvecinat, pe cnd cele
maligne sunt hipoecogene sau nu
contrasteaz deloc. Specificitatea criteriilor
de caracterizare a leziunilor focale hepatice
variaz ntre 95-100% [14-16]. Diferena
este dat de nutriia tumorilor maligne
asigurat de artere.
CEUS poate depista vase arteriale cu
diametrul sub 100 m n diametru,
comparativ cu CT sau angiografia.
n general, o leziune heterogen sau
omogen, cu hipercontrast n timpul fazei
arteriale i washout n faza portal sau
tardiv reprezint aspecte tipice n ecografia
cu
substan
de
contrast
pentru
hepatocarcinomm [17].
Contrastul n faza arterial este de
obicei omogen, ns poate fi i heterogen,
datorit degenerescenei grsoase sau
necrozei intratumorale [18]. Leziunea cu
contrast dup injectare, care devine
hipocontrastant, se definete ca avnd
washout (Fig. 1-4) [6].
Metastazele hepatice au grade diferite
de vascularizaie. Cele omogene n faza
arterial sunt hipervasculare i de obicei
deriv
din
tumori
neuroendocrine
(carcinoide), celule insulare tumorale
(insulinom/gastrinom),
choriocarcinom/
cancer ovarian, carcinom tiroidian sau renal,
melanom sau sarcom, n timp ce leziunile
hipovasculare deriv din adenocarcinoame
(tract gastrointestinal, plmn) sau carcinom
cu celule scuamoase.
Totui, o astfel de difereniere conform
vascularizaiei nu ofer informaii despre
originea tumorii.
343
De exemplu, limfoamele pot produce

metastaze hepatice hipervasculare, dar i
hipovasculare.
Pentru
identificarea
corect
a
numrului de leziuni prezente, CEUS, dei
are o sensibilitate mai mare dect ecografia
convenional, este mai puin sensibil dect
CT sau MRI, care ofer o imagine mai
amnunit a parenchimului hepatic.
CARACTERIZARE DE LEZIUNI
FOCALE
DETECTATE
N
PROGRAMUL DE URMRIRE A
PACIENTULUI CU CIROZ
Carcinomul hepatocelular este una din
cele mai frecvente tumori maligne,
reprezentnd 70-85% din cazurile de tumori
hepatice primare. Diagnosticul precoce a
devenit principalul obiectiv al imagisticii,
deoarece tratamentele cu potenial curativ,
cum ar fi transplantul hepatic, rezecia
chirurgical i terapia ablativ local, pot fi
utilizate cu succes n mbuntirea
prognosticului.
Descrierea
arhitecturii
vasculare intralezionale este folositoare n
diagnosticul i prognosticul carcinomului
hepatocelular [13,17,19].
Supravegherea pacientului cu boal
hepatic cronic i n special a celui cu
ciroz este necesar pentru diagnosticul
precoce al carcinomului hepatocelular.
Programul de urmrire include
ecografia i dozarea alfa-fetoproteinei serice,
la interval de 6 luni, cu scopul de a detecta
tumorile cu diametrul sub 3 cm.
Din motive practice i economice, dar
i pentru evitarea rezultatelor fals pozitive
ale CT, ecografia este considerat
investigaia de prim linie folosit n
screening. Detectarea unui nodul hepatic de
mici dimensiuni pe un ficat cirotic prin
ecografie
convenional
necesit
un
ecografist cu experien i cteva condiii
favorabile gsirea nodulului cu sonda de
ecografie i existena caracterelor ecografice
diferite ale nodulului fa de parenchimul
nvecinat.
Atrofia hepatic i interpoziia gazelor
intestinale
reduc
accesibilitatea
parenchimului hepatic. Atenuarea i
Timofte O. et al.
344
distorsionarea semnalului datorit fibrozei,

ncrcrii grase i micro/macronodulilor
limiteaz studiul segmentelor hepatice.
Problema confirmrii diagnosticului de
hepatocarcinom a fost discutat la
Conferina EASL din 2000 Barcelona,
unde s-a decis:
- Detecia unui nodul hipo sau
hiperecoic la ecografia standard
trebuie s ridice suspiciunea unui
hepatocarcinom.
- Studii de morfopatologie au artat c
jumtate dintre nodulii cu mrime sub
1 cm nu sunt hepatocarcinoame, de
aceea protocolul prevede n acest caz
repetarea ecografiei la 3 luni, pn ce
leziunea depete 1 cm, moment n
care sunt necesare alte tehnici
diagnostice.
- Cnd un nodul nu depete 2 cm, este
recomandat
biopsia,
deoarece
metodele imagistice nu au suficient
acuratee
n
a
diferenia
un
hepatocarcinom de alte leziuni benigne
sau maligne.
- n cazul nodulilor peste 2 cm,
diagnosticul neinvaziv poate fi realizat
prin minim 2 metode radiologice care
evideniaz
hipervascularizaia
arterial.
CEUS nu a fost luat n calcul n
strategia de diagnostic, deoarece nu existu la
acea dat suficiente date legate de acurateea
sa. n prezent se tie c hepatocarcinomul
prezint contrast puternic n faza arterial a
CEUS, urmat de washout rapid. n faza
trzie, exist un contrast slab fa de
parenchimul
nconjurtor,
exceptnd
formaiunile bine difereniate, care rmn
izoecoice [20,21].
Diagnosticul diferenial se face cu
nodulii de regenerare, care au contrast
sincron cu parenchimul din jur, ramnnd
isoecoici n fazele portal i trzie.
Aceast tehnic ar putea reprezenta o
metod imediat pentru caracterizarea
oricrei leziuni nodulare sau modificri
focale detectate n ecografia convenional,
limitnd astfel utilizarea altor tehnici pentru
caracterizarea modificrilor vasculare i
reducnd
deci
tratamentului.
ntrzierea
aplicrii
STADIALIZAREA I
URMRIREA PACIENILOR CU
CANCER
Conform EFSUMB, 6 CEUS ar trebui
practicate la toi pacienii cu cancer pentru
cutarea metastazelor. Motivul acestei
recomandri este reprezentat de faptul c
CEUS crete capacitatea ecografiei de a
detecta metastazele hepatice, vizualiznd
modificrile arteriale i portale, dar i
fenomenul de wash-out al tumorilor. Unele
studii au demonstrat c acurateea CEUS
este comparabil cu cea a CT spiral sau MRI
cu contrast.
O alt aplicaie n oncologie este
reprezentat de monitorizarea rspunsului la
chimioterapie.
Post-chimioterapie,
proprietile acustice ale parenchimului
hepatic se modific, ceea ce face dificil
compararea cu examinrile precedente. ns
CEUS evalueaz modificrile reelei
vasculare tumorale, dei lipsa contrastului
arterial nu nseamn ntotdeauna absena
progresiei.
De asemenea, CEUS are rolul de
caracteriza tromboza venoas portal
malign n relaie cu hepatocarcinomul.
IMPACTUL ASUPRA
UNITILOR MEDICALE
Implementarea ghidurilor EFSUMB va
duce la creterea cererii de CEUS, deci la
achiziia de echipamente noi, ce presupune
medici pregtii la traininguri, introducerea
CEUS ca practic de rutin. CEUS va
nlocui o parte din investigaiile CT/RMN,
dei, n unele cazuri, acestea nc ofer o
evaluare mai fidel a parenchimului hepatic,
lucru esenial pentru pregtirea oricrei
intervenii.
CONCLUZIE
Dei experiena n folosirea CEUS este
nc limitat, iar utilizarea optim n diferite
situaii clinice rmne a fi dovedit pe larg,
CEUS are potenialul de a deveni
modalitatea de elecie n evaluarea

imagistic, caracterizarea i detectarea
precoce a leziunilor focale hepatice.
Autorii nu declar niciun conflict de
interese.
BIBLIOGRAFIE
1. Sporea I, Badea R, Martie A, irli R, Socaciu
M, Popescu A, et al. Contrast Enhanced
Ultrasound for the characterization of focal
liver lesions. Medical Ultrasonography 2011;
13(1): 38-44.
2. Albrecht T, Blomley M, Bolondi L, et al.
Guidelines for the use of contrast agents in
ultrasound. Ultraschall Med 2004; 25:
249-256.
3. Claudon M, Cosgrove D, Albrecht T, et al.
Guidelines and good clinical practice
recommendations for contrast enhanced
ultrasound (CEUS)- Update 2008. Ultraschall
Med 2008; 29: 28-44.
4. Sftoiu A, Vilmann P. Contrast-enhanced
endoscopic
ultrasonography.
World
J
Gastroenterol 2011; 17(1): 28-41.
5. Ter Haar G. Ultrasonic imaging: safety
considerations. Interface Focus 2011; 1:
686-697.
6. Martie A, Sporea A, Popescu A, irli R,
Dnil N, erban C, et al. Contrast Enhanced
Ultrasound for the characterization of
hepatocellular
carcinoma.
Medical
Ultrasonography 2011; 13(2): 108-113.
7. Sporea I, irli R, Martie A, Popescu A, Dnil
M. How Useful is Contrast Enhanced
Ultrasonography for the Characterization of
Focal Liver Lesions? J Gastrointestin Liver
Dis 2010; 19(4): 393-398.
8. Sndulescu L, Badea R, Sporea I, Popescu A,
Socaciu M, Sftoiu A. Contrast-Enhanced
Ultrasound for the Evaluation of Focal Liver
Lesions a Multicenter Trial in Romania.
Medical Ultrasonography 2011; 13(3):
258-259.
9. Badea A, Dumitriu D, Socaciu M, Bciu G.
Aportul diagnostic al ecografiei optimizate cu
substan de contrast n mase tumorale
cervicale. Rezultate preliminare. Clujul
Medical 2011; 84(Suppl.1): 11-14.
10. Kim KT, Jang HJ, Wilson S. Microbubble
Contrast Agents for Ultrasound Imaging
Safety and Efficacy in Abdominal and
Vascular Imaging. US Radiology 2008; 1:
54-57.
11. Wong GLH, Xu HX, Xie XY. Detection of
focal liver lesions in cirrhotic liver using
contrast-enhanced ultrasound. World J Radiol
2009; 1(1): 25-36.
345
12. Quaia E, Alaimo V,Baratella E, Pizzolato R,

Cester G, Medeot A, Cova MA. Effect of
Observer Experience in the Differentiation
Between Benign and Malignant Liver Tumors
After Ultrasound Contrast Agent Injection. J
Ultrasound Med 2010; 29: 2536.
13. Bolondi L, Correas JM, Lencioni R, Weskott
HP, Piscaglia F. New perspectives for the use
of contrast-enhanced liver ultrasound in
clinical practice. Digestive and Liver Disease
2007; 39: 187195.
14. von Herbay A, Vogt C, Willers R, Hussinger
D. Real-time Imaging With the Sonographic
Contrast Agent SonoVue. Differentiation
Between Benign and Malignant Hepatic
Lesions. J Ultrasound Med 2004; 23:
15571568.
15. Tranquart F, Le Gouge A, Correas JM, et al.
Role of contrast-enhanced ultrasound in the
blinded assessment of focal lesions in
comparison with MDCT and CEMRI: Results
from a multicentre clinical trial. EJC 2008;
suppl 6: 9-15.
16. Tranquart F, Correas JM, Ladam Marcus V, et
al. Echographie de contraste temps reel dans la
prise en charge diagnostique des lesions
nodulaires
hepatiques:
evaluation
des
performances diagnostiques et de limpact
economique sur une etude multicentrique
francaise. J Radiol 2009; 90: 109-122.
17. Xu HX. Era of diagnostic and interventional
ultrasound. World J Radiol 2011; 3(5):
141-146.
18. Dnil M, Sporea I, irli R, Popescu A,
endroiu M, Martie A. The role of contrast
enhanced ultrasound (ceus) in the assessment
of liver nodules in patients with cirrhosis.
Medical Ultrasonography 2010; 12(2):
145-149.
19. Liu GJ, Lu DM. Diagnosis of liver cirrhosis
with contrast-enhanced ultrasound. World J
Radiol 2010; 2(1): 32-36.
20. Gmez Molins I, Fernndez Font JM, lvaro
JC, Lled Navarro JL, Fernndez Gil M,
Fernndez Rodrguez CM. Contrast-enhanced
ultrasound in diagnosis and characterization of
focal hepatic lesions. World J Radiol 2010;
2(12): 455-462.
21. Skovgaard LP. Role of contrast enhanced
ultrasonography in the assessment of hepatic
metastases: A review. World J Hepatol 2010;
2(1): 8-15.
346
Timofte O. et al.
ORIGINAL PAPER
347
ROBOTIC ASSISTED LAPAROSCOPIC MYOMECTOMY

VERSUS CLASSICAL MYOMECTOMY
- A COMPARATIVE STUDY Sidonia Maria Sceanu 1,, V. urlin 2, Cristina Angelescu 3, t.Ptracu 2,
I. Georgescu 2, A. Genazzani 4
1) Department for Gynecology and Obstetrics, Emergency Clinic Hospital Craiova
2) First Clinic of Surgery, Emergency Clinic Hospital Craiova
3) Department for Medical Genetics, University of Medicine and Pharmacy Craiova
4) Cisanello Clinic of Obstetrics and Gynecology, Pisa, Italy
ROBOTIC ASSISTED LAPAROSCOPIC MYOMECTOMY VERSUS CLASSICAL

MYOMECTOMY. A COMPARATIVE STUDY (Abstract): AIM:The objective of this study was
to perform a comparative analysis between robotic assisted laparoscopic and open approach, for
patients with uterine leiomyoma, in terms of feasibility and quality of operation (duration of
surgery, number and dimensions of extracted miomas, intraoperative blood loss). MATERIAL
AND METHODS: We conducted a retrospective study on 166 patients diagnosed with uterine
fibroids who have received conservative surgery myomectomy over a period of 3 years (20082010). 38 cases were treated by robotic assisted laparoscopic myomectomy (RALM) and 128
patients underwent open myomectomy. RESULTS: BMI was higher among patients with RALM,
27.68 vs 22.63, respectively. The average time of interventions was similar, 111.8 min for RALM.
Time for myomectomy itself was 50.39 min and 22.37 min for the uterine suture. Open
myomectomy took an average of 103 min, 21.05 min for myomectomies itself, and 21.05 min for
the uterine suture. In RALM, a higher number of myomas were extracted, but with a smaller
volume, 2.26 myomas with a volume of 57 mm3 vs 1.8 myomas with a volume of 156 mm3 for
open myomectomy. Blood loss was significantly lower during robotic-assisted laparoscopic
myomectomy compared to open myomectomy, 140 mL vs 267 mL. Patients treated by RALM
had a shorter length of stay 2.05 versus 6 days. Postoperative complications in RALM were
insignificant. In open miomectomy we noted: a case of uncontrollable intraoperative bleeding that
required the use the Gelaspon, 4 cases of postoperative febrile syndrome and one case of urinary
infection. CONCLUSIONS: RALM is feasible and allows superior results compared to open
myomectomy, with less blood loss and shorter postoperative hospital stay.
KEY WORDS: UTERINE LEIOMYOMA; MYOMECTOMY; ROBOTIC SURGERY;
DA VINCI SURGICAL SYSTEM
SHORT TITLE: Robotic myomectomy
HOW TO CITE: Sceanu SM, Surlin V, Angelescu C, Ptracu S, Georgescu I, Genazzani A. Robotic assisted
laparoscopic myomectomy versus classical myomectomy. A comparative study. Jurnalul de chirurgie (Iai). 2012; 8(4):
347-352.
INTRODUCTION
Uterine leiomyoma is the most
common benign uterine tumor that has an
incidence of approximately 40% among
women of childbearing age. This condition
is
often
diagnosed
on
symptoms
like
menometrorrhagia,
pelvic
and
Correspondence to: Dr. Sidonia Maria Sceanu
County Emergency Clinic Hospital Craiova
Str. Tabaci, no. 1, 200642, Craiova, Romania
Phone: 0040 (0) 745 75 65 90
Fax: 0040 (0) 251 53 45 23
e-mail: ssidoniam@yahoo.com
abdominal pain, back pain and a history of

infertility [1].
Most of the times, myomectomy is
performed by laparotomy, even if a long
time has passed since the demonstration of
the feasibility of minimally invasive
approach. The reason why myomectomy still
348
occurs via open surgery is that enucleation

of myomas, suturing and control of
hemostasis are very difficult to achieve by
laparoscopy [2].
Myomectomy can be more easily
performed by robotic assisted laparoscopic
approach, due to much better focus, a greater
precision and ergonomic position therefore
reducing also the fatigue [3]. Recently, it
was possible to add CT and MRI scans
(augmented and virtual reality) during
surgery for a better identification, location
and characteristics of myomas [4].
Candidates for robotic assisted
laparoscopic myomectomy are patients
presenting [5]:
1) symptomatic uterine fibroids in the
case of a patient who wants to
maintain fertility or preserve uterus;
2) no more than 6 fibroids;
3) a fibroid size not exceeding 10 cm.
The objective of this study was to
perform a comparative analysis between
robotic assisted laparoscopic and open
approach, for patients with uterine
leiomyoma, in terms of feasibility and
quality of operation (surgery time, number
and dimensions of extracted miomas,
intraoperative blood loss).
MATERIAL AND METHOD
We conducted a retrospective study on
166 patients diagnosed with uterine fibroids
who have received conservative surgery myomectomy.
We have removed from our study
patients treated with classical laparoscopic
approach because comparative studies
between laparotomy and laparoscopy or
between laparoscopy and robotic approach
have already been carried out. In addition,
most of the conservative treatment of uterine
fibroid is performed through open surgery.
Therefore, we decided to compare the
classic, most common, with the latest
surgical method that exists in the medical
world, robotic assisted surgery.
From the 166 patients included in the
study, 38 cases (22.89%) were treated by
robotic assisted laparoscopic myomectomy
Sceanu SM. et al.

(RALM), in 2008-2010, in the Cisanello
Clinic of Obstetrics and Gynecology, Pisa,
Italy (Fig. 1, 2), and 128 patients (77,1%)
underwent myomectomy by laparotomy
(ML), during the same period, in the General
Surgery Clinic, Emergency Clinic Hospital
Craiova, Romania (Fig. 3, 4).
Fig. 1 Robotic assisted laparoscopic myomectomy

intraoperative view
Fig. 2 Robotic assisted laparoscopic myomectomy

uterine suture, intraoperative view
All patients gave their informed

consent about surgery and the use of data for
scientific research.
Both interventions were performed
under general anesthesia and endotracheal
intubation. A bladder catheter was inserted
in all patients, and a uterine manipulator was
used only in patients submitted to robotic
assisted approach.
Interventions were carried out
according to the well codified techniques, in
robotic group the specimen being removed
by morcellation.
The following data were collected:
age, body mass index (BMI), personal
physiological and disease antecedents,
Robotic myomectomy
clinical and histopathological diagnosis, time
for robot deployment, duration of surgery
(total duration, duration of myomectomy
itself and of uterine suture), estimated blood
loss, intraoperative incidents, accidents,
conversions, reasons for conversions,
postoperative complications, mortality.
349
RESULTS
The patients clinical data included in
the study were reported in Table I.
The characteristics of these patients
were similar; the only parameter that
significantly differed was body mass index.
Table I Patients characteristics
ML
38
128
Age (years)
36.870.98
36.40.72
NS
Menarche (years)
12.470.1
12.50.22
NS
Births (n)
0.530.13
10.26
NS
Abortions (n)
1.580.35
1.80.66
NS
BMI (kg/m2)
27.680.43
22.630.93
0.0002
Fig. 3 Myomectomy by laparotomy

intraoperative view
NS statistically not significant (P0.05)
Table II Operative and postoperative data
Overall surgical
time (min)
Myomectomies
time (min)
Uterine suture
time (min)
Myomas (n)
Fig. 4 Myomectomy by laparotomy

uterine suture, intraoperative view
To determine whether the values

obtained had a Gaussian distribution, we
applied the Kolmogorov-Smirnov and
Shapiro-Wilk tests. When the data were not
Gaussian distributed, we applied nonparametric tests (Wilcoxon matched-pairs
signed rank test, Mann-Whitney test,
Kruskal-Wallis test, Spearman correlation
test). P values < 0.05 were considered
statistically significant. Statistical analysis
was performed using GraphPad software,
GraphPad Prism 5 InStat.
RALM
RALM
ML
P*
111.86.13
1037.27
NS
50.393.32
21.500.43
0.0005
22.371.03
21.051.68
NS
2.260.26
(range 1-7)
1.80.25
(range 1-5)
NS
Overall myomas
volume (cm3)
Preoperative Hb
(g/dL)
Postoperative
Hb (g/dL)
57.39.92
156.25.9
0.0002
12.140.14
12.080.23
NS
11.630.13
10.730.24
0.005
Hb (g/dL)
0.510.06
1.350.19
< 10-3
140.710.67
26722.95
< 10-3
Blood loss (mL)
* Mann-Whitney test ; NS statistically not significant (P0.05);

Hb hemoglobin; Hb difference between preoperative and
postoperative hemoglobin
This value was higher among patients

who have received robotic assisted
laparoscopic myomectomy, 27.68 vs 22.63
respectively (P= 0.0002).
One of the main outcomes of this
study was to analyze and compare the time
duration of the two types of surgical
350
procedures. In Table II we presented several

operative data: mean surgical time, mean
time for myomectomy and for uterine suture,
number of myomas, overall myomas
volume and data about intraoperative blood
loss.
Comparing the surgery time, we
noticed that the average time of
interventions was similar: 111.86.13
minutes for RALM and 1037.27 minutes
for ML. In RALM group the time for
myomectomy itself was 50.393.32 minutes
and 22.371.03 minutes for the uterine
suture. In ML group, myomectomy lasted
21.500.43 and uterine suture lasted
21.051.68 minutes.
We noticed that in the RALM group, a
higher number of myomas were extracted:
2.260.26 myomas vs 1.80.25. However
the
overall
myomas
volume
was
significantly higher in ML group: 57.39.92
cm3 156.25.9 cm3; P=0.0002.
Blood loss was significantly lower
during
robotic-assisted
laparoscopic
myomectomy:
140.710.67
mL
vs
26722.95 mL; P < 10-3. In this way the
postoperative Hb was higher in RALM
group (11.630.13 g/dL vs 10.730.24 g/dL;
P=0.005);
the
difference
between
preoperative and postoperative Hb ( Hb)
was lower in RALM group (0.510.06 g/dL
vs 1.350.19 g/dL; P < 10-3). We also noted
a case of intraoperative hemorrhage
controlled using Gelaspon patch.
The postoperative hospital stay was
also lower in RALM group: 2.050.04 days
vs 5.90.28 days; P < 0.0001.
In RALM group, the overall
postoperative morbidity was 2.63% (one
case of urinary infection) and no procedure
related postoperative morbidity was
reported.
In ML group, the overall postoperative
morbidity rate was 3.16%: hyperthermia
syndromes and in only one case urinary
infection was bacteriological confirmed.
DISCUSSION
Myomectomy is one of the most
common interventions used in women of
Sceanu SM. et al.

childbearing potential following a diagnosis
of uterine fibroids who want to preserve
their fertility.
Considering this reason, quality and
results of this technique must be flawless
and immediate and remote complications
should be minimal [2]. In this study we
aimed to analyze the advantages and
feasibility
of
robotic
myomectomy
compared
with
standard
treatment,
laparotomy.
The first aspect analyzed was the
overall surgical time and we noticed that
classical intervention was, in average, only 8
minutes shorter than the assisted robotic
myomectomy; however the duration of
myomectomy itself doubled in the case of
computer assisted interventions.
In conventional myomectomy, time is
lost with opening and closing of the
peritoneal cavity and control of hemostasis.
Longer duration for robotic assisted
myomectomy is due to the fact that patients
in that group presented a greater number of
fibroids than those in the laparotomy
myomectomy group.
Similar time between the two
interventions is explained by the fact that
during a robotic assisted surgery, a longer
time is attributed to the deployment and
installation of the robot and changing
forceps.
In its analysis, Gargiulo et al, in 2012,
showed a time of 195 minutes for a robotic
myomectomy [6]. Approximately the same
results are reported by Barakat et al, with a
time of 181 minutes for robotic
myomectomy and respectively, 126 minutes
for open myomectomy, [5].
We believe that a difference of 8
minutes during the whole intervention, and 1
minute between the times for uterine suture
is minimal and demonstrates that robotic
assisted surgery is not necessarily associated
with an extended operating time, compared
to laparotomy.
The number of extracted myomas
during laparotomy interventions was of 1.8,
with a total volume of 156 cm3, and during
robotics myomectomy 2.26, with a volume
Robotic myomectomy
of 57cm3. Barakat et al, in his comparative
analysis, similar to ours, indicates uterine
volume similar in the two groups, of 223
cm3 for robotic myomectomy and 263 cm3
for open myomectomy [5]. Roopina Sangha
et al, in another study performed in
2010, indicated a dimension of extracted
myomas in robotic interventions greater than
7.6 cm [7].
Thus, we can observe that computer
assisted myomectomy is more suitable in
case of a larger number of myomas, but with
a
smaller
size,
while
laparotomy
myomectomy is more suitable for myomas
with larger size.
The difference in blood loss between
the two types of interventions was greater
than 100 mL, with a difference in
postoperative hemoglobin of about one unit.
We have found in other studies values
similar to ours. In his analysis, Bedient et al,
in 2009 [8], reported a blood loss of
approximately 100 mL, and Barakat et al, in
2011 [5], in a comparative study, reported
the following results: 200 mL for
laparotomy myomectomy and 150 mL for
robotic myomectomy. Also, a comparative
analysis was performed by Ranisavljevic et
al, in 2012 reported a blood loss of 397 mL
in laparotomy interventions and 387 mL in
robotic assisted interventions [9].
The length of hospital stay was 3 times
greater for open myomectomy, and
implicitly the in-hospital costs. In his study,
Ranisavljevic et al, in 2012, indicated a
duration of hospitalization of 7.2 days for
open myomectomy, and 3.9 days for patients
who received robotic assisted treatment [9].
At the same time, Barakat et al. reported an
in-hospital stay of one day for robotic
assisted myomectomy and 3 days for
laparotomy myomectomy [5].
From the point of view of
intraoperative
and
postoperative
complications,
we
noticed
more
complications in the group of patients who
suffered laparotomy interventions.
From these results we concluded that
robotic assisted laparoscopic treatment
comes with superior results compared to
351
open myomectomy, with less blood loss and

a shorter length of hospital stay.
Morbidity of patients who received
robotic assisted laparoscopic was lower
compared to open-surgery patients, due to
much lower postoperative pain, minimized
incidence of postoperative anemia and rapid
reintegration into society.
Even if the cost of robotic assisted
surgery is higher compared to open, superior
results and conditions for surgery should be
sufficient to determine more medical centers
to buy such equipment and train their own
teams in this technique.
However, we are still pioneering in
this technique and it is necessary to publish
many more similar comparative studies, in
order to demonstrate and highlight the
superiority of robotic surgery over
laparotomy.
ACKNOWLEDGEMENTS
The first author was supported by the
POSDRU/88/1.5/S/52826 grant entitled
Development of PhD Schools by offering
scholarships to full-time PhD students.
During PhD she was enrolled for four
months in the Santa Chiara Hospital under
direct supervision of Professor Andrea
Genazzani.
CONFLICT OF INTERESTS
None to declare.
REFERENCES
1. Holloway RW, Patel SD, Ahmad S. Robotic
surgery in gynecology. Scandinavian Journal
of Surgery. 2009; 98: 96-109.
2. Senapati S, Advincula AP. Surgical tehniques:
robot-assisted laparoscopic myomectomy with
the da Vinci Surgical System. J Robotic Surg.
2007; 1: 69-74.
3. Lobontiu A, Loisance D. Chirurgia robotic:
viitor la present. 2006. www.emedic.ro;
available online at: http://www.emedic.ro
/Articole/15.htm
4. Soler L, Forest C, Nicolau S et al. Computerassisted operative procedure:from preoperative
planning to simulation. Eur Clinics Obstet
Gynaecol. 2007; 2: 201-208.
5. Barakat EE, Bedaiwy MA, Zimberg S, Nutter
B, Nosseir M, Falcone T. Robotic-assisted,
laparoscopic, and abdominal myomectomy: a
352
comparison of surgical outcomes. Obstet

Gynecol. 2011; 117(2 Pt 1): 256-265.
6. Gargiulo AR, Srouji SS, Missmer SA, Correia
KF, Vellinga T, Einarsson JI. Robot-assisted
laparoscopic myomectomy compared with
standard laparoscopic myomectomy. Obstet
Gynecol. 2012; 120(2 Pt 1): 284-291.
7. Sangha R, Eisenstein DI, George A, Munkarah
A, Wegienka G. Surgical outcomes for
robotic-assisted laparoscopic myomectomy
compared to abdominal myomectomy. J
Robotic Surg. 2010; 4(4): 229233.
Sceanu SM. et al.

8. Bedient CE, Magrina JF, Noble BN, Kho RM.
Comparison of robotic and laparoscopic
myomectomy. Am J Obstet Gynecol. 2009.
201(6): 566.e1-5.
9. Ranisavljevic N, Mercier G, Masia F, Mares P,
De Tayrac R, Triopon G. Robot-assisted
laparoscopic myomectomy: Comparison with
abdominal myomectomy. J Gynecol Obstet
Biol Reprod (Paris). 2012; 41(5): 439-444.
ARTICOLE ORIGINALE
353
Jurnalul de Chirurgie (Iai), 2012, Vol. 8, Nr.4
TULBURRILE COGNITIVE POSTOPERATORII I

NECESITATEA ANALGOSEDRII
Oana-Diana Marcoci 1, , Maria Vrabete 2
1) Laboratorul de sntate mintal Tg. Jiu
2) Clinica de Chirurgie Plastic i Reconstructiv,
Universitatea de Medicin i Farmacie Craiova
POSTOPERATIVE
COGNITIVE
DISFUNCTIONS
AND
NECESSITY
OF
ANALGOSEDATION (Abstract) : We observed and noted clinical symptoms, and used screenig
tests as tools for evaluating the values of pain and neuropsychiatric changes. We introduced as
instrument of measurements: rating numerologic scale of pain, Ramsay Sedation Scale (RSS),
criteria of delirium diagnose applied in early period of arrousal (20 minutes - 4 hours) at the
moment T1, at 4-7 hours: complete arrousal (T2) and at 72 hours (T3). We tried to correlate the
results of answers to these questionnaires to EEG aspects, auditory evoked potentials (AEP), with
morphopathologic and biochemical aspects characteristic for the evolution toward wounds
healing. We selected 100 patients from the Plastic and Recontructive Surgery Department. We
associated to those moments the functional values: arterial pressure, central pulse, diuresis,
respiratory frequency, (to evaluate the autonomic nervous sistem implication) and laboratory
parameters oxidants/antioxidant values (free O2 radicals as peroxides, NO, capacity antioxidant of
plasma (CAO) and superoxide dismutase (SOD), for evaluating the implication of oxidative stress
in postoperative evolution. All values were compared among them and correlated with
morphopathological aspects from optic microscopy, from biopsies prelevated immediately after
the postoperative period and at the end of postoperative wounds healing. The most important
conclusion of our study was that: appropriate information of patients about surgery and anesthesia
reduces preoperative anxiety, post-operative pain and hospital stay length.
KEY WORDS: PAIN; ANXIETY; DELIRIUM; POCD; ANALGOSEDATION
SHORT TITLE: Analgosedarea
Anaglosedation
HOW TO CITE: Marcoci DO, Vrabete M. [Postoperative cognitive disfunctions and necessity of analgosedation].
INTRODUCERE
n ultimii ani, au fost folosite scorurile,
scalele, indicatorii etc. ca instrumente de
evaluare ale strii evolutive, a pacienilor
critici sau a pacienilor chirurgicali (n
perioada peri- i postoperatorie). n perioada
postoperatorie
imediat
se
remarc
reducerea
memoriei
i
concentrrii,
modificri de personalitate, tulburri
cognitive i/sau instabilitate emoional.
Alterarea strii psihice, postoperator, a
fost sesizat de mai muli autori, care
nsumnd totalitatea perturbrilor, le-au
ncadrat n entitatea patologic, recunoscut
de medicii anesteziologi, sub denumirea de :

disfuncie
cognitiv
postoperatorie
(Postoperative Cognitive Dysfunction POCD).
Dezvoltarea POCD, n perioada
postoperatorie
imediat,
prelungete
internarea i mrete costurile spitalizrii; de
aceea, cercetrile actuale sunt orientate spre
descoperirea factorilor de risc i a
strategiilor curativo-profilactice, necesare
anihilrii apariiei complicaiilor i/sau
cronicizrii unor boli psihice [1].
Nevoia elaborrii acestor terapii este
dovedit
de
existena
Institutului

Correspondence to: Dr. Oana-Diana Marcoci
Spitalul Judeean de Urgen Tg-Jiu, Laboratorul de Sntate Mintal
Str. Progresului, nr.18, 210218, Tg. Jiu, Romania
Tel: 0040 (0) 722 87 18 73
e-mail: dianaomd@yahoo.com
354
internaional de studiu al disfunctiei

cognitive postoperatorii, care testeaz terapii
ale funciilor mentale, alterate postoperator
(manifestate ca delir i/sau alterri
cognitive).
Manifestrile POCD sunt: pierderea
memoriei, perturbri psihomotorii, demena,
delirul, depresia, tulburrile de coordonare i
alterarea nivelului cognitiv [2].
Modificrile cognitive sunt tranzitorii,
iar revinerea la normal, se produce n cteva
zile dup operaie [3].
POCD
este
cauza
apariiei
complicaiilor postoperatorii i a instalrii
unor disabiliti pe o perioad ndelungat.
International Study of Postoperative
Cognitive
Dysfunction
(ISPOCD)
a
confirmat c POCD se asociaz cu reducerea
activitii zilnice, creterea dependenei de
suport social i creterea mortalitii.
n lucrrile lui Yildizelli B. [4] se
prezint ca elemente epidemiologice decesul
a 70% dintre pacienii cu POCD, dup 5 ani
de la intervenia chirurgical fa de doar
35% la pacienii, care nu au avut astfel de
manifestri.
Ali autori susin c naintarea n vrst
este asociat cu astfel de manifestri datorit
faptului c pacienii peste 60 de ani pot fi
supui la mai multe anestezii, odat cu
trecerea anilor [5].
Motivaia prezentului studiu este de a
observa pacienii operai (fr tulburri de
personalitate, n perioada preoperatorie) i a
reaciilor lor psihologice fa de durere i
fa de actul anestezico-chirurgical, n
primele 72 de ore postoperator, pentru
stabilirea unor scheme de algosedare
adecvate, individualizate.
MATERIAL I METOD
Am selectat 100 de pacieni din secia
de Chirurgie Plastic i Reparatorie, avnd
acceptul Comisiei de Etic a Universitii de
Medicin
i
Farmcie
Craiova
i
consimmntul informat al pacienilor.
Criteriile de includere n studiu au fost:
absena comorbiditilor cronice, de tip
diabet zaharat, ateroscleroz, HTA; absena
medicaiei antipsihotice sau a unor boli
Marcoci DO. et al.

psihice, n antecedente; absena durerii
cronice (hiperalgezie, allodinie) i a abuzului
de medicamente analgetice.
n funcie de diagnostic, tipul i durata
interveniei chirurgicale i a anesteziei,
pacienii au fost mprii n 3 grupe:
- Grup A (grup martor):
- 20 cazuri (20%);
- Interventia chirurgical: boala
Dupuytren;
- Durata interveniei: 40- 60 minute;
- Tip anestezie: local.
- Grup B:
- 40 cazuri (40%);
- Intervenia chirurgical: refacerea
structurilor
neuro-tendinoase
secundar traumatismelor minii;
- Durata
interveniei:
60-120
minute;
- Tip anestezie: general.
- Grup C:
- 40 cazuri (40%);
- Intervenia chirurgical: restaurare
de nervi, oase, tendoane, muchi i
pat vascular;
- Durata
interveniei:
120-180
minute;
- Tip anestezie: general.
Am aplicat acelai tip de anestezie
general, cu intubaie oro-traheal.
Anestezia general este considerat i
chiar definit ca o com programat
medicamentos pentru obinerea strii de
incontien (confortul pacientului) i
reducerea activitii micrilor musculare
(confortul chirurgului).
Am
folosit
tehnica
anesteziei
balansate, reprezentat de: combinarea
substanelor anestezice pentru:
- reducerea anxietii - cu anxiolitice:
midazolam 6,93,3 mg/kgc;
- inducerea somnului hipnoza: cu
thiopental sodic: 302185 g/Kgc;
- inducerea strii de incontien:
propofol 1812 g/Kgc/min;
- asigurarea analgeziei: fentanyl 9268
g/Kgc;
- asigurarea
relaxrii
musculare:
pancuronium: 102,5 g/Kgc.
Analgosedarea
Meninerea anesteziei chirurgicale s-a
realizat cu isoflurane, propofol, fentanyl,
pancuronium, n funcie de durata operaiei,
prin repetarea a din doza de inducie.
Cu ajutorul acestor substane s-a
obinut patrulaterul anestezic analgezie,
hipnoz, efect antioc i relaxare,
caracteristic, anesteziei adecvate.
Au fost analizai diferii parametri
demografici (vrst, mediu de provenien,
condiii de via, educaie) i anestezici
(calitatea anesteziei, a trezirii din anestezie,
a analgo-sedrii, din perioada peri- i
postoperatorie imediat, scorul bispectral
(BIS) i scala de sedare Ramsay (RSS)).
Au fost definii urmtoarele intervale
de timp: T1 20 min 4 h postoperator; T2
4 7 h postoperator; T3 72 h postoperator.
Scorul bispectral (BIS) este un indice
complex, care se exprim cantitativ pe o
scal de la 0 la 100, n concordan cu
diferite frecvene ale semnalului EEG.
Frecvenele nalte ale undelor EEG
corespund cu valorile mari ale BIS i reflect
o bun integrare cortical, fenomen prezent
n strile de contien. Creterea
aprofundrii anesteziei const n scderea
integrrii corticale i scderea scorului BIS.
Valorile BIS cuprinse ntre 4055 sunt
caracteristice anesteziei generale [6].
Scala de sedare Ramsay (RSS)
cuprinde 6 niveluri: 1) pacient treaz, anxios
i agitat sau nelinitit, ori amndou; 2)
pacient treaz, cooperant, orientat i linitit;
3) pacient treaz care rspunde doar la
comenzi; 4) pacient adormit, rspuns vioi,
rapid, la stimularea luminoas sau stimuli
auditivi puternici; 5) pacient adormit,
rspuns greoi la stimularea luminoas i la
stimulii auditivi puternici; 6) pacient adormit
nu rspunde la stimularea luminoas i nici
la stimulii auditivi puternici. Valoarea
normala a scorului RSS este de 4.
De asemenea, a fost notat evoluia
postoperatorie a plgii operatorii.
REZULTATE
Trezirea foarte rapid s-a remarcat la
majoritatea pacienilor, la care durata
interveniei nu a depit 90 de minute.
355
Durata analgeziei, restant postanestezic, a fost subliniat de lipsa nevoii de

administrare a analgeticelor majore, dup
trezire. La aceti pacieni medicaia antiinflamatorie aplicat local sau/i n circulaia
sistemic, prin abord venos, a avut efecte
benefice, asupra vindecrii eficiente a
plgilor operatorii.
Fig. 1 Distribuia cazurilor n funcie de apariia

durerii centrale n timpul revenirii din anestezie
2=48,582; P (2)= 2.82 x10-11; P (test Fisher) < 10-4
Fig. 2 Distribuia cazurilor n funcie de valoarea

scorului RSS i timpul revenirii din anestezie
2=14,117; P(2)= 0,00086; P(test Fisher)=0,0002
Fig. 3 Distribuia cazurilor n funcie de corelaia

dintre scorul bispectral (BIS>80) i timpul revenirii
din anestezie
2=22,746; P(2)= 0,00185; P(test Fisher)=0,0001
356
A fost constatat o legtur puternic

ntre timpul scurs de la nceputul revenirii
din anestezie i valoarea RSS obinut pe
cele doua loturi de pacieni (B i repsectiv,
C) (2=14,117; P(2)= 0,00086; P(test
Fisher)=0,0002).
S-a notat de asemenea, o corelaie ntre
scorul bispectral (BIS) i timpul trecut de la
nceputul revenirii din anestezie, la pacienii
din loturile B i C (2=22,746; P(2)=
0,00185; P(test Fisher)=0,0001)) (Fig. 3).
Vindecarea plgilor postoperatorii
Pentru lotul martor (grup A) la toi
pacienii s-a notat o vindecare eficient
(cicatrice minim, recuperare funcionalconform etapelor vindecrii plgilor) n 7-10
zile.
Pentru pacienii din grupul B evoluia
postoperatorie a fost bun cu externare la 21
de zile i kinetoterapie pentru recuperarea
funcional timp de 6 sptmni dup
intervenia chirurgical.
Pentru pacienii din grupul C, 20%
(n=20) au avut o evoluie bun cu externare
dup 21 zile postoperator. Complicaii
infecioase au aprut la 15% (n=15), ce au
impus o spitalizare prelungit, externarea
fiind dup 62 de zile. n acelai lot, s-au
practicat diferite reintervenii la 2% (n=2)
ntre 21 i 30 zile postoperator. n 3% din
cazuri (n=3) s-au practicat amputaii ale
falangelor, durata tratamentului fiind de
peste 3 luni.
Efectuarea acestui studiu complex, ale
crui rezultate ne-au evideniat, cum era de
ateptat, o foarte mare variabiltate a
reactivitii biologice i comportamentale a
pacientului chirurgical [7], ne-a permis s
identificm i s definim 6 grupe, de
reactivizi
neuro-psihice,
bine
individualizate:
- 60% pacieni, care nu i-au amintit
nimic despre perioada intraoperatorie
i nici din perioada de trezire imediat
(T1). Analgezia acestora s-a meninut,
n toat perioada T1, cu sublinierea c
am administrat, n dou reprize,
midazolam: 2,51,8 mg [8].
Marcoci DO. et al.

- 15% dintre pacieni au avut comaruri,
asociate cu dureri minore, dar
supradimensionate,
ca
exprimare
subiectiv. Pentru acest grup, s-a
administrat: midazolam sau diazepam
i meperidin, la cererea pacientului
[9].
- 10% dintre pacieni au avut fobii fa
de:
perfuzii,
administrarea
de
medicamente, fa de spital i fa de
personalul
intraspitalicesc
(n
perioadele T2-T3). Am apreciat c
mijlocul cel mai eficient de tratament,
n aceste cazuri , este discuia cu alte
persoane care au trecut printr-o
procedur chirurgical, asemntoare.
- 10% dintre pacieni au rmas cu
amintirea
sondei
endotraheale,
alctuind grupul cu experien de
rechemare / trezire [10,11]. Pentru
acetia s-a administrat meperidin, n
doze dependente de nevoile lor, n
legtur cu durerea, exacerbat
subiectiv i cu apariia frisonului,
imediat la T1 i n T2.
- 3% din cazuri au prezentat halucinaii,
dintre care 2% au avut tentative
suicidare; aceti pacieni au fost
transfera n secia de neuropsihiatrie.
- 2% dintre pacieni i-au manifestat,
anxietatea preexistent, nu doar fa de
actul anestezico-chirurgical ci i fa
de vindecare, de funcionalitatea
segmentului operat i fa de viitor.
Pentru
aceast
categorie
s-au
administrat substane anxiolitice [12].
DISCUII
Durerea este o percepie senzorial,
care este intricat cu starea emoional a
subiectului. Durerea reflect prezena unor
perturbri locale ale homeostaziei O2, de
aceea administrarea unor concentraii
crescute de O2, n perioada postoperatorie
reduce intensitatea durerii, posibil, datorit
reducerii eliberrii de substan P, metod,
prin care se influeneaz cile inhibitorii ale
durerii, la nivelul nervilor periferici [13].
Analgosedarea
n mod asemntor, o migren nsoit
de vomismente nu necesit, n primul rnd,
terapia analgetic opioid. n afara
demerolului injectabil, recomandat pentru
controlul migrenei se poate asigura, o bun
hidratare, prevenirea strilor hipoglicemice /
hiperglicemice, a deplsrilor rapide ale
curbelor insulinei, eliminarea alimentaiei
alergogene i controlul vasospasmului, prin
metode de autoreglare, care s asigure
restaurarea homeostaziei O2, local sau
sistemic [13].
Controlul durerii prin respiraie, este o
metod energetic, prin care ciclul respirator
este modificat, n sensul creterii duratei
expirului [14]. Se subliniaz c terapiile cu
O2 administrat direct, pe masc sau hiperbar,
au efecte benefice, n controlul cefaleelor i
migrenelor. ntr-un alt experiment, respiraia
n 100% oxigen timp de 15 minute sau mai
puin, n timpul perioadelor de cefalee
controleaz sau reduce semnificativ durerea
cronic sau atacul dureros, la toi subiecii.
Beneficiile algosedrii se reflect n
efectele
favorabile
ale
rspunsului
neuroendocrin, eliberarea, n proporii
adecvate a hormonilor: adrenocorticotrop
(ACTH), prolactin, hormon de cretere,
vasopresin,
cortizol,
aldosteron
i
catecolamine, glucagon i insulinosupresie.
Activarea
axei
hipofizo-corticosuprarenale-pancreas, amplific rspunsul
inflamator, evideniat de creterea nivelului
citokinelor
proinflamatorii,
prostaglandinelor i substanei P eliberate,
care acioneaz n cerc vicios, susinnd
durerea si condiiile de apariie ale
complicaiilor infecioase [15].
Intensitatea
stressului
(traumei)
chirugical, postoperator este apreciat,
evalund durerea periferic prin analizarea
aspectelor: clinic local, morfopatologic i
modificrilor
metabolico-funcionale.
Aspectul
psiho-afectiv
al
durerii
caracterizeaz durerea central i se
datorete
sensibilitii
pacienilor
i
reactivitii lor, la stressul anestezicochirurgical [16].
Deoarece rspunsul dureros este
extrem de durere diferit i individualizat,
357
strategiile de realizare a analgeziei sunt i ele

foarte difereniate / individualizate [7].
Durerea asociat cu hiperreactivitatea
simpatic, sugereaz necesitatea scderii
tonusului simptatic i a consumului de
oxigen pentru stabilizarea hemodinamic a
pacientului i pentru a trata agitaia psihomotorie. Analgosedarea i anestezia
adecvat, protejeaz pacientul mpotriva
stressului postoperator i menin anxioliza,
somnul i amnezia [15,17].
Benzodiazepinele
folosite
ca
anxiolitice i sedative, se leag de receptorii
de pe macrofage i inhib capacitatea lor de
a produce IL-1, IL-6 i TNF alfa [18,19].
Suplimentarea acestui tip de substane,
asociat cu administrarea de propofol, poate
avea un important efect antioxidant [20].
CONCLUZII
Asocierea analgeziei cu sedare
protejeaz pacienii fa de stimulii toxici,
rezultai din catabolismul local, ntreine
anxioliza, somnul i amnezia i scade
tonusul simpatic, meninnd stabilitatea
hemodinamic i consumul redus, de O2.
Monitorizarea BIS se coreleaz cu
sedarea clinica si poate servi ca instrument
auxiliar pentru cuantificarea profunzimii
sedrii si analgeziei,servind la stabilirea
medicaiei adecvate.
Este
necesar
alegerea
unor
medicamente analgo-sedative, sigure, care s
nu aib efecte nefavorabile, asupra
sistemului cardio-vascular, respirator, asupra
metabolismelor i s nu exagereze reaciile
de hipersensibilitate, eliberarea de histamin
i/sau durerea, la locul de puncie venoas.
interese.
BIBLIOGRAFIE
1. Phillips-Bute B, Mathew JP, Blumenthal JA et
al. Association of neurocognitive function and
quality of life 1 year after coronary artery
bypass graft (CABG) surgery. Psychosom
Med. 2006; 68(3): 369-375.
2. Raja PV, Blumenthal JA, Doraiswamy P.
Cognitive deficits following coronary artery
bypass grafting: prevalence, prognosis, and
358
therapeutic strategies. CNS Spectrums. 2004;

9: 763772.
3. Ahlgren E, Lundqvist A, Nordlund A, Aren C,
Rutberg H. Neurocognitive impairment and
driving performance after coronary artery
bypass surgery. European Journal of CardioThoracic Surgery. 2003; 23: 334340.
4. Yildizeli B, Ozyurtkan MO, Batirel HF.
Factors associated with postoperative delirium
after thoracic surgery. Ann Thorac Surg. 2005;
79(3): 1004-1009.
5. Morimoto Y, Yoshimura M, Utada K,
Setoyama K, Matsumoto M, Sakabe T.
Prediction of postoperative delirium after
abdominal surgery in the elderly. J Anesth.
2009; 23(1): 51-56.
6. Vernon JM, Lang E, Sebel PS, Manberg P.
Prediction of movement using bispectral
electroencephalographic
analysis
during
propofol/alfentanil or isoflurane/alfentanil
anesthesia. Anesth Analg. 1995; 80(4): 780785.
7. Hall-Lord ML, Larsson G, Steen B. Pain and
distress among elderly intensive care unit
patients: Comparison of patients experiences
and nurses assessments. Heart Lung. 1998; 27:
123132.
8. Fujisawa T, Takuma S, Koseki H, et al.
Recovery of intenional dynamic balance
function after intravenous sedation with
midazolam in young and elderly subjects. Eur
J Anaesth. 2006; 23: 422-425.
9. Gommers D, Bakker J. Medication for
analgesia and sedation in the intensive care
unit: an overview. Crit Care. 2008; 12: S4.
10. Cigada M, Pezzi A, Di Mauro P et al. Sedation
in the critically ill ventilated patient: possible
role of enteral drugs. Intensive Care Med.
2005; 31: 482-486.
11. Fraser GL, Prato S, Berthiaume D, et al.
Evaluation of agitation in ICU patients:
Incidence, severity, and treatment in the young
versus the elderly. Pharmacotherapy. 2000;
20: 7582.
Marcoci DO. et al.

12. Van Houdenhove B, Onghena P. Pain and
depression. In, Robertson MM, Katona C,
editors, Depression and physical illness. New
York: John Wiley &Sons LTD; 1997.
13. Casai A, Fanelli G, Pietropaoli P et al.
Continuous monitoring of cerebral oxygen
saturation in surgery minimizes brain exposure
to potenial hypoxia. Anesth Analg. 2005; 101:
740747.
14. Ali M. Nature's Preoccupation With
Complementarity and Contrariety, The
Principles and Practice of Integrative
Medicine Volume II. Washington DC, New
York: Capital University Press and Canary 21;
2001.
15. Jacobi J, Fraser GL, Coursin DB et al. Clinical
practice guidelines for the sustained use of
sedatives and analgesics in the critically ill
adult. Crit Care Med. 2002; 30: 119-141.
16. .Manning S. The Brain-Body connection and
the relationship between depression and pain.
Medscape. December 17, 2002.
17. Sessler CN, Grap MJ, Brophy GM.
Multidisciplinary management of sedation and
analgesia in critical care. Semin Respir Crit
Care Med. 2001; 22: 211-225.
18. Cibelli M. Microglia and astrocyte activation
in the hippocampus in a model of orthopedic
surgery in adult mice. Anesthesiology. 2007;
107: A1557.
19. Wan Y, Xu J, Ma D et al. Postoperative
impairment of cognitive function in rats. A
possible
role
for
cytokine-mediated
inflammation
in
the
hippocampus.
Anesthesiology. 2007; 106(3): 436443.
20. Zdrehu C. Fiziologia cerebral. In,
Acalovschi I, editor, Anestezie clinic. Cluj
Napoca: Ed. 44 Clussium; 2005. p. 39-58
ORIGINAL PAPERS
359
PANCREATIC PSEUDOCYST
ACTUAL THERAPEUTIC OPTIONS
Departament of Surgery, University of Medicine and Pharmacy Craiova
First Surgical Clinic, Emergency County Hospital Craiova
PANCREATIC PSEUDOCYST ACTUAL THERAPEUTIC OPTIONS (Abstract):
BACKGROUND: Pancreatic pseudocyst (PP) is one of the most frequent complications of acute
and chronic pancreatitis; patients with these disorders often benefit from interventional treatment,
or minimally invasive surgery. Progress of new minimally invasive interventional techniques
(endoscopic internal drainage, external drainage guided by ultrasound / CT / laparoscopic surgery)
for the treatment of pancreatic pseudocyst formed the basis for the arguments of this article.
AIM: The purpose of this article is to analyze and highlight the above views on a series of
consecutive cases of pancreatic pseudocyst. MATERIAL AND METHOD: We studied 46
patients diagnosed with pancreatic pseudocyst in a period of 6 years, from 2006 to 2011.
RESULTS: 26 patients (56.52%) were treated conservatively and followed periodically by
imaging (ultrasound, CT); 20 patients (43.47%) required therapeutic attitude because of
symptomatic PP or lack of tendency to resorption (increase in size at successive examinations). 2
patients (4.34%) were drained externally under ultrasound/CT guidance. 10 patients (21.7%) were
submitted to endoscopic drainage as follows: 2 transpapillary drainage, 5 transgastric and 3
transduodenal drainage, respectively. Surgical interventions were performed in 8 patients
(17.39%), 4 cysto-gastrostomy, 3 cysto-jejunostomy and 3 external drainages (2 patients with dual
localization of PP). We noted a postoperative complication after cysto-jejunostomy: upper
gastrointestinal bleeding at 6th postoperative day from splenic artery hemorrhage, inside the PP. It
was diagnosed by angiography and re-operation was required for hemostasis. Data from the
literature concerning the therapeutic protocol in pancreatic pseudocyst ere reviewed.
CONCLUSION: The PP management depends on PP site, size and matureness and is
individualized for each case. Different treatment options are available: external drainage under CT
/ ultrasound guidance, endoscopic drainage, surgical procedures. To minimize the postoperative
morbidity rate, surgical internal drainage is addressed to PP mature over 6 weeks from the last
episode of acute pancreatitis.
KEY WORDS: PANCREATIC PSEUDOCYST; PANCREATITIS
SHORT TITLE: Pancreatic pseudocyst
HOW TO CITE: Sndulescu S, urlin V, Busuioc I, Cartu D, Georgescu E, Georgescu I. [Pancreatic pseudocyst actual
therapeutic options] Jurnalul de chirurgie (Iai). 2012; 8(4): 359-364.
INTRODUCTION
Pancreatic pseudocyst (PP) is a fluid
collection intra or peripancreatic without
epithelial coating containing pancreatic juice
rich in proteolytic emzimes without clinical
signs of infection. It is bordered by the
scleroinflamatory tissue from surrounding
anatomical structures, the wall being formed
Correspondence to: Sarmis Sndulescu, MD
First Surgical Unit, Emergency County Hospital Craiova
Clinica I Chirurgie Craiova
Str. Tabaci No. 1 Craiova, Romania
Phone / Fax: 0040 (0) 251 50 22 85
E-mail: ssarmis@yahoo.com
of a fibrous and granulation tissue derived

from parietal and visceral peritoneum.
Pancreatic pseudocyst is one of the
most frequent complications of acute and
chronic pancreatitis, patients with these
disorders often benefit from interventional
treatment, or minimally invasive surgery.
Diagnosis of pancreatic pseudocyst has
360
become much easier thanks to advanced

imaging techniques and due to improved
prognosis of patients with acute pancreatitis
by standardizing to some extent the
treatment of this abdominal drama.
Progress of new minimally invasive
interventional
techniques
(endoscopic
internal drainage, external drainage guided
by ultrasound/ CT/laparoscopic surgery) for
the treatment of pancreatic pseudocyst
formed the basis for the arguments of this
article.
The purpose of this article is to
analyze and highlight the above views on a
series of consecutive cases of pancreatic
pseudocyst.
MATERIAL AND METHOD
We studied 46 patients diagnosed with
pancreatic pseudocyst in a period of 6 years,
from 2006 to 2011. These cases represent
evolutive complications of 172 cases of
acute pancreatitis, admitted, treated and
long-term followed in this period in our
clinic. We analyzed the types of procedures
in function of imagistic data and the
immediate postoperative outcome of each
procedure. Necessary data were collected
from the general clinical observation charts
of patients.
RESULTS
Reporting the number of cases of PP to
the number of cases of AP results in a
proportion of 26.7% as risk for a PP. Median
age at diagnosis was 41 years, with a range
between 22 and 63 years. The man to
women ratio was 2.
Etiology of acute pancreatitis in cases
complicated by PP was:
- alcoholic: 19 patients (41.30%);
- biliary: 14 cases (30.43%);
- metabolic: 2 patients (4.34%);
- idiopathic: 11 cases (23.91%).
In about half of the patients (47.8%,
n=22) asymptomatic pseudocysts were
diagnosed on the occasion of periodic
imaging checks after the episode of acute
pancreatitis. The other patients (52.2%,
n=24) experienced different symptoms; the
Sndulescu S. et al.
most frequent were: abdominal pain
(41.30%, n=19), nausea and vomiting
(34.78%, n=16), palpable mass in the upper
abdomen (23.91%, n=11), jaundice (8.69%,
n=4). It was also noted other less frequent
symptoms: weight loss, flatulence, signs of
upper digestive tract hemorrhage, anemia,
fever and chills.
Blood amylase level was increased in
only 4 patients.
Different imagery exams were
performed to confirm the diagnosis:
abdominal ultrasound (100%; n=46), CT
(91.3%, n=42), endoscopic ultrasound exam
(34.7%, n=16), endoscopic retrograde
cholangiopancreatography (8.69%, n=4).
Imaging work-up identified in 5 patients
suggestive signs for chronic pancreatitis.
Morphologically, in 39 patients
(84.78%) PP was unique and in 7 cases
(15.21%) multiple. Dimensions of PP ranged
from 1.5 to 22 cm, 26 of them with
dimensions of 6 cm.
The PP site was:
- pancreatic head: 30.4% (n=14);
- pancreatic body: 34.7% (n=16);
- pancreatic tail: 19.5% (n=9).
Of the 46 patients diagnosed with PP,
26 patients (56.52%) were treated
conservatively and followed-up periodically
by imagery exams (ultrasound, CT).
From these, only 22 had a pseudocyst
size less than 6 cm; the other 4 have had a
PP larger than 6 cm, but were
oligosymptomatic and diagnosed at 1 month
after the onset of acute pancreatitis and
spontaneous resorption was taken into
account. Patients received symptomatic
treatment and broad-spectrum antibiotics
prophylaxis.
20
patients
(43.47%)
required
therapeutic attitude because of symptomatic
PP or lack of tendency of resorption
(increase in size at successive examinations).
Two patients (4.34%) were externally
drained under ultrasound/CT guidance. In
one case there was a prolonged drainage
followed by a pancreatic fistula. Drainage
decreased progressively after 6 weeks after
surgery, and subsequently closed.
Pancreatic pseudocyst
Ten patients (21.7%) were submitted
to endoscopic drainage as follows: 2
transpapillary
drainage,
5
and
3
transduodenal and transgastric drainage,
respectively. Endoscopic drainage was
effective in decreasing the size of PP leaks
through the stent placed inside the cyst. To
the other 6 patients endoscopic approach
was tempted but it failed for different
reasons: technical, collateral circulation,
inhomogeneous
content,
thick
wall,
significant bleeding at puncture site. One
patient required emergency surgery due to
hemorrhage.
Surgical procedures were performed in
8 patients (17.39%): 4 cysto-gastrostomy, 3
cysto-jejunostomy and 3 external drainages
(2 patients with double localization of PP).
We have noted a complication after
cysto-jejunostomy: upper gastrointestinal
bleeding at 6th postoperative day because of
an erosion of the splenic artery inside the PP.
It was diagnosed by angiography and needed
surgical re-intervention for hemostasis.
In other 2 patients who have
undergone external drainage of PP
(immature
wall
not
adequate
for
anastomosis) a pancreatic fistula followed
with prolonged external drainage (50 and 62
days respectively.
The
postoperative
course
was
uneventful for the other patients.
DISCUSSIONS
According to Atlanta classification [1],
there are 4 distinct concepts that define
pancreatic collections:
- acute fluid collections occurring early
in evolution of PA, without welldefined wall;
- acute pancreatic pseudocyst, which is a
well established wall of granulation
tissue and fibrosis, which occurs in 4-6
weeks after the onset of PA;
- chronic pseudocyst occurring in the
evolution of chronic pancreatitis;
- pancreatic abscess, infection occurring
through one of the three collections.
Recently described, a new entity in the
classification of pancreatic collections,
361
namely walled-off pancreatic necrosis [2]

tends to replace the term pancreatic abscess
or infected pancreatic collection, either focal
pancreatic necrosis or pancreatic pseudocyst.
An acute pancreatic pseudocyst is
defined as a fluid collection containing
pancreatic juice, delimited by a fibrous wall
of granulation tissue without epithelium
consequence of acute pancreatitis or
pancreatic trauma. Chronic pancreatic
pseudocyst is a fluid collection of pancreatic
juice enclosed by a wall and fibrous
granulation tissue that occurs in the
development of chronic pancreatitis in the
absence of an episode of acute pancreatitis.
In general, acute and chronic pseudocysts
have a different natural history, although
many studies do not distinguish acute from
chronic pseudocyst.
Acute pseudocysts following an
episode of acute pancreatitis are called
postinflammatory/postnecrotic pseudocysts
as it further develops pancreatic necrosis and
extravasations of pancreatic juice. They
contain pancreatic enzymes and develop at
more than 4 weeks from the episode of
severe acute pancreatitis, a necessary time
for maturation of the pseudocyst wall and
appearance of granulation tissue. This acute
pancreatic pseudocyst and pancreatic
necrosis are differentiated pancreatic fluid
collections occurring early in the evolution
of acute pancreatitis. All patients with the
acute pancreatic pseudocyst and pancreatic
necrosis areas [3], but not all patients with
pancreatic or peripancreatic necrosis will
subsequently develop pancreatic pseudocyst
[4].
Pancreatic pseudocysts that this
evolution in size over 6 cm, persists more
than 4 weeks are symptomatic, have a high
risk
of
complications:
infection,
compression, rupture into the peritoneum or
hollow organs, bleeding. In the literature
indicated that spontaneous resolution of
pseudocyst varies between 8 and 70% of
patients [5-11].
The pancreatic pseudocyst persists for
more than 6 weeks episode of PA with the
spontaneous resolution rate decreases [12].
362
Also, the authors suggest that the rate of

spontaneous resolution does not depend
strictly on the size of PP.
The rate of spontaneous resolution of
pancreatic pseudocysts depends on several
factors:
- multiple pseudocysts [13];
- caudal location [14];
- wall thickness [15];
- communication with the pancreatic
duct, associated proximal stricture;
- enlargement
at
successive
examinations;
- biliary etiology of AP [16].
- chronic pancreatic pseudocyst.
The severity of acute pancreatitis and
extent of pancreatic necrosis seem to
influence the rate of spontaneous resolution
of PP.
Chronic pseudocysts occurring during
the evolution of chronic pancreatitis are
called retention pseudocysts due to
obstructions in the pancreatic ductal system.
Morphological
lesions
of
chronic
pancreatitis (calcification) and structural
changes of pancreatic duct (strictures, ductal
anomalies) are criteria that suggest a lack of
spontaneous resolution of these pseudocysts.
PP classification based on etiology and
pancreatic duct anatomy is proposed by
Nealon and Walser [17]:
- Type I: normal ductal anatomy without
communication with the cyst;
- Type II: normal duct, with cyst
communicating;
- Type III: pancreatic duct strictures
without cystic communication;
- Type IV: strictures in the pancreatic
duct and communication with the cyst;
- Type V: completely obstructed duct;
- Type VI: ductal lesions of chronic
pancreatitis without communication
with PP;
- Type VII: ductal lesions of chronic
pancreatitis, and PP communication.
THERAPEUTIC MODALITIES
Experience gained over the years in
treating these asymptomatic pseudocysts
suggest that PP, which do not grow or
Sndulescu S. et al.
decrease in size, can be treated
conservatively, with symptomatic medical
therapy. Systematic periodic follow-up
(ultrasound, CT) is mandatory for
complications or adverse outcome. In these
cases, appropriate treatment is necessary.
In the present, at least three therapeutic
options are available for interventional
treatment of these pseudocysts: guided
percutaneous external drainage eco/CT,
endoscopic transgastric and transpapillary
internal drainage and open surgical internal
drainage or laparoscopic.
These therapeutic modalities are
addressed to symptomatic pseudocysts,
usually those over 6 cm, manifested by pain,
nausea, vomiting, jaundice, weight loss due
to compression of the neighboring organs
(stomach, duodenum, bile duct, colon), and
some of them will evolve and the
complications
(bleeding,
infection,
fistulization). [4]
Each patient requires an individual
assessment of the characteristics of PP and
has chosen the best method of treatment of
PP for long-term favorable results.
In recent years, conventional surgery is
outclassed by the new minimally invasive
interventional techniques represented by
guided endoscopic drainage, percutaneous
drainage or even laparoscopic approach.
These interventions are characterized by a
low rate of complications and mortality, and
a higher rate of success.
CT/ultrasound guided percutaneous
drainage
The drainage is achieved by
introducing a catheter under ultrasound
guidance or tomography within PP content
and removal of it. It is recommended for
patients with symptomatic PP but high risk
for other interventions, PP with immature
walls or infected. [18-22]
This treatment method is to be avoided
in case of PP communicating with pancreatic
ductal system (shown by ultrasound, CT,
ERCP) as the drainage becomes a pancreatic
fistula with risk of infection through the
drainage tube.
Pancreatic pseudocyst
Short-term results of external drainage
are good, with improvement of symptoms.
Persistent drainage for a long time, over four
weeks may require further interventional
method for solving PP (fistula-digestive
anastomosis, endoscopic internal drainage or
surgical resection of pseudocyst).
Endoscopic drainage
Endoscopic drainage is recommended
to the patients with PP closely adjacent to a
digestive lumen, as an alternative to
conventional or laparoscopic surgery. The
approach can be achieved through the
digestive wall (trans-gastric or transduodenal) or trans-papillary for PP
communicating with the pancreatic duct, but
showing strictures or stenosis as in chronic
pancreatitis [23,24].
Endoscopic ultrasound appreciate
pseudocyst wall thickness (wall maturity),
distance to the cavity of PP, gastric varices
and collateral circulation that prevents
puncture marked by increased risk of
bleeding, PP content more or less fluid that
may require insertion of multiple catheters
or even external naso-cystic drainage [22].
Success rate is over 90% in selected cases,
with favorable effects on symptoms and
minimal immediate complications: bleeding
(may require emergency surgery if not
resolved endoscopically), perforation with
peritonitis [4]. Late complications are stent
obstruction, its migration, infection of
pancreatic
pseudocyst
[21].
These
complications may require repeated drainage
procedures by endoscopic or surgical
approach [23].
Surgical treatment
It was for a long time the standard
treatment of pancreatic pseudocyst, but its
importance decreased with improving
techniques of guided external or endoscopic
drainage, which have a lower mortality and
morbidity.
Different surgical treatment techniques
were described: external drainage, internal
drainage
(cysto-gastrostomy,
cystoduodenostomy, cysto-jejunostomy), PP
363
resection (especially for the caudal PP).

Some of these interventions can be
performed laparoscopic, with better results
and faster postoperative recovery.
External drainage is indicated when PP
is infected or it is insufficiently mature wall
and fit for digestive anastomosis [21]. The
risk of pancreatic fistula with prolonged
drainage may lead to the need for further
surgery to deal with it (fistula-jejunostomy
or pancreatic resection) [17].
Transgastric cysto-gastrostomy or
cysto-jejunostomy using a Roux Y loop is
the classical surgical treatment of PP. For
best results it is essential that the wall of PP
is suitable for an anastomosis and this is
sufficiently large (at least 3cm) to prevent
stenosis [25].
Pancreatic resection is possible when
PP is located on the tail of the pancreas
and/or it isnt possible to exclude a
pancreatic cystadenocarcinoma. However
intervention
is
difficult
because
inflammatory
changes
after
acute
pancreatitis [26].
Laparoscopic approach may be carried
out with a cysto-jejunostomy or cystogastrostomy. Experience is still quite
limited, with long lasting interventions, but
with apparently rapid postoperative recovery
[27. Teixeira J, Gibbs KE, Vaimakis S, Rezayat C, Laparoscopic
Roux-en-Y pancreatic cyst-jejunostomy, Surg Endosc 2003
17:1910-1913].
CONCLUSIONS
In patients not fit for surgery or with
severe comorbidities, percutaneous or
endoscopic drainage can be done to improve
patient status. The risk is represented by the
formation of an external pancreatic fistula
which may require further interventions.
There are no randomized studies to
develop a therapeutic protocol for pancreatic
pseudocyst; the PP management is
individualized for each case depending on
the morphological PP characteristics,
procedures availability and team experience.
Endoscopic internal drainage is an
effective therapeutic approach for selected
cases with minimal complications.
364
Surgical internal drainage is addressed

to PP mature over 6 weeks from the episode
of acute pancreatitis.
None to declare.
REFERENCES
1. Bradley EL 3rd. A clinically based
classification system for acute pancreatitis.
Ann Chir. 1993; 47(6): 537-541.
2. Stamatakos M, Stefanaki C, Kontzoglou K,
Stergiopoulos S, Giannopoulos G, Safioleas M.
Walled-off pancreatic necrosis. World J
Gastroenterol. 2010; 16(14): 1707-1712.
3. Frey CF. Peripancreatic fluid collections. In:
Beger HG, Warshaw AL, Buchler MW, et al.
Editors.. The Pancreas tome I. New York:
Blackwell Science ; 1998. p. 423-437.
4. ndrn-Sandberg , Dervenis C. Pancreatic
pseudocysts in the 21st century. Part I:
Classification, pathophysiology, anatomic
considerations, and treatment. Journal of the
Pancreas. 2004; 5: 824.
5. Sankaran S, Walt AJ. The natural and
unnatural history of pancreatic pseudocysts. Br
J Surg. 1975; 62: 3744.
6. Agha FP. Spontaneous resolution of acute
pancreatic pseudocysts. Surg Gynecol Obstet.
1984; 158: 22-26.
7. McConnell DB, Gregory JR, Sasaki TM,
Vetto RM. Pancreatic pseudocyst. Am J Surg.
1982; 143: 599-601.
8. Pollack EW, Michas CA, Wolfman EF.
Pancreatic pseudocyst: management in fifty
four patients. Am J Surg. 1978; 135: 199-201.
9. Czaja AJ, Fisher M, Marin GA. Spontaneous
resolution of pancreatic masses (pseudocysts?)
development and disappearance after acute
alcoholic pancreatitis. Arch Intern Med. 1975;
135: 558-562.
10. Bradley E, Clements J, Gonzales AC: The
natural history of pancreatic pseudocysts: a
unified concept of management. Am J Surg.
1979; 137: 135-141.
11. Lankisch PG, Weber-Dany B, Maisonneuve P,
Lowenfels AB. Pancreatic pseudocysts:
Prognostic factors for their development and
their spontaneous resolution in the setting of
acute pancreatitis. Pancreatology. 2012; 12(2):
85-90.
12. Warshaw AL, Rattner DW. Timing of surgical
drainage for pancreatic pseudocyst. Clinical
and chemical criteria. Ann Surg. 1985; 202:
720-724.
13. Aranha GV, Prinz RA, Esguerra AC, Greenlee
HB: The nature and course of cystic pancreatic
lesions diagnosed by ultrasound. Arch Surg.
1983; 118: 486488.
Sndulescu S. et al.
14. Maringhini A, Uomo G, Patti R, et al.
Pseudocysts in acute nonalcoholic pancreatitis:
incidence and natural history. Dig Dis Sci.
1999; 44: 1669-1673.
15. Forsmark CE, Grendell J. Complications of
pancreatitis. Semin Gastrointest Dis. 1991; 2:
165-176.
16. Nguyen BL, Thompson JS, Edney JA, Bragg
LE, Rikkers LF. Influence of the etiology of
pancreatitis on the natural history of pancreatic
pseudocysts. Am J Surg. 1991; 162: 527-531.
17. Nealon WH, Walser E. Main pancreatic ductal
anatomy can direct choice of modality for
treating pancreatic pseudocysts (surgery
versus percutaneous drainage). Ann Surg.
2002; 235(6): 751-758.
18. Freeny PC. Percutaneous management of
pancreatic fluid collections. Baillieres Clin
Gastroenterol. 1992; 6: 259-272.
19. DEgidio A, Schein M. Percutaneous drainage
of pancreatic pseudocysts: a prospective study.
World J Surg. 1992; 16: 141-146.
20. Gumaste VV, Dave PB: Pancreatic pseudocyst
drainage the needle or the scalpel? J Clin
Gastroenterol. 1991; 13: 500-505.
21. Pitchumoni CS, Agarwal N. Pancreatic
pseudocysts. When and how should drainage
be performed? Gastroenterol Clin North Am.
1999; 28: 615-639.
22. Nealon WH, Walser E. Main pancreatic ductal
anatomy can direct choice of modality for
treating pancreatic pseudocysts (surgery
versus percutaneous drainage). Ann Surg.
2002; 235: 751-758.
23. Baron TH, Harewood GC, Morgan DE,
Yates MR. Outcome differences after
endoscopic drainage of pancreatic necrosis,
acute pancreatic pseudocysts, and chronic
pancreatic pseudocysts. Gastrointest Endosc.
2002; 56: 7-17.
24. Sharma SS, Bhargawa N, Govil A. Endoscopic
management of pancreatic pseudocyst: a longterm follow-up. Endoscopy. 2002; 34: 203207.
25. Parks RW, Tzovaras G, Diamond T, et al.:
Management of pancreatic pseudocysts. Ann R
Coll Surg Engl. 2000; 82: 383387.
26. Behrns KE, Ben-David K. Surgical therapy of
pancreatic pseudocysts. J Gastrointest Surg.
2008; 12: 2231-2239.
27. Teixeira J, Gibbs KE, Vaimakis S, Rezayat C,
Laparoscopic Roux-en-Y pancreatic cystjejunostomy. Surg Endosc. 2003; 17: 19101913.
ARTICOLE ORIGINALE
365
PANCREATICOGASTROANASTOMOZA VERSUS
PANCREATICOJEJUNOANASTOMOZA DUP
DUODENOPANCREATECTOMIA CEFALIC
STUDIU COMPARATIV
S. Verzea 1, , V. Scripcariu 2
1) Secia de Chirurgie, Spitalul Judeean de Urgene Piatra Neam
2) Departamentul de chirurgie, Universitatea de Medicin i Farmacie Gr.T. Popa Iai
PANCREATICOGASTROANASTOMOSIS
VERSUS
PANCREATICOJEJUNOANASTOMOSIS AFTER PANCREATICODUODENECTOMY A COMPARATIVE STUDY
(Abstract): Pancreatic fistula is one of the most important complications following pancreatic head
resection. The type of pancreatic anastomosis is thought to have an influence over the rate of
complications. The pancreaticogastroanastomosis was developed in order to decrease the risk of
fistula. There are some advantages advocated for this type of anastomosis. 44 patients with
duodenopancreatectomy were studied, operated consecutively between 2005 and 2008 in two
separate surgical units, both with relative small volume of pancreatic resections. There were not
only resections for pancreatic head carcinoma. For the first group (32 patients), only the
pancreaticogastroanastomosis was used, and for the second one (12 patients) the
pancreaticojejunoanastomosis. There were no fistulas in the first group, but there were 4 cases in
the group II. Many factors were studied for the 2 groups: age, gender, education, economical
status, smoking, associated diabetes, anemia, hypoalbuminemia, jaundice, the diameter of the
pancreatic duct, the texture of pancreatic tissue, blood loss during intervention, the type of
pancreatic anastomosis. In a statistical study of linear regression, only the type of pancreatic
anastomosis was found to influence the rate of pancreatic fistula. For these two small groups of
patients, the pancreaticogastroanastomosis was more safe and was a protective factor against
pancreatic fistula.
KEY
WORDS:
PANCREATICODUODENECTOMY;
ANASTOMOSIS; PANCREATICOJEJUNO-ANASTOMOSIS;
PANCREATIC RESECTION
PANCREATICOGASTROPANCREATIC FISTULA;
SHORT TITLE: Pancreaticogastroanastomoza dup DPC

Pancreaticogastroanastomosis after PD
HOW TO CITE: Verzea S, Scripcariu S. [Pancreaticogastroanastomosis versus pancreaticojejunoanastomosis after
pancreaticoduodenectomy a comparative study] Jurnalul de chirurgie (Iai). 2012; 8(3): 365-372.
INTRODUCERE
Insuficiena anastomozei pancreatice
dup
duodenopancreatectomia
cefalic
(DPC) a constituit un element important de
blocaj n calea rspndirii folosirii
rezeciei Whipple. n 1948 Cattell [1] a
recomandat
tehnica
pancreaticojejunoanastomozei termino-laterale. Incidena
fistulei pancreatice a continuat ns s fie
mare peste tot n lume. n 1993, analiznd
serii multiple care au cumulat 1828 de

pacieni, incidena fistulei pancreatice se
situa n jurul valorii de 13,6% [2].
Numeroase modificri au fost aduse
tehnicii de rezecie duodenopancreatic i de
reconstrucie. Dintre acestea poate cea mai
important a fost duodenopancreatectomia
cu prezervarea pilorului, operaie practicat
iniial de Watson, n Anglia, n 1940 [3],
pentru ca Traverso i Longmire s o

Adresa de coresponden: Dr. Silviu Verzea, doctorand Universitatea de Medicin i Farmacie Gr.T. Popa Iai
Secia de chirurgie, Spitalul Judeean de Urgene Piatra Neam
B-dul Traian, Nr. 1, Piatra Neam, Jud. Neam, Romania
Tel.: 0040 (0) 0233 21 94 40
e-mail : silviuverzea@yahoo.com
Verzea S. et al.
366
introduc n practica larg i s o

popularizeze n 1978 [4].
Pancreaticogastroanastomoza reprezint
una din modalitile propuse pentru a scdea
rata fistulei pancreatice dup DPC.
MATERIAL I METOD
n studiu au fost inclui 44 de pacieni
care au fost supui unei DPC, alctuind 2
loturi distincte. Primul lot de pacieni (Lot I),
care este i cel mai voluminos (32 de cazuri),
cuprinde toi pacienii la care a fost indicat
i s-a efectuat DPC n secia Chirurgie I a
Spitalului de Urgen Militar Central
Bucureti, n perioada mai 2005 martie
2008 i care au fost urmrii prospectiv. La
toi aceti pacieni reconstrucia dup DPC sa realizat prin anastomoz pancreaticogastric.
Lotul II este alctuit din 12 pacieni, la
care de asemenea s-a efectuat DPC. Aceti
pacieni au fost inclui n lotul de studiu pe
baza cercetrii dosarelor medicale unice
(DMU) existente la Spitalul din Chambry,
Rhone Alpes, Frana. Este deci vorba despre
un studiu retrospectiv efectuat pe 12 pacieni
consecutivi operai pentru patologie a
regiunii periampulare n aceeai perioad cu
Lotul I, la care s-a efectuat aceeai
intervenie chirurgical, cu anumite diferene
de tehnic, dar ntr-un alt centru chirurgical.
Un element de subliniat este c pentru toate
cazurile din lotul II (Frana) s-a practicat
anastomoza pancreaticojejunal.
Tabelul I Distribuia pacienilor n funcie de
indicaiile DPC
Lotul I
Lotul II
ADK pancreatice
15 (46,8%)
6 (50%)
0,43
Tumori coledoc
distal
2 (6,25%)
2 (16,7%)
0,17
Tumori ampulare
4 (12,5%)
1 (8,3%)
0,38
Tumori duodenale
2 (6,25%)
0,26
Pancreatita cronic
5 (15,6%)
0,09
Tumori de colon *
2 (6,25%)
0,26
Tumori neuroendocrine
2 (6,25%)
1 (8,3%)
0,40
Tumori chistice
2 (16,7%)
0,03
DIAGNOSTIC
ADK: adenocarcinom;
* cancer de colon cu invazie duodenal sau cefalopancreatic
Dei la jumtate din cazuri, n ambele

loturi, indicaia de DPC a fost reprezentat
de adenocarcinomul pancreatic, putem
considera c cele 2 grupuri sunt relativ
neomogene din punct de vedere al
diagnosticului pentru care s-a indicat DPC
(Tabel I).
Metoda statistic:
Pentru manipularea statistic a datelor
obinute prin consemnarea parametrilor pre-,
intra- i postoperatori s-a folosit programul
Epi Info 7.0.8.3 (CDC), i cu ajutorul
aplicaiilor Visual Dashbord i StatCalc s-au
calculat: P, testul 2, precum i un model de
analiza multivariat (regresie liniar).
Tehnica chirurgical:
Lotul I: pancreaticogastroanastomoza (PGA)
Anastomoza
pancreaticogastric
respect urmtorii pai:
- rezecia economic a antrului gastric,
pentru evitarea tensiunii pe peretele
gastric ;
- seciunea istmului pancreatic cu
bisturiul rece;
- hemostaza atent pe trana pancreatic
(fire n X, Prolene 4/0 i 5/0);
- eliberarea bontului pancreatic pe o
lungime de 3-4 cm (se trec 2 fire de
reper pe extremitile tranei)(Fig. 1);
- incizie de maxim 3 cm pe faa
posterioar a stomacului;
- bontul pancreatic este telescopat n
stomac utilizndu-se firele de reper
(Fig. 2);
- se realizeaz anastomoza propriu-zis,
n 2 planuri: un plan endoluminal (cu
mucoasa gastric) i un plan
extragastric (cu stratul sero-musculos);
- se pune accentul pe o hemostaz
atent, din cauza riscului hemoragic
ridicat (att din mucoasa gastric, ct
i din trana pancreatic).
n acest fel, dup ce este definitivat
stratul posterior, bontul pancreatic se
regsete invaginat pe o distan de
aproximativ 1 cm n interiorul stomacului,
prin peretele posterior al acestuia.
Pancreaticogastroanastomoza dup DPC

Nu se realizeaz o anastomoz ductla-mucoas.
Calea de acces intragastric este
reprezentat de trana rezultat dup
antrectomie. n cazul opiunii de prezervare
piloric, se realizeaz o gastrotomie
anterioar pentru a se putea efectua
anastomoza.
Fig. 1 Lotul I (PGA), aspecte intraoperatorii
De remarcat bontul pancreatic mobilizat, cu cele 2 fire de reper,

incizia pe peretele posterior al stomacului, precum i primul strat
realizat din planul exogastric (pe la se pot observa artera hepatic
comun i artera hepatic proprie, captul secionat al cii biliare
principale. Stomacul, la rndul su secionat la nivel antral, este
mobilizat n plan vertical).
Fig. 1 Lotul I (PGA), aspecte intraoperatorii
De remarcat folosirea firelor de reper de pe trana pancreatic

(acestea au i un rol hemostatic, fiind trecute n colurile tranei)
pentru telescoparea bontului pancreatic n stomac. Urmeaz
plasarea unui fir surjet pentru planul endoluminal i efectuarea
celui de-al doilea strat, posterior, al planului exogastric).
Urmeaz
realizarea
anastomozei
hepatico-jejunale, monostrat, de obicei cu un
fir polidoxanon (PDO) 4/0 sau Maxon 4/0,
trecut surjet. Aceasta se realizeaz n
manier termino-lateral, n majoritatea
cazurilor pe ansa jejunal ascensionat
367
printr-o bre n mezocolonul transvers. n 2

cazuri ansa jejunal a fost trecut precolic.
Anastomoza
gastrojejunal
se
efectueaz ultima, de obicei ntr-un singur
strat. Aceasta se realizeaz la aproximativ 60
de cm de anastomoza hepatico-jejunal,
folosind de obicei partea stng a tranei de
seciune gastric, dup nchiderea parial
dinspre mica curbur. Este o anastomoz
termino-lateral, cu fir monofilament
resorbabil (Maxon sau PDS 3/0).
Lotul II: pancreaticojejunoanastomoza (PJA)
S-a realizat astfel:
- se mobilizeaz bontul pancreatic pe o
lungime de 2 cm, pentru a permite
plasarea suturilor din planul posterior
al anastomozei;
- se plaseaz fire de reper pe marginile
superioar i inferioar ale bontului
pancreatic. Un instrument bont este
folosit pentru canularea ductului
pancreatic. Aceste manevre permit
manevrarea mai bun a bontului pentru
plasarea firelor pe trana posterioar.
- primul pas l reprezint plasarea a cel
puin 3 suturi ductale, la nceput
anterior, din afar nuntru, apoi
posterior, dinuntru n afar. Se
completeaz
apoi
pe
ntreaga
circumferin a ductului, folosind ca
ajutor retracia pereilor ductali oferit
de cateterul descris anterior. Se
pstreaz acele i se ordoneaz firele.
- se realizeaz primul strat de fire
separate pe capsula pancreatic dorsal
i parenchimul adiacent, la distan de
4-6 mm ntre ele. Se adapteaz cu
atenie jejunul la pancreas i se
nnoad astfel nct firele s nu
secioneze esutul pancreatic.
- marginea posterioar a bontului
pancreatic rmne accesibil pentru
stratul al doilea, intern al anastomozei
- se deschide jejunul pe peretele
antimezenteric, iar mucoasa care
prolabeaz poate fi fixat cu 4-8 suturi
ntrerupte cu fire PDS 6/0;
- se realizeaz al doilea strat, intern al
tranei posterioare prin adaptarea
Verzea S. et al.
368
jejunului la marginea posterioar a

bontului pancreatic i prin integrarea
n acest plan a firelor de sutur ductal.
Se realizeaz o afrontare atent a
mucoasei jejunale la mucoasa ductal,
pentru a evita orice obstacol pentru
evacuarea secreiilor pancreatice.
se trec apoi firele din afar spre
nuntru pe marginea anterioar a
pancreasului, ncepnd din poriunea
superioar i se integreaz similar
firele de sutur ductal, cu afrontarea
corect a mucoaselor ductal i
jejunal.
al doilea strat anterior ntre jejun i
pancreas acoper fr tensiune stratul
intern i invagineaz pe o poriune de
1 cm bontul pancreatic n jejun.
suturile
ductale
anterioare
i
posterioare
permit
realizarea
anastomozei fr a fi necesar
stentarea separat a ductului pancreatic
printr-un cateter sau tub de dren.
se prefer anastomoza termino-lateral
pentru c aceasta permite o mai bun
adaptare, fr tensiune a jejunului la

bontul pancreatic.
Pentru cazurile n care ductul wirsung
are un diametru fin, tehnica se modific n
modul urmtor: se realizeaz iniial un surjet
posterior ntre capsula pancreatic i jejun,
apoi un surjet ntre trana pancreatic i
jejun. Pe faa anterioar se realizeaz de
asemenea 2 surjeturi, primul ntre trana
pancreatic i jejun, al doilea, de
nfundare, ntre capsula pancreatic i
peretele jejunal.
Au fost nregistrai pentru toi pacienii
urmtorii parametri: mediul de provenien,
nivelul studiilor (reflectat parial n nivelul
economic), fumatul, consumul de alcool,
diabetul zaharat, obezitatea, antecedentele
chirurgicale
n
sfera
hepato-biliopancreatic, prezena icterului la momentul
diagnosticului,
valorile
sczute
ale
hemoglobinei i albuminei plasmatice,
structura pancreasului, calibrul ductului
pancreatic, diagnosticul, durata operaiei,
volumul de snge pierdut intraoperator,
complicaiile precoce, durata de spitalizare.
Tabel II Morbiditatea i mortalitatea postoperatorie

Tip complicaie
Lotul I
Lotul II
Fistul pancreatic
0%
33,33%
0,001
Fistul biliar
3,13%
16,67%
0,09
Fistul gastrojejunal
0%
0%
0,21
Hemoperitoneu
0%
16,67%
0,03
Hemoragie digestiv superioar
9,375%
8,33%
0,48
Abces intra-abdominal
6,25%
16,67%
0,17
Pancreatit acut postoperatorie
6,25%
8,33%
0,40
Complicaii de plag
12,5%
3,12%
0,38
Evacuare gastric ntrziat
6,25%
16,66%
0,17
Pneumotorax
6,25%
8,33%
0,40
Bronhopneumonie
3,12%
0%
0,36
Infarct miocardic
3,12%
0%
0,36
Trombembolism pulmonar
3,12%
0%
0,36
Flebit cauzat de cateterul venos central
6,25%
8,33%
0,40
Morbiditate global
21
65,62%
12
100%
0,008
Mortalitate
9,37%
0,18
Reintervenii
21,88%
25%
0,40

REZULTATE
La pacienii Lotului I vrsta medie este
de 543,2 de ani (cu extreme ntre 26 i 75
de ani), iar pentru cei din Lotul II de
63,54,5 ani, cu extreme cuprinse ntre 16 i
82 de ani (P=0,76)
Raportul ntre sexe este n favoarea
sexului masculin pentru Lotul I (B/F=1,13;
17 pacieni de sex masculin vs 15 de sex
feminin), fiind egal n cazul Lotul II (cte 6
pacieni din fiecare categorie) (P=0,43).
Morbiditatea postoperatorie global a
fost de 65,6% n Lotul I i de 100% n Lotul
II (P=0,008); de notat c incidena fistulei
pancreatice a fost nul n Lotul I i de 33,3%
(n=4) n Lotul II (P=0,001) (Tabelul II). Cu
toate acestea, rata mortalitii postoperatorii
a fost de 9,37% n Lotul I i nul n Lotul II,
369
dar rezultatul nu este semnificativ statistic

(P=0,18) (Tabelul II).
Cauzele de deces au fost: infarct
miocardic perioperator (pacient de 69 de
ani), trombembolism pulmonar masiv
(pacient de 75 de ani) i respectiv oc septic
prin infecie intraspitaliceasc cu stafilococ
auriu meticilinorezistent (pacient de 68 de
ani).
Reinterveniile au avut o pondere
similar n cele dou loturi (21,8% vs 25%,
P=0,40) (Tabelul II).
Referitor la fistula pancreatic,
introducnd datele ntr-un model de regresie
logistic s-a constatat ca factor de risc doar
tipul de anastomoz pancreatico-digestiv,
PGA fiind mai sigur dect PJA (P=0,022;
OR: 0,13) (Tabelul III).
Tabel III Influena tipului de anastomoz pancreatic asupra ratei fistulei pancreatice
Coeficient
Std Error
F-test
Anastomoza pancreatic (PJA/PGA)
0,257
0,106
5,922
0,022
Anemie
-0,018
0,103
0,031
0,863
Antecedente biliopancreatice (Yes/No)
-0,129
0,125
1,068
0,310
Consum alcool (Yes/No)
-0,146
0,150
0,951
0,338
Diabet zaharat (Yes/No)
-0,091
0,105
0,763
0,390
Duct dilatat peste 3mm
0,007
0,133
0,003
0,956
Durata mare a operaiei (peste 5 ore)
0,164
0,118
1,940
0,175
Fumtor (Yes/No)
0,034
0,108
0,096
0,758
Hipoalbuminemie
-0,054
0,129
0,171
0,682
Icter la prezentare
0,027
0,135
0,040
0,842
Obezitate
0,055
0,097
0,329
0,571
Snge pierdut (peste 750 mL = Yes)
0,074
0,101
0,539
0,469
Sex (M/F)
-0,070
0,121
0,331
0,569
Structura pancreasului restant (moale / dur)
0,042
0,129
0,103
0,749
Adenocarcinom pancreatic ductal
-0,028
0,107
0,070
0,793
Variabila
DISCUII
Interveniile efectuate de Whipple,
Parsons i Mullins ncepnd cu 1934,
constnd n rezecii n 2 sau 3 timpi, ulterior
ntr-un singur timp pentru cancerele
ampulare au reprezentat un pas hotrtor n
evoluia chirurgiei pancreatice. Whipple a
precizat clar c duodenopancreatectomia
cefalic este procedeul de elecie, iar nu

rezecia n 2 timpi. Ulterior din ce n ce mai
muli chirurgi din America i din Europa au
nceput s practice operaia Whipple.
Entuziasmul nu a fost ns unanim, iar
mortalitatea operatorie rmnea mare. De
exemplu, n Statele Unite n 1969,
mortalitatea operatorie pentru cele 271 de
370
rezecii Whipple era de 32% [5]. Asta a fcut

ca n 1970, Crile, de la Cleveland Clinic, s
afirme c din cauza acestei mortaliti
extrem de ridicate, el nu va mai practica
aceast intervenie pentru carcinomul
pancreasului exocrin [6].
Din fericire, nc din 1968 au nceput
s fie comunicate serii de pacieni cu
mortalitate nul (Howard [7], Cameron [8],
Trede [9]). n acest fel s-a putut demonstra
c prin concentrarea i acumularea
experienei, mortalitatea poate fi sczut sub
valoarea de 5%. O serie de modificri ale
tehnicii de rezecie precum abordul posterior
sau abordul primar al arterei mezenterice
superioare (artery first approach) au
contribuit la ameliorarea rezultatelor
postoperatorii [10-13].
Particularitatea
anastomozei
pancreatice este c afecteaz n acelai timp
un
canal
(Wirsung)
i
trana
parenchimatoas istmic activ n plan
secretor. Aciunea litic a secreiilor
pancreatice
rspunde
de
producerea
fistulelor pancreatice. Proteazele activate
(elastaza, tripsina) pot avea o aciune litic
asupra esuturilor peripancreatice. Prin
interesarea structurilor vasculare, evoluia
poate fi uneori grav n urma hemoragiilor
fulminante [11,12]. Fistula pancreatic dup
duodenopancreatectomia
cefalic
este
considerat drept cea mai important
complicaie dup acest tip de intervenie [11].
Au fost propuse numeroase variante
pentru a trata bontul pancreatic dup
finalizarea timpului de rezecie. Fie c se
refer la anastomoza cu jejunul, cu stomacul
sau la simpla nchidere a bontului pancreatic,
toate aceste aspecte tehnice i propun s
reduc n primul rnd rata fistulei
pancreatice. Deoarece pn n prezent nu s-a
reuit demonstrarea superioritii evidente a
uneia dintre metode n comparaie cu
celelalte, se consider c un factor
determinat
n
obinerea
rezultatelor
favorabile l are experiena echipei
chirurgicale [14].
Pancreatogastrostomia
a
fost
demonstrat fezabil tehnic prin experiene
pe cini n 1934 [15], de ctre Tripodi i
Verzea S. et al.
Sherwin, date confirmate ulterior de ctre
Person [16] i Glenn. Wuagh i Clagett au
fost primii care au introdus tehnica
pancreaticogastroanastomozei n clinc, n
1946 [17].
Au fost enunate de la nceput o serie
de avantaje ale PGA; n primul rnd, se
consider a fi o anastomoz mai uor de
efectuat, deoarece peretele posterior al
stomacului se situeaz n imediata vecintate
(anterior) a bontului pancreatic mobilizat
[18]. n al doilea rnd, vascularizaia foarte
bogat a peretelui gastric este considerat un
suport pentru vindecarea anastomozei[19] .
Prin decompresia nazo-gastric se realizeaz
golirea continu a stomacului i deci se
asigur o tensiune sczut n anastomoz. n
plus, prin contactul secreiei pancreatice cu
sucul gastric, cu un pH sczut i lipsa
enterokinazei, se previne activarea enzimelor
pancreatice [20]. Astfel se poate preveni
autodigestia (enzimatic) a anastomozei
[21]. Prin realizarea uneia din anastomoze cu
stomacul, se reduce numrul de anastomoze
pe o singur ans jejunal, prevenind astfel
fenomenul de kinking al ansei [22]. Se
evit de asemenea, formarea unei anse lungi
ntre anastomozele biliar i pancreatic, n
care se pot acumula i activa secreiile
biliare i pancreatice, cu creterea tensiunii
n ans i mai ales la nivelul anastomozelor
[23].
Un alt avantaj evident al anastomozei
cu stomacul l constituie posibilitatea
practic de a vizualiza anastomoza pe cale
endoscopic [24]. Se poate astfel realiza o
hemostaz a bontului pancreatic sau pe
trana de anastomoz pancreatogastric,
utiliznd posibilitile tehnice variate i
eficiente pe care le ofer endoscopia
(coagulare, clipare etc.) [25].
n literatura de specialitate, ntre 1946
i 1990 au fost descrise 199 de cazuri de
PGA, cu o mortalitate de 4,5% (9/199) i o
rat de fistul pancreatic de 1% (2/199)
[26]. Cele 9 decese nu au fost atribuibile
anastomozei pancreaticogastrice propriuzise.
ntre 1991 i 1997, numrul de cazuri
descrise n literatur cu PGA a crescut la 614

[26]. Mortalitatea n acest grup a fost de
3,3% (20/614), iar rata fistulelor pancreatice
a fost de 4,8% (29/614) [26]. Doar trei
decese din acest grup au fost legate de
anastomoza pancreaticogastric, 1 din cauza
hemoragiei, 2 din cauze septice.
Acestea sunt rezultatele unei metaanalize realizate de Mason [26] pe cazurile
de PGA ntre 1946 i 1997.
Dup 1997, tehnica a devenit mult mai
rspndit, studiile prospective nereuind
ns s demonstreze superioritatea ei n
raport cu PJA [27].
n cazul loturilor studiate, dimensiunea
redus a acestora i lipsa de omogenitate a
indicaiilor pentru DPC nu permit extragerea
unor concluzii n favoarea PGA, dar ofer o
dovad a eficienei acestei tehnici chiar i
ntr-un centru cu volum relativ mic de
intervenii. Indiferent de metoda aleas
pentru a efectua anastomoza pancreatic,
acestui timp al interveniei trebuie s i se
acorde cea mai mare atenie, tehnica fiind
realizat cu cea mai mare grij [28]
CONCLUZII
Cele dou spitale n care s-a efectuat
studiul nu sunt centre cu volume mari de
ceea ce explic valorile relativ mari ale
mortalitii i morbiditii postoperatorii.
n ceea ce privete principala
complicaie a DPC, fistula pancreatic,
aceasta s-a ntlnit numai la cazurile din
Lotul II cu PJA. Analiza statistic a
evideniat c apariia fistulei pancreatice a
fost influenat doar de tipul de anastomoz
pancreatic, anastomoza cu stomacul
reprezentnd un factor de protecie.
interese.
BIBLIOGRAFIE
1. Cattell RB. A technic for pancreaticoduodenal
resection. Surg Clin North Am. 1948; 28: 761775.
2. Johnson CD. Pancreaticogastrostomy after
resection of the pancreatic head. In: Beger HG,
Buchler M, Malfertheiner P, editors,
Standards in Pancreatic Surgery. Berlin:
Springer; 1993. p. 663-681.
371
3. Watson K. Carcinoma of the ampulla of Vater:

successful radical resection. Br J Surg. 1944;
31: 368-373
4. Traverso LW, Longmire WP. Preservation of
the pylorus in pancreaticoduodenectomy. Surg
Gynecol Obstet. 1978; 146: 959-962
5. Herman RE. Current approaches to surgery in
pancreatic cancer: panel discussion. Am J
Surg. 1978; 135: 188-189
6. Crile G. The advantages of bypass operations
over radical pancreatoduodenectomy in the
treatment of pancreatic carcinoma. Surg
Gynecol Obstet. 1970; 130: 1049-1053
7. Howard JM. Pancreaticoduodenectomy: 41
consecutive Whipple resections without an
operative mortality. Ann Surg. 1968; 168: 629640
8. Cameron JL, Pitt HA, Yeo CJ, Lillemoe KD,
Kaufman HS, Coleman J. One hundred and
forty-five
consecutive
pancreaticoduodenectomies without mortality. Ann Surg.
1993; 217: 430-435
9. Trede M, Schwall G, Saeger HD. Survival
after pancreatoduodenectomy: 118 consecutive
resections without an operative mortality. Ann
Surg. 1990; 211: 447-458
10. Watson K. Carcinoma of the ampulla of Vater:
successful radical resection. Br J Surg. 1944;
31: 368-373
11. Popescu I, Dumitracu T. Duodenopancreatectomia cefalic trecut, prezent i
viitor. Chirurgia. 2011; 106(3): 287-296.
12. Popescu I, David L. Duodenopancreatectomia
cefalic prin abord posterior. Enciclopedia de
Chirurgie. Bucureti: Editura Celsius 2006; 1.
13. Moldovanu
R.
Clasificarea
rezeciilor
pancreatice. Jurnalul de chirurgie (Iai). 2007;
3(2): 177-179.
14. Miron A, Ardelean M. Anastomoza
pancreatico-digestiv
dup
duodenopancreatectomia cefalic. Chirurgia. 2007;
101(2): 149-155.
15. Ionescu M, Stroescu C, Barbuta C.
Duodenopancreatectomia cefalic - operaie de
rutin? Chirurgia. 2003; 98(2): 103-108.
16. Tripodi AM, Sherwin CF. Experimental
transplantation of the pancreas into the
stomach. Arch Surg. 1934; 28: 345356.
17. Person EC, Glenn F. Pancreaticogastrostomy,
experimental transplantation of the pancreas
into the stomach. Arch Surg. 1939; 39: 530
550.
18. Aranha GV, Hodul PJ. Zero Mortality after
152consecutive
Pancreatoduodenectomies
with Pancreaticogastrostomy. J Am Coll Surg.
2003; 197(2):223-231
19. Waugh JM, Clagett OT. Resection of the
duodenum and head of pancreas for
carcinoma. An analysis of thirty cases.
Surgery. 1946; 20: 224232.
372
20. Schlitt HJ, Schmidt U. Morbidity and

mortality
associated
with
pancreatogastrostomy
and
pancreatojejunostomy
following
partial
pancreatoduodenectomy. British Journal of
Surgery. 2002; 89: 1245-1251
21. Fernndez-Cruz L, Cosa R, Blanco L.
Pancreatogastrostomy with gastric partition
after
pylorus-preserving
pancreatoduodenectomy versus conventional pancreatojejunostomy a prospective randomized study.
Annals of Surgery, 2008. 248(6): 930937
22. Shen YF, Jin WI. Reconstruction by
Pancreaticogastrostomy versus pancreaticojejunostomy
following
pancreaticoduodenectomy: a meta-analysis of randomized
controlled trials. Gastroenterology Research
and Practice. 2012; 201: 1-7.
23. Morris DM, Ford RS. Pancreaticogastrostomy:
preferred reconstruction for Whipple resection.
Journal of Surgical Research. 1993; 54(2):
122-125.
Verzea S. et al.
24. Standop J, Schafer N, Overhaus M.
Endoscopic management of anastomotic
hemorrhage from pancreatogastrostomy. Surg
Endosc. 2009; 23(9): 2005-2010.
25. Ota Y, Kikuyama M, Sasada Y. Endoscopic
management of stenotic anastomosis using a
randezvous technique after pancreatogastrostomy. Digestive Endoscopy. 2009;
21(3): 201-204.
26. Mason
GR.
Pancreatogastrostomy
as
reconstruction for pancreatoduodenectomy:
review. World J Surg. 1999; 23: 221226.
27. Wente MN, Shrikhande SV, Mller MW,
Pancreaticojejunostomy versus pancreaticogastrostomy: systematic review and metaanalysis, American Journal of Surgery. 2007;
193(2): 171183.
28. Gouillat C. Pancreaticoduodenectomy; the
prevention of the
pancreatic
stump
complications. Jurnalul de chirurgie (Iai).
2005; 1(3): 334-339.
ORIGINAL PAPER
373
DIETARY THERAPY IMPACT FOR CIRRHOTIC PATIENTS

WITH HEPATIC ENCEPHALOPATHY
Adriana Teiuanu 1, , Mirela Ionescu1, S. Gologan1, Adriana Stoicescu1,
M. Andrei1, T. Nicolaie1, M. Diculescu2
1) Gastroenterology, Hepatology and Digestive Endoscopy Clinic,
Elias Emergency University Hospital
2) Gastroenterology and Hepatology Centre, Fundeni Clinical Institute
DIETARY THERAPY IMPACT FOR CIRRHOTIC PATIENTS WITH HEPATIC
ENCEPHALOPATHY (Abstract): BACKGROUND: Malnutrition is prevalent in all forms of
liver disease and it is associated with increased number of complications and increased short and
long term mortality. AIM: to evaluate the level of serum ammonia, recurrence of hepatic
encephalopathy (HE), improvement of mental status and of the nutritional status after one month
of high protein high calorie (HPHC) diet the effect of a dietary therapy on cirrhotic patients with
HE. MATERIALS AND METHODS: Our study was designed as a descriptive prospective
analysis of patients with cirrhosis and a previous episode of HE, admitted in Gastroenterology
Department of Elias Emergency Hospital, during one year (January 2010-January 2011). The
diagnosis of cirrhosis was based on the medical history, physical examination, biochemical
findings and imagistic methods. It was evaluated mental status, serum level of ammonia and
nutritional parameters, before and after one month diet. RESULTS: A significant decrease in the
blood ammonia levels was observed. A significant number of patients showed an improvement of
their mental status assessed by West Haven scale after diet. A significant improvement of number
connection test (NCT) scores was also noted. Body weight was slightly but significantly increased
after a month of diet. Mid-arm muscle circumference (MAMC) increased after one month diet,
but not statistically significant. CONCLUSIONS: The HPHC diet has a beneficial effect on the
patients with cirrhosis and hepatic encephalopathy, more significant regarding the mental status,
level of the serum ammonia and the body weight. It was noted an improvement of mid arm
muscle circumference. Key words: hepatic encephalopathy, diet, malnutrition, liver cirrhosis.
KEY WORDS: MALNUTRITION; HEPATIC ENCEPHALOPATHY; SERUM AMMONIA;
HIGH PROTEIN HIGH CALORIE DIET.
SHORT TITLE: Hepatic encephalopathy: dietary therapy
HOW TO CITE: Teiuanu A, Ionescu M, Gologan S, Stoicescu A, Andrei M, Nicolaie T, Diculescu M [Dietary therapy
impact for cirrhotic patients with hepatic encephalopathy] Jurnalul de chirurgie (Iai). 2012; 8(4): 373-378.
INTRODUCTION
Malnutrition has a high prevalence in
all forms of liver disease, ranging from 20%
in compensated liver disease to more than
80% in those patients with decompensated
liver disease and 100% in hospitalized
patients with acute alcoholic hepatitis
superimposed on cirrhosis [1]. Patients with
alcoholic cirrhosis have a higher incidence
Correspondence to: Adriana Teiuanu, MD
Gastroenterology, Hepatology and Digestive Endoscopy Clinic
Elias Emergency University Hospital,
Bd. Mrti, No. 17, 011461, Bucureti, Romania
Phone: 0040 (0) 745 98 07 16.
e-mail: adrianateiusanu@yahoo.com
of malnutrition than those with nonalcoholic

liver disease.
Protein-calorie malnutrition (PCM)
can be identified in all clinical stages, but is
easier observed in advanced stages of liver
disease [2].
There are a number of factors that
contribute to malnutrition in patient with
liver disease such as decreased calories
374
intake, decreased nutrients absorption or

impaired metabolic absorption [3].
Many descriptive studies have shown
higher rates of complications and mortality
in
cirrhotic
patients
with
protein
malnutrition as well as reduced survival
when such patients undergo liver
transplantation [4].
Hepatic encephalopathy (HE) is a
neuropsychiatric condition that leads to
mental status changes and abnormal
neuromuscular function in patients with
acute and chronic liver failure [5].
More than 35% of hospitalizations are
related to HE, with lengths of stay between 5
and 7 days [6].
Two forms of HE are recognized:
minimal hepatic encephalopathy (MHE) and
overt hepatic encephalopathy (OHE).
Patients with MHE have no clinical
symptoms of HE, but subtle deficits in
cognitive function that can be detected by
psychometric or neurophysiologic testing.
OHE is characterized by symptoms ranging
from trivial lack of awareness to loss of
consciousness, and is usually assessed using
the West-Haven grading system [7].
Multiple recent studies have shown the
importance of maintaining the positive
nitrogen balance via increased protein and
caloric intake in cirrhotic patients [5].
Negative nitrogen balance due to protein
restriction
leads
to
protein-calorie
malnutrition (PCM) [8], and decrease the
survival rate in patients with liver cirrhosis
[5].
The end point was to evaluate the level
of serum ammonia, recurrence of HE,
improvement of mental status and the
nutritional status in patients with liver
cirrhosis before and after 1 month of high
protein high calories diet.
MATERIALS AND METHODS
Our study was designed as a
descriptive prospective analysis of patients
with cirrhosis and a previous episode of HE,
admitted in Elias Emergency Hospital,
Gastroenterology Department, during one
year (January 2010-January 2011).
Teiuanu A. et al.
Inclusion criteria were: age between
18 and 80 years, documented liver cirrhosis
in a stable hemodynamic condition,
compliance to dietary recommendations and
medical treatment, with a previous episode
of HE.
Exclusion criteria were: overt hepatic
encephalopathy (OHE) stage III or IV (West
Haven criteria), active gastrointestinal
bleeding, ongoing alcoholism, sepsis, liver
failure, hepatocellular carcinoma or other
known malignancies.
The diagnosis of cirrhosis was based
on
the
medical
history,
physical
examination, biochemical findings and
imagistic methods (ultrasound and/or
computed tomography).
Assessment of the mental status was
performed using West Haven scale. Those
who were with no abnormalities detected
(stage 0) had to perform a conventional
Number Connection Test (NCT), using
circles numbered from 1 to 25, used for
psychometric performance evaluation.
Laboratory tests included cell blood
count
(CBC),
bilirubin,
albumin,
prothrombin time (PT), serum ammonium,
International Normalized Ratio (INR), urea,
creatinine, which were used to calculate
Child Pugh score and to laboratory
evaluation; all markers were measured by
standard laboratory methods.
In order to evaluate the nutritional
status of the patients with cirrhosis we used
mid-arm muscle circumference (MAMC)
[9,10], an anthropometric parameter were
that is not affected by the presence of ascites
or peripheral edema and body weight.
Patients from this study received
medical treatment including lactulose in
order to obtain 2-3 semisolid stools daily
and rifaximin 1200 mg/day.
They were followed for 1 month.
During that period they received high caloric
high protein (HPHC) diet: 30kcal/kg/day
and 1.2g of proteins/kg/day. They were
allowed to eat only 100g of poultry meat or
fish twice a week. The proteins were from
vegetables, cereals or milk products,
approximately 20-25% vegetables and fruits,
Hepatic encephalopathy: dietary therapy

25-30% cereals and 45-50% milk and milk
products. The feeding pattern was designed
to provide 4 meals during the day and a latenight snack rich in carbohydrates at 10 p.m.
They were asked to choose from a menu
with several alternatives by individual
preference and tolerance. The tolerance of
the
cirrhotic
patients
to
dietary
recommendation was excellent; no one
withdrew from this study because of lack of
compliance.
The protocol conformed to the
Declaration of Helsinki and Guidelines for
Good Clinical Practice in Clinical Trials and
was approved by the Elias Emergency
Hospital Committee. All patients signed an
informed consent.
A descriptive study of the quantitative
values was undertaken by using mean and
standard deviation values, and qualitative
values were expressed as frequencies.
RESULTS
A series of 68 hospitalized patients
with cirrhosis, 43 male (63%) and 25 female
(37%), was included, the median age was 54
(range 30-68).
The etiology of liver disease was
alcoholic in 26 patients (38%), viral-related:
B, C, B+D, B+C in 24 (35%), mixed:
alcohol + viral in 13 patients (19%) and
other etiologies (autoimmune, primary
biliary cirrhosis, cryptogenic) in 5 patients
(8%).
The degree of liver disease was
assessed using the Child Pugh classification.
Liver function was relatively well preserved
(Child A) in 19 patients (28%), moderately
compromised (Child B) in 46 patients (67%)
and severely compromised (Child C) in 3
patients (5%).
Clinical examination included the
evaluation of the presence of ascites and
edema. 53 patients (77%) had ascites, as
followed: 33 patients with slight ascites
(63%) and 20 with moderate ascites (37%),
and 15 patients (23%) didnt have. Only 9
patients had edema (13%).
From all that patients (28) only 10
patients had abnormal NCT (36%),
375
corresponding
to
minimal
hepatic
encephalopathy (MHE).
A significant decrease in the blood
ammonia levels was observed after a month
of HPHC diet, when all patients included in
the study were considered. The decrease in
blood ammonia level was observed in all
patients as it is revealed in Table I.
Table I The ammonia level and NCT scores before
and after HPHC diet
Blood ammonia *
Before
diet
(mean)
After
diet
(mean)
P value
58.3
35.2
<0.0001
62
52
<0.0001
NCT scores
* normal range: 11-33 mol/L
No patient was withdrawn from the

study due to a recurrent episode of HE. A
significant number of patients showed an
improvement of their mental status after
diet: 45% from stage I patients (West Haven
scale) meaning 10 patients became stage 0.
Fourteen patients with stage II (75%)
became stage I and only 4 (25%) from 18
patients remained in stage II (Table II).
Table II Evolution of the mental status according to
the initial stage of HE assessed by West Haven scale.
No improvement
(%)
Initial
West
Haven stage I
1 stage
improvement
(%)
12 (55)
10 (45)
Initial
West
Haven stage II
4 (25)
14 (75)
That means, after a month of diet, the

classification of the patients contains: 38
patients (56%) with stage 0, 26 patients
(38%) stage I and only 4 (6%) with stage II.
None of these patients worsened the mental
status.
The repartition of different stages,
before and after the diet, is revealed in
Table III.
A significant improvement of number
connection test (NCT) scores was also noted
Teiuanu A. et al.
376
when the initial scores were compared with

the scores obtained after a month of HPHC
diet.
Taking into account the severity of
liver disease, 63% of patients (29 patients) in
Child B stage had an improvement in the
grade of HE, compared with only one patient
(33%) with Child C cirrhosis.
Table III Global repartition of different West Haven
stages, before and after the diet
No of patients
Stage 0
Stage I
Stage II
Before diet
28
22
18
After diet
56
38
The improvement of HE after the diet

was not as good in patients with alcoholic
cirrhosis as in patients with viral or mixed
etiology. 35% of alcoholic patients improved
their mental status after HPHC diet,
compared with 43% of patients with viral
etiology and with 46% of patients with
mixed etiology, but this difference didnt
reach statistical significance (P=0.06).
Body weight was slightly but
significantly increased after a month of diet.
Mean value before diet was 68.3 kg and
after the HPHC diet reached up to 69.2 kg
(P =0.008). Mid-arm muscle circumference
(MAMC) increased from 28.6 cm to 29.3 cm
after one month diet, but not statistically
significant.
DISCUSSION
Hepatic encephalopathy (HE) is a
neuropsychiatric condition of impaired
mental status and abnormal neuromuscular
function that may occur in patients with
advanced liver disease and has a potential
for full reversibility [8].
Minimal
hepatic
encephalopathy
(MHE) has no recognizable clinical
symptoms. It is present in 30-84% of
patients with liver cirrhosis. It is diagnosed
by neuropsychological tests.
Hepatocellular failure, portosystemic
shunting, sepsis, variceal bleeding, excess
dietary intake or electrolyte imbalance are
the most common precipitating factors that

contribute to develop of HE [8].
European
Society for
Clinical
Nutrition and Metabolism (ESPEN)
recommends that patients with liver cirrhosis
should receive 35-40 kcal/kg per day [11].
Protein requirements are increased in
cirrhotic patients and high protein diets are
generally well tolerated in the majority of
patients.
The inclusion of adequate protein in
the diets of malnourished patients is often
associated with a sustained improvement in
their mental status. Protein helps preserve
lean body mass; skeletal muscle makes a
significant contribution to ammonia
removal. Protein restriction must be avoided
and the recommendation is to maintain 1.21.5 g proteins/kg/day [12].
In severely protein-intolerant patients
it is recommended branched-chain amino
acids (BCAA) supplementation. These
amino acids (leucine, isoleucine and valine)
cannot be synthetized de novo.
Chronic liver disease is characterized
by a decrease in the serum level of BCAA,
whereas hyperammonemia increases their
utilization [13].
The Fischer ratio, the balance between
branched-chain amino acids (BCAA) and
aromatic amino acids (AAA), is 3:1 in
healthy population. It becomes inverted in
cirrhotic patients. BCAA are essential for
protein production and prevent the
catabolism. AAA are precursors for false
neurotransmitters such as octopamine and
phenylethylamine,
contributing
to
neurologic dysfunction [13].
A
meta-analysis
of
BCAA
supplementation revealed the improved rate
of recovery from episodic HE, but did not
demonstrate a survival advantage [14].
Long-term oral supplementation with
BCAA mixture is better than ordinary food
to improve the serum albumin level and the
energy metabolism in cirrhotic patients [15].
In the same study body weight was slightly
but significant increase in the BCAA group.
A
significant
correlation
was
established
with
midarm
muscle
Hepatic encephalopathy: dietary therapy

circumference (MAMC), but not with triceps
skinfold thickness (TST).
In a randomized, double-blind,
multicenter study, comparing a supplement
of BCAA or maltodextrin the conclusions
were that the supplementation with BCAA
after an episode of HE does not decrease
recurrence of HE. BCAA improve minimal
HE and muscle mass [16].
The timing of BCAA supplementation
may be crucial. This issue was addressed by
a crossover study. At 3 months, a significant
increase in serum albumin level was
observed in patients administered nocturnal
BCAA.
It leads to an increase of serum protein
of approximately 10% if given before
bedtime [17]. Problems that limit the use of
BCAA in the treatment of HE are their taste
and expense.
Our study shows that protein and
energy requirements for cirrhotic patients
may be maintained in patients with HE. It
leads to improvement of mental status in
90% of patients. Our study confirms recent
studies showing that patients tolerate highprotein diets and benefit of them.
Most patients tolerate HPHC diet
without risk of HE. It improves mental status
in a significant way. A higher proportion of
patients with severe impairment of the
mental status improved after one month diet
(63%). A lower proportion of patients with
alcoholic cirrhosis improved their mental
status compared with those with viral or
mixed etiology. A significant improvement
of number connection test (NCT) scores was
also noted after the diet.
A decrease in blood ammonia level
was noted not only for patients with
improvement of mental status, but also for
the patients that maintained their mental
status. No one had an increase of serum
level ammonia. This HPHC diet had a
significant improvement on the body weight
and mid arm muscle circumference
(MAMC) after a month of treatment.
We used an eating schedule
characterized by 4 meals during the daytime
a a late evening snack consisting in food
377
reach in carbohydrates. Like similar studies

that referred to reach in BCAA late evening
snacks diets, this study shows a better
outcome from the mental status and
nutritional point of view.
CONCLUSION
High protein high calorie diet had a
beneficial effect on the patients with
cirrhosis and hepatic encephalopathy. This
effect was statistically significant regarding
the mental status, level of the serum
ammonia and the body weight.
The daily eating pattern consisting in 4
meals and l late evening snack contributed to
HE improvement, avoiding protein loading
in a period of day, but maintaining the
protein positive balance.
None to declare.
REFERENCES
1. Krenitski J. Nutrition for Patients with Hepatic
Failure. Practical Gastroenterology. 2003; 6:
23-42.
2. Charlton M. Branched-Chain Amino Acid
Enriched Supplements as Therapy for Liver
Disease. The Journal of Nutriton. 2006; 136:
295S-298S.
3. Parrish CR, Krenitsky J, McCray S. Hepatic
Module. University of Virginia Health System
Nutrition Support Traineeship Syllabus.
Available through the University of Virginia
Health System Nutrition Services in January
2003.
4. Alberino F, Gatta A, Amodio P, et al.
Nutrition and survival in patients with liver
cirrhosis. Nutrition 2001; 17: 445450.
5. OBrien A, Williams R. Nutrition in end-stage
liver disease: priciples and practice.
Gastroenterology. 2008; 134: 1729-1740.
6. Munoz SJ. Hepatic encephalopathy. Med Clin
North Am. 2008; 92(4): 795-812.
7. Bajaj JS, Cordoba J, Mullen P, et al. Review
article: the design of clinical trials in hepatic
encephalopathy. Aliment Pharmacol Ther.
2011; 33: 739-747.
8. Chadalavada R, Biyyani RS, Maxwell J,
Mullen
K.
Nutrition
in
hepatic
encephalopathy. Nutr Clin Pract. 2010; 25(3):
257-264.
378
9. Plauth M, Cabr E, Riggio O, Assis-Camilo

M, Pirlich M, Kondrup J; DGEM (German
Society for Nutritional Medicine), Ferenci P,
Holm E, Vom Dahl S, Mller MJ, Nolte W;
ESPEN (European Society for Parenteral and
Enteral Nutrition). ESPEN guidelines on
enteral nutrition: liver disease. Clin Nutr.
2006; 25(2): 285-294.
10. Bemeur C, Desjardins P, Butterforth R. Role
of nutrition in the management of hepatic
encephalopathy in end-stage liver failure. J
Nutr Metab. 2010;2010:489823.
11. Plauth M, Cabr E, Campillo B, Kondrup J,
Marchesini G, Schtz T, Shenkin A, Wendon
J; ESPEN. ESPEN guidelines on Parenteral
Nutrition: hepatology. Clin Nutr. 2009; 28(4):
436-444.
12. Merli M, Riggio O. Dietary and nutritional
indications in hepatic encephalopathy. Metab
Brain Dis. 2009; 24(1): 211-221.
Teiuanu A. et al.
13. Frederick RT. Current concepts in the
pathophysiology and management of hepatic
encephalopathy. Gastroenterol Hepatol (NY).
2011; 7(4): 222-233.
14. Als-Nielsen B, Koretz RL, Kjaergard LL.
Branched chain amino acids for hepatic
encephalopathy. Cochrane Database Syst Rev.
2003; 2: CD001939.
15. Nakaya Y, Okita K, Suzuki K, et al. BCAAenriched snak improves nutritional state of
cirrhosis. Nutrition. 2007; 23: 113-120.
16. Les I, Doval E, Martinez RG, et al. Effects of
branched-chain amino acids supplementation
in patients with cirrhosis and a previous
episode of hepatic encephalopathy: a
randomized study. Am J Gastroenterol. 2011;
106: 1081-1088.
17. Khanna S, Gopalan S. Role of branched-chain
amino acids in liver disease. Curr Opin Clin
Nutr Metab Care. 2007; 10(3): 297-303.
ARTICOLE ORIGINALE
379
VALOAREA ATELEI DE RECONSTRUCIE DIN TITAN N

PLASTIA PIERDERILOR DE SUBSTAN CONSECUTIVE
REZECIEI IN CONTINUITATE A MANDIBULEI
VV Costan1, , M Balan1, Marilena Bdlu1, Otilia Boiteanu2,
Raluca Dragomir1, Eugenia Popescu1
Universitatea de Medicin i Farmacie Gr. T. Popa Iai
Spitalul Sf. Spiridon Iai
1) Clinica de Chirurgie Oral i Maxilo-Facial
2) Clinica Anestezie Terapie Intensiv
THE VALUE OF TITAN PLATE FOR THE PLASTY OF BONE LOSS RESULTED FROM
SEGMENTAL RESECTION OF MANDIBLE (Abstract): BACKGROUND: Any bone loss that
interrupts the continuity of the mandible has important functional and aesthetic consequences.
One of the posibilities of plasty is represented by the use of the titan reconstruction plate and the
optimization of results by association of free flaps. MATERIAL AND METHODS: Between
2006 - 2012, for a number of 26 patients the titan plate was used for restoring mandibular
continuity for bone defects resulted from the excision of malignant tumors. RESULTS: In all
cases a free flap was asociated, usually a latissimus dorsi myocutaneous flap (20 cases); in one
case a radial fascio-cutaneous flap combined with a pectoralis major myocutaneous flap. In 5
cases the modelation of the fibula flap was performed on a mandibular reconstruction plate. 3 of
the reconstruction plates were removed postoperative, one of them because of the necrosing of a
latissimus dorsi free flap, and the other two because of cutaneous or intraoral decubitus lesions. In
the rest of the patiens the results were good or very good, with the resumption of oral feeding, a
good diction and restoration of facial symmetry. CONCLUSIONS: The use of voluminous
muscular free flaps is followed by a reduced rate of exteriorization of the reconstruction plates,
with good and very good aesthetic and functional results. The association of reconstruction plates
to fibula free flaps allows the restoration of a good symmetry with good stability in time.
KEY WORDS: TITANIUM PLATE; MANDIBLE RECONSTRUCTION; FREE FLAPS;
LATISSIMUS DORSI FREE FLAP; FIBULA FREE FLAP
SHORT TITLE: Reconstrucia mandibular
Mandible reconstruction
HOW TO CITE: Costan VV, Balan M, Bdlu M, Boiteanu O, Dragomir R, Popescu E. [The value of titan plate for the
plasty of bone loss resulted from segmental resection of mandible]. Jurnalul de chirurgie (Iai). 2012; 8(4): 379-385.
INTRODUCERE
Scopul reconstruciei dup o rezecie
segmentar de mandibul este de a menine
funcia, a restabili un aspect cosmetic
acceptabil pentru a permite o bun calitate a
vieii [1,2]. Dac ndeprtarea prii laterale
a mandibulei nu are consecine funcionale
sau estetice deosebite chiar n absena
refacerii continuitii mandibulare, n schimb
Adresa de coresponden: Dr. Costan Victor
Clinica de Chirurgie Oral i Maxilo-Facial,
Spitalul Clinic de Urgene Sf. Spiridon Iai
Bd. Independenei, nr. 1, 700111, Iai, Romnia
Tel.: 0040 (0) 232 24 08 22
Fax: 0040 (0) 232 21 77 81
e-mail: victorcostan@gmail.com
rezecia segmentar a arcului anterior

mandibular are consecine funcionale ori
estetice deosebite, refacerea continuitii n
acest caz fiind, n general, deosebit de
dificil.
Tratamentul chirurgial al tumorilor
teritoriului oro-maxilo-facial poate face
necesar rezecia n continuitate a
mandibulei.
Costan VV. et al.
380
Restabilirea unui aspect estetic

acceptabil, alturi de reluarea fonaiei,
masticaiei i a deglutiiei constituie
deziderate nu foarte uor de atins, avnd n
vedere dificultile tehnice asociate unui
status general adesea precar al pacientului.
O soluie pentru a scurta durata

interveniei chirurgicale i de a obine, n
acelai timp rezultate postoperatorii de bun
calitate o constituie utilizare atelelor de
reconstrucie din titan.
Fig. 1 Carcinom gingivoalveolar ram orizontal

stng mandibul
A: aspect intraoral; B: ortopantomografie - se evideniaz liza
osoas la nivelul ramului orizontal stng al mandibulei
MATERIAL I METOD
ntre anii 20062012, n Clinica de
Chirurgie OMF a Spitalului Sf. Spiridon
din Iai a fost utilizat atela de reconstrucie
din titan la 26 de pacieni, pentru plastia
unor defecte n continuitate a mandibulei,
consecina extirprii unor formaiuni
tumorale maligne n 22 de cazuri (Fig. 1) sau
benigne n celelalte 4 cazuri.
n marea majoritate a cazurilor, atela a
fost utilizat n acelai timp operator cu
extirparea tumorii, doar ntr-un singur caz
fiind realizat plastia secundar a defectului
postoperator, la 10 ani de la extirparea unui
ameloblastom de la nivelul hemimandibulei
stngi.
Fig. 2 Reconstrucia cu atel din titan, dup rezecia

hemimandibulei stngi cu conservarea condilului
A: aspect intraoperator; B: ortopantomografie
REZULTATE
La toi pacienii, la reconstrucia
mandibular, folosirea atelei de reconstrucie
din titan (Fig. 2) a fost asociat, cu cel puin
un lambou liber. Pentru a diminua riscul de
exteriorizare a atelei, am preferat utilizarea
unor lambouri voluminoase, din latissimus
dorsi (Fig. 3) la 17 pacieni (3 lambouri fiind
cu cte dou palete cutanate). n alte cazuri,
l-am asociat cu un lambou liber din peroneu
(2 cazuri) sau cu unul pediculat din marele
pectoral (1 caz).
Pentru a crete stabilitatea reconstruciei, lamboul osos din peroneu a fost
modelat pe o atel de titan n 4 cazuri iar
ntr-un alt caz a fost necesar utilizarea i a
unui lambou liber transferat radial pentru
Reconstrucia mandibular
reconstrucia buzei, la un defect complex ce
a interesat att mandibula ct i toat buza
inferioar. La un alt caz atela de
reconstrucie a fost asociat cu un lambou
pediculat de mare pectoral pentru refacerea
defectului intraoral i cu unul liber radial
pentru refacerea defectului cutanat. De cte
ori a fost posibil, atela de reconstrucie
mandibular a fost modelat pe marginea
bazilar a mandibulei, nainte de secionarea
ei (la 7 pacieni), permind o reconstrucie
optim; de altfel, aceast atel a fost utilizat
ntr-un caz ca reper pentru refacerea
secundar a mandibulei, la 14 luni de la
prima intervenie chirurgical, prin utilizarea
unui lambou liber transferat din peroneu.
Fig. 3 Aspectul intraoral la 2 ani postoperator
Se remarc palet cutanat a lamboului de latissimus dorsi i cu o

bun ocluzie dentar n jumtatea dreapt .
Fig. 4 Aspect clinic la 2 ani postoperator
Restabilirea simetriei faciale, cu o bun deschidere a gurii i cu

diminuarea volumului muchiului latissimus dorsi
381
O evoluie n procedeele reconstructive

o constituie utilizarea modelelor stereolitice
mandibulare, care permit modelarea
preoperatorie a atelei de reconstrucie,
permind
astfel
creterea
calitii
reconstruciei odat cu scurtarea duratei
actului operator.
Trei atele de reconstrucii s-au
exteriorizat i au trebuit ndeprtate. ntr-un
caz a fost consecina necrozrii lamboului
din latissimus dorsi. Celelalte dou atele de
reconstrucie ndeprtate, au fost folosite
pentru plastia unor defecte situate la nivelul
arcului anterior al mandibulei. Astfel, la unul
dintre pacieni, atela s-a exteriorizat n
cavitatea oral i a trebuit ndeprtat la 12
luni postoperator. La un alt pacient atela s-a
exteriorizat cutanat i a fost ndeprtat la 18
luni postoperator; continuitatea mandibulei a
fost restabilit la 30 luni de la intervenia
iniial cu un lambou liber transferat din
peroneu, fixat pe o nou atel de
reconstrucie din titan i la care a fost
necesar asocierea unui lambou pediculat de
mare pectoral.
Rezultatele estetice postoperatorii au
fost bune si foarte bune la pacienii la care
defectul nu a afectat tegumentul (Fig. 4);
interesarea tegumentului i necesitatea de a
utiliza dou lambouri diferite pentru plastia
defectelor de pri moi a fost urmat, de
obinerea unor rezultate estetice bune.
Rezultatele funcionale au fost bune,
pacienii avnd o dicie inteligibile i o
alimentaie oral.
Utilizarea implanturilor dentare din
titan urmat de restaurarea protetic a fcut
ca pacienii la care a fost posibil aceast
abordare (2 cazuri), s aib o via
cvasinormal.
DISCUII
n momentul in care se stabilete
planul terapeutic al unui pacient trebuie inut
cont de mai muli factori.
n afara stadiului de boal trebuie inut
cont de starea general a pacientului dar i
de posibilitile tehnice ale serviciului.
Defectele complexe compozite orocutanate (aflate n stadiile III i IV) creeaz
382
dificulti majore nu numai datorit

aspectelor tehnice ale plastiei primare dar i
a faptului c n timp, apar numeroase
complicaii care fac necesar, adesea,
utilizarea unui nou lambou [3,4].
Dei adesea, pentru reconstrucia
osului este suficient un singur lambou osos
microvascular, cele mai bune rezultate se
obin cnd sunt utilizate 2 lambouri
microvasculare, deoarece lambourile libere
cu os revascularizat folosite obinuit au un
deficit de pri moi iar n tratamentul
tumorilor maligne, acest deficit este unul
semnificativ [5].
Byars [6] i Freeman [7] se nscriu
ntre primii care au utilizat materiale
aloplastice pentru refacerea continuitii
mandibulare. Reconstrucia primar a osului
mandibular n cazul tumorilor maligne avea
o rat crescut de eec datorit contaminrii
zonei receptoare [8].
Progresele microchirurgiei au fcut ca
asocierea unor lambouri bine vascularizate la
diverse implanturi aloplastice s fie urmat
de o rat de succes semnificativ mai mare
dect n cazul utilizrii lambourilor regionale
ori locoregionale [9].
n acelai timp cu evoluia tehnicilor
chirurgicale de reconstrucie au evoluat
semnificativ i biomaterialele care au permis
folosirea unor atele cu biocompatibilitate
superioar i cu o rezistent crescut la
forele intense ce se exercit la nivel
mandibular cu diminuarea semnificativ a
anselor de fracturare a atelelor de
reconstrucie [2].
Ideal
este
utilizarea
osului
vascularizat liber transferat care elimin o
mare parte dintre dezavantajele susmenionate. Exist mai multe tipuri de
lambouri osoase liber transferate, cu
caracteristici diferite, fiecare cu indicaie
special n reconstrucia anumitor tipuri de
defecte mandibulare [9]. n anumite situaii
ns, pentru obinerea unor rezultate optime
este esenial utilizarea a dou lambouri
libere [5,10].
n experiena noastr, utilizarea
lambourilor osoase liber transferate crete
semnificativ durata interveniei chirurgicale
Costan VV. et al.

astfel nct trebuie folosite doar atunci cnd
starea general a pacientului permite acest
lucru.
Una dintre indicaiile de utilizare a
atelelor de reconstrucie este de a diminua
morbiditatea la nivelul regiunii donatoare i
de a reduce n acelai timp durata
interveniilor chirurgicale. Pentru a diminua
ansele de eliminare ale atelei i de a crete
calitatea rezultatului postoperator, atelele de
titan pot fi asociate unui lambou liber
transferat [11,12]. Prin acoperirea atent a
atelelor de reconstrucie cu esuturi de bun
calitate furnizate de lambourile libere, la
pacieni la care nu este prevzut o
restaurare protetic, rezultatele funcionale
ori estetice sunt bune ori foarte bune.
O soluie foarte bun pentru acoperirea
atelelor din titan o reprezint lambourile
fasciocutanate antebrahiale radial liber
transferate, dup Schusterman [13]. Autorul
consider c prin reducerea tensiunii la
nivelul zonei receptoare, mai ales cnd
aceasta este situat la nivelul arcului anterior
al mandibulei, este diminuat semnificativ
ansa de eliminare a atelei de reconstrucie.
n reconstrucia defectelor compozite,
din punct de vedere funcional este mai
important refacerea defectelor n volum ale
prilor moi dect refacerea structurilor
ososase [14]. Utilizarea unor lambouri
voluminoase este esenial deoarece permite
umplerea spaiilor moarte, meninerea unei
bune mobiliti a limbii.
n acelai timp aceast refacere
voluminoas permite o radioterapie cu
efecte secundare mult diminuate; la circa 6
luni dup terminarea radioterapiei volumul
se diminueaza semnificativ.
Boyd [15] este unul dintre autorii care
consider c, n cazul pacienilor aflai n
stadii avansate, primeaz calitatea vieii i n
consecin o nchidere ct mai simpl a
defectelor este esenial.
Acest lucru nu este ns adesea valabil,
o reconstrucie de o calitate mai slab avnd
drept consecin un aspect estetic mai puin
acceptabil i rezultate funcionale de o
calitate mai slab. n acelai timp,
complicaiile postoperatorii numeroase
contribuie suplimentar la scderea calitii
vieii acestor pacieni, cu creterea
semnificativ a duratei de spitalizare.
Retracia lambourilor favorizeaz
apariia leziunilor de decubit iar, pe de alt
parte, exercit fore care acionnd asupra
atelelor de reconstrucie pot conduce la
slbirea uruburilor pe osul mandibular ori
prin obosirea metalului la fracturarea
atelelor de reconstrucie.
n cazul n care atela de reconstrucie
este utilizat pentru defecte situate n partea
anterioar a mandibulei, este eliminat ntr-o
proporie mai mare (44%) fa de defectele
laterale mandibulare (27%) la pacienii la
care plastia prilor moi a fost realizat cu
ajutorul lambourilor pediculate de mare
pectoral. n acelai timp este eliminat mult
mai rar atunci cnd prile moi au fost
refcute cu un lambou liber transferat, pentru
defecte laterale mandibulare (12%) [16].
Blackwell [11] consider c expunerea
extraoral a atelelor de titan utilizate pentru
plastia unor defecte mandibulare laterale este
consecina retraciei prilor moi care,
comprimate pe un plan dur se necrozeaz,
conducnd astfel la expunerea atelei. innd
cont de aceeai explicaie, am considerat i
constatat c cele mai bune rezultate
postoperatorii se obin prin utilizarea
lambourilor libere musculare voluminoase
din latissimus dorsi, care prin retracie, ajung
postoperator la un volum convenabil, care
ns nu determin leziuni de decubit pe
materialul utilizat n reconstrucie. Wei [14]
constat ns c utilizarea unor lambouri
voluminoase nu nltur riscul de eliminare a
atelei din titan ci doar o scdere
semnificativ a acestuia.
O diferen cu adevrat important
apare n momentul n care atela este utilizat
pentru conformarea unor lambouri osoase
libere [11,17]. Chiar dac apar mici expuneri
cutanate ori mucozale acestea se vindec
spontan dup ndeprtatea materialului de
titan dup osteointegrarea osului transferat.
n cazul n care atela de reconstrucie
este utilizat singur pentru refacerea
continuitii mandibulare, poate fi cu
usurin exteriorizat. n cazul n care este
383
folosit cu un lambou osos liber transferat,

este placat de acesta determinnd apariia
unei grosimi superioare i fcnd
posibilitatea de exteriorizare mult redus,
ajungnd s fie comparabil cu cea a
miiniplcuelor de osteosintez din titan
[18]. Pe de alt parte, atelele de reconstrucie
sunt voluminoase i pot s devin cu
uurin vizibile sub esuturile faciale, spre
deosebire de placutee de osteosintez, cu o
grosime mai mic i care, n consecin au
un rezultat estetic superior.
Astfel, alternativa la utilizarea atelelor
de reconstrucie din titan este reprezentat de
miniplcuele de titan, indicaie introdus de
Hidalgo n 2002 [19]. Aceste plcue care
utilizeaz uruburi cu diametrul maxim de 2
mm, prezint o serie de avantaje (sunt mai
maleabile i mai uor de aplicat, permit
scderea duratei interveniei chirurgicale, au
un risc mai mic de lezare a pediculului
vascular i, nu n ultimul rnd au un volum
mai mic [20]. Pe de alt parte, dimensiunile
reduse i, n consecin rezistena mai mic
ar indica un risc mai mare de fracturare i
deci de apariie a unui calus de proast
calitate ori chiar absena acestuia [21]. Din
considerente legate de rezistena mai mic a
miniplcuelor din titan, am preferat
utilizarea acestora doar la pacieni la care a
for realizat reconstrucia primar a unor
defecte laterale a mandibulei, in celelalte
situaii, la lambourile de peroneu prefernd
atela de reconstrucie din titan.
Marele dezavantaj al conformrii
dificile a atelelor de reconstrucie este
reprezentat modelele tridimensionale care
permit modelarea ideal preperatorie a
atelelor [22], att n cazul n care sunt
folosite n asociere cu un lambou liber osos
dar i atunci cand sunt utilizate ca singur
soluie de refacere a continuittii
mandibulare. n acest mod este diminuat
durata interveniei chirurgicale i, n acelai
timp, crete calitatea reconstruciei prin
restabilirea simetriei iniiale.
O problem legat de utilizarea
atelelor de reconstrucie n cazul asocierii la
lambourile osoase liber transferate este dat
de preluarea forelor mecanice i eliminarea
384
stresului funcional asupra osului ceea ce

conduce la osteodistrofie la nivelul
neomandibulei [23]. Forele care n mod
normal se transmit prin osul mandibular sunt
preluate de atela de reconstrucie; nemaifiind
necesar s menin forele de tensiune, osul
se resoarbe i densitatea lui diminua [24].
Shpitzer [12] evideniaz riscul de
fractur al atelei de titan i, n acelai timp
de apariie a complicaiilor infecioase la
nivelul regiunii receptoare; una dintre
complicaiile frecvente este reprezentat de
eliminarea uruburilor de pe os. Acelai
autor relateaz despre expunerea unei atele
de reconstrucie utilizat cu un lambou
osteofascial din peroneu, dei defectul era
situat n partea lateral a mandibulei.
Oricum, cele mai multe expuneri ale atelelor
de reconstrucie au loc n primul an
postoperator.
CONCLUZII
Atela de reconstrucie din titan este
deosebit de util n refacerea continuitii
mandibulare consecutiv unor exereze
tumorale, fiind utilizat n dou ipostaze:
singur ori n asociere cu un lambou liber
transferat din fibula.
Experiena ultimilor ani a evideniat
obinerea unor rezultate superioare atunci
cnd atela de reconstrucie este protejat prin
folosirea lambourilor musculocutanate din
latissimus dorsi, liber transferate.
interese.
BIBLIOGRAFIE
1. Schusterman MA, Reece GP, Kroll SS,
Weldon ME. Use of the AO plate for
immediate mandibular reconstruction in
cancer patients. Plast Reconstr Surg. 1991;
88(4): 588-593.
2. Irish JC, Gullane PJ, Gilbert RW, Brown DH,
Birt BD, Boyd JB. Primary mandibular
reconstruction with the titanium hollow screw
reconstruction plate: Evaluation of 51 cases.
Plast Reconstr Surg. 1995; 96(1): 93-99.
3. Daniel RK. Mandibular reconstruction with
free tissue transfers. Ann Plast Surg.
1978; 1: 346-352.
Costan VV. et al.

4. Chen HC, Demirkan F, Wei FC, Cheng SL,
Cheng MH, Chen IH. Free fibula
osteoseptocutaneous-pedicled pectoralis major
myocutaneous
flap
combination
in
reconstruction of extensive composite
mandibular defects. Plast Reconstr Surg.
1999; 103(3): 839-845.
5. Wei FC, Demirkan F, Chen HC, Chen IH.
Double free flaps in reconstruction of
extensive composite mandibular defects in
head and neck cancer. Plast Reconstr Surg.
1999; 103(1): 39-47.
6. Byars LT. Subperiosteal mandibular resection
with internal bar fixation. Plast. Reconstr.
Surg. 1946; 1: 236.
7. Freeman BS. The use of vitallium plates to
maintain function following resection of the
mandible. Plast. Reconstr. Surg. 1948; 3: 73.
8. Hamaker
RC.
Irradiation
autogenous
mandibular grafts in primary reconstructions.
Laryngoscope 1981; 91: 1031-1051.
9. Cordeiro PG, Hidalgo DA. Conceptual
considerations in mandibular reconstruction.
Clin Plast Surg. 1995; 22(1): 61-69.
10. Urken ML, Weinberg H, Vickery C, et al. The
combined sensate radial forearm and iliac crest
free flaps for reconstruction of significant
glossectomy-mandibulectomy
defects.
Laryngoscope. 1992; 102(5): 543-558.
11. Blackwell KE, Buchbinder D, Urken ML.
Lateral mandibular reconstruction using softtissue free flaps and plates. Arch Otolaryngol
Head Neck Surg. 1996; 122(6): 672-678.
12. Shpitzer T, Gullane PJ, Neligan PC, et al. The
free vascularized flap and the flap plate
options: Comparative results of reconstruction
of lateral mandibular defects. Laryngoscope.
2000; 110(12): 2056-2060.
13. Schusterman MA, Kroll SS, Weber RS, Byers
RM, Guillamondegui O, Goepfert H. Intraoral
soft tissue reconstruction after cancer ablation:
A comparison of the pectoralis major flap and
the free radial forearm flap. Am J Surg. 1991;
162(4): 397-399.
14. Wei FC, Celik N, Yang WG, Chen IH, Chang
YM, Chen HC. Complications after
reconstruction by plate and soft-tissue free flap
in composite mandibular defects and
secondary salvage reconstruction with
osteocutaneous flap. Plast Reconstr Surg.
2003; 112(1): 37-42.
15. Boyd B, Mulholland S, Gullane P, et al.
Reinnervated lateral antebrachial cutaneous
neurosome flaps in oral reconstruction: Are we
making sense? Plast Reconstr Surg. 1994;
93(7): 1350-1359.
16. Cordeiro PG, Hidalgo DA. Soft tissue
coverage of mandibular reconstruction plates.
Head Neck Surg. 1994; 16: 112-115.
17. Balan M, Popescu E, Costan VV, Boiteanu O,
Reu R. Valoarea lamboului liber vascularizat
din fibula in reconstrucia pierderilor de
substan segmentare ale mandibulei. J Chir.
(Iai). 2012; 7(2): 238-244.
18. Robey AB, Spann ML, McAuliff TM,
Meza JL, Hollins RR, Johnson PJ. Comparison
of miniplates and reconstruction plates in
fibular
flap
reconstruction
of
the
mandible. Plastic Reconstr. Surg. 2008;
122(6): 1733-1738.
19. Hidalgo DA, Pusic AL. Free-flap mandibular
reconstruction: A 10-year follow-up study.
Plast Reconstr Surg. 2002; 110(2): 438-449;
20. Malata CM, McLean NR, Alvi R, McKiernan
MV, Milner RH, Piggot TA. An evaluation of
the
Wurzburg
titanium
miniplate
osteosynthesis system for mandibular fixation.
Br J Plast Surg. 1997; 50(1): 26-32.
385
21. Evans GRD, Clark N, Manson PN,

Leipziger LS. Role of mini- and micro-plate
fixation in fractures of the midface and
mandible. Ann Plast Surg. 1995; 34: 453-458.
22. Balan M, Popescu E, Dumitra CG, Ciofu M,
Boiteanu M, Costan VV. Valoarea modelului
tridimensional n reconstrucia pierderilor de
substan
segmentare
ale
mandibulei.
Observaii pe marginea unui caz clinic. Rev
Med Chir Soc Med Nat Iasi. 2011; 115(1):
227-231.
23. Strackee SD, Kroon FHM, Bos KE. Fixation
methods in mandibular reconstruction using
fibula grafts: A comparative study into the
relative strength of three different types of
osteosynthesis. Head Neck. 2001; 23(1): 1-7.
24. Kennady MC, Tucker MR, Lester GE,
Buckley MJ. Stress shielding effect of rigid
internal fixation plates on mandibular bone
grafts. Int J Oral Maxillofac Surg. 1989;
18(5): 307-310.
386
Costan VV. et al.
ARTICOLE ORIGINALE
387
ULCERELE DE STRES - ULCERELE CUSHING:

DIAGNOSTIC, TRATAMENT, PROFILAXIE
R. cerbina , G. Ghidirim, A. Dolghii, V. Lescov,
V. Burunsus, I. Glavan, Liliana Florea
Catedra chirurgie Nr. 1 N. Anestiade
Universitatea de Stat de Medicin i Farmacie N. Testemianu Chiinu, Republica Moldova
STRESS ULCERS: CUSHING ULCERS, DIAGNOSIS, TREATMENT, PREVENTION
(Abstract): BACKGROUND: Cushing ulcers appear at the 3rd to 5th day after stress situations
accompanied with hemorrhage in 5-10%, perforations in 4%. METHODS: Between 2007-2011 in
the National Scientific and Practical Center for Emergency Medicine Kishinev, 1917 patients with
superior gastric hemorrhages were treated, from which 139 in ICU. RESULTS: In 45 cases were
diagnosed Cushing ulcers: men 30, women 15 with age between 21 years and 87 years. The
disease causes were: cerebral vascular diseases 13(28.8%); fractures with hip replacement 16
(35.5%); chronic renal insufficiency and septic states - 3 (12.32%); severe head trauma 10
(22.2%). The mortality rate was 22.2% (10 patients). Gastroscopy revealed hemorrhages followed
by endoscopic hemostasis. For the prophylaxis of hemorrhage relapse all patients underwent
repeated endoscopic hemostasis 2 to 3 times. One patient was operated for a perforated bulbar
Cushing ulcer and another one due to Forrest IA hemorrhage that didnt respond to endoscopic
hemostasis Bilroth I antrum resection. Both patients died due to multiple organ dysfunction
syndrome (MODS). Patients with Cushing ulcers received anti-ulcer treatment: PPI, H2 blockers
in maximum dosages, hemostatic and repeated blood plasma transfusions. CONCLUSIONS:
Gastroscopy is obligatory in all patients with severe head trauma, septic states, chronic renal
insufficiency and severe cerebral vascular diseases. Anti-ulcer and hemostatic treatment insures
ulcer healing and scarring in most of the cases.
KEY WORDS: CUSHING ULCERS; DIAGNOSIS; TREATMENT
SHORT TITLE: Ulcerele Cushing
Cushing ulcers
HOW TO CITE: cerbina R, Ghidirim Gh, Dolghii A, Lescov V, Burunsus V, Glavan I, Florea L. [Stress ulcers - Cushing
ulcers: diagnosis, treatment, prevention]. Jurnalul de chirurgie (Iai). 2012; 8(4): 387-391.
INTRODUCERE
Dei ulcerele de stress sunt cunoscute
de mult vreme, ele rmn n actualitate
datorit complicaiilor grave care apar
evolutiv.
MATERIAL I METOD
Am urmrit retrospectiv frecvena
ulcerelor de stres din Centrul Naional
tiinifico-Practic de Medicin de Urgen
(CNPMU) al Republicii Moldova din
perioada 20072011, consultnd toate
nregistrrile medicale ale bolnavilor.
S-au nregistrat 1917 bolnavi cu

hemoragii digestive superioare (HDS), dintre
care 139 pacieni au necesitat tratament
intensiv n seciile de ATI (7,2%).
REZULTATE
Repartiia dup sex i vrst pacienii
este consemnat n Tabel I.
Endoscopia
digestiv
superioar
(EDS) a diagnosticat ulcere acute la 45
pacieni i ulcere cronice la 94 pacieni. n
Tabelul II sunt repartizate leziunile
hemoragice dup etiologie.

Adresa de coresponden: Conf. Dr. Romeo cerbina
Catedra chirurgie Nr.1 N. Anestiade, Universitatea de Stat de Medicin i Farmacie N. Testemianu Chiinu
Bd. tefan cel Mare i Sfnt, nr. 165; MD-2004, Chiinu, Republica Moldova
Tel.: 00373 22 24 34 08
Fax: 00373 22 24 23 44
e-mail: romeo_scerbina@yahoo.com
cerbina R. et al.
388
n Tabelul III sunt prezentate gradele

de HDS dup clasificarea Forest.
Dintre toi pacienii investigai ulcerele
Cushing au fost ntlnite la 45 pacieni
(Tabelul IV).
n Tabelul V sunt notate afeciunile
care au provocat ulceraiile Cushing.
Tabel I. Repartiia pacienilor dup sex i vrst
tratai n seciile ATI cu hemoragii digestive
superioare
Repartiia pacienilor dup sex/
vrst (ani)
Femei
Brbai
< 20 ani
21 30 ani
31 40 ani
41 50 ani
51 60 ani
61 70 ani
71 80 ani
> 80 ani
Nr. pacieni
(%)
50 (35,9% )
89 (64,1% )
2 (1,43% )
10 (7,2% )
8 (5,76% )
23 (16,5%)
41 (30,0% )
22 (15,8% )
25 (18,0% )
8 (5,76% )
Tabel III. Clasificarea Forest a HDS n seciile ATI
Tabel II. Etiologia leziunilor hemoragice

Localizarea ulcerelor sau eroziunilor
Ulcer prepiloric
Ulcer gastric
Ulcerul bulbului duodenal
Ulcer subcardial
Sindromul Mallory-Weiss
Esofagita eroziv - ulceroas
Varice esofagiene
Gastrit hemoragic
Bulbit eroziv
Sindromul Delafois
Ulcere acute ale bontului gastric
Ulcer pepptic al anastomozei
Ulcer postbulbar
Polip gastric
- inhibitori de pomp de protoni asociat

antibioterapiei anti HP.
Acest tratament a fost continuat timp
de 68 sptmni indiferent de starea
bolnavului i patologia, care a indus apariia
acestor ulcere.
S-a
repetat
endoscopia
pentru
evaluarea n dinamic a ulceraiilor
depistate.
Au necesitat intervenie chirurgical 2
bolnavi:
- un pacient cu ulcer duodenal bulbar
anterior de stres perforat (sutura
perforaiei) i respectiv,
- un pacient cu ulcer duodenal Forest IA
cu hemoragie grav pe fondul traumei
cranio-cerebrale severe (hemostaz
endoscopic eec antrectomie cu
anastomoz Pean Bilroth I).
Din 45 pacieni cu ulceraii Cushing,
10 au decedat (22,2%). Majoritatea (80%;
n=8) au decedat din cauza afeciunilor de
baz, etiologia ulceroas fiind responsabil
doar n cele 2 cazuri operate.
Nr. pacieni
7
40
66
1
8
7
6
12
3
6
1
8
2
1
Pacienii cu ulcer Cushing pacienii au

primit urmtorul tratament antiulceros:
- inhibitori de pomp de protoni n doze
maxime, de prim intenie la pacienii
cu boala ulceroas, dar i la pacienii
cu
traumatism
grav
cerebral,
insuficien cronic renal, stri
septice;
Clasificarea HDS / Forest
Nr. pacieni
Forest 1A
13
Forest IB
27
Forest IIA
66
Forest IIB
30
Forest IIC
Forest III
TOTAL INVESTIGAII
3
142
DISCUII
Ulcerele Cushing reprezint o
patologie grav prin apariia lor la pacienii
cu diverse patologii ale sistemului nervos
central, traumatisme grave cerebrale,
osteoarticulare, stri septice.
Pentru prima dat legtura ntre trauma
cranio-cerebral i perforaia stomacului a
stabilit-o Hunter n 1772 [1]. n 1932 Harvey
Cushing a descris ulcerele acute aprute la
pacienii cu traume cerebrale grave. Au
urmat cercetri n domeniul ulcerelor de
stres (A. Dupuytren,1832; S. Cooper, 1839;
G. Lomg, 1840; J. Svan, 1883). G. Bergman
Ulcerele Cushing
389
n 1932 a subliniat rolul sistemului nervos n

etiologia bolii ulceroase. C. Rokitansky n
1839 a descris apariia ulcerelor la pacienii
cu afeciuni i traume ale sistemului nervos
central.
Tabel IV Sexul i vrsta pacienilor cu ulceraii
Cushing
Sexul pacienilor
Nr. pacieni
(%)
Brbai
Femei
30 (66,6%)
15 (33,4%)
Vrsta pacienilor (ani)

< 20
21 - 30
31 - 40
41 - 50
51 - 60
61 - 70
71 - 80
>80
TOTAL
0 (0%)
2 (4,4%)
4 (8,8%)
7 (15,5%)
12 (26,6%)
5 (11,1%)
13 (28,8%)
2 (4,4%)
45(100%)
Tabel V. Patologiile care au indus apariia ulcerelor

Cushing
Patologiile ce au indus ulcerele
Cushing
Nr. pacieni
(%)
Bolile cerebrovasculare
13 (28,8%)
Fracturi cu protezare de old
16 (35,5%)
Patologii grave urologice
3 (6,6%)
Stri septice
3 (6,6%)
Traumatisme grave cranio-cerebrale
10 (22,2%)
Total
45 (100%)
Dup A.L. Grebenev i A.A. eptulin

(1989) ulcerele de stres, numite ulcere
Cushing sunt atribuite clasei 1B ulcere
simptomatice: aprute n cadrul traumelor
cranio-crebrale, hemoragiilor cerebrale i n
cadrul operaiilor neuro-chirurgicale, dup 35 zile [1]. Complicaiile hemoragice se
dezvolt n 5-10% cazuri, iar perforaiile n
4% [1]. Din cauza strii grave tabloul clinic
esta ters, uneori fiind mascat de semnele
clinice i simptomatologia patologiei de
baz. Hemoragiile, chiar i cele masive,
datorit parezei intestinale, nu sunt

exteriorizate imediat sub form de
hematemez i melen. Semnele clinice
precoce greuri, vome, vertij, uscciune n
gur, slbiciune, tahicardia erau atribuite
leziunilor traumatice. Bolnavii fiind de
obicei comatoi n absena anamnezei,
diagnosticul este stabilit doar endoscopic.
Clinica i simptomatologia n cadrul
traumelor multiple, asociate este n strict
concordan cu intensitatea hemoragiei cea
ce are loc i n fracturile oaselor lungi, ale
oaselor bazinului, traumatismelor grave
cranio-cerebrale, care centraliznd circulaia
sangvin provoac ischemia mucoasei
gastrice i duodenale.
Este indicat tratamentul conservator cu
supravegherea endoscopic i hemotologic
n dinamic a pacienilor cu ulcere
necomplicate. n cazul ulcerelor complicate
se va stabili cauza declanrii hemoragiei,
caracterul procesului patologic, vrsta
pacientului, gradul gravitii i patologia
asociat. E cunoscut c pacienii cu HDS
grave suport mai uor tratamentul
chirurgical, dect pacienii cu hemoragie
progresiv cu extenuarea sistemelor de
aprare chiar i n cadrul unei terapii
volemice adecvate [1].
Ulcerele Cushing sunt cele mai severe
complicaii ale traumatismului cerebral cu o
mortalitate de peste 50% [2]. Etiologia este
multifactorial dar apariia ulcerelor i
eroziunilor hemoragice acute sunt asociate
cu perfuzia splanhnic inconsistent i
ischemia mucoasei. Ele se dezvolt la
pacienii intubai peste 24 ore, la tramatizaii
cerebrali, la cei resuscitai pentru oc,
hemoragie, sepsis, icterici, la pacienii cu
MSOF i SIRS. Ulcerele de stres sunt leziuni
superficiale ale mucoasei predominant n
regiunea fundic gastric i e necesar de
difereniat
de
reactivarea
diatezelor
ulceroase preexistente. Ele apar dup traume
severe i septicemii i se disting ca ulcere
Cushing, care se deosebesc de ulcere induse
medicamentos. Ele sunt rezultatul ischemiei
mucoasei gastrice, factor important al
apariiei leziunii, cu implicarea acidului
clorhidric i pepsinei luminale, care
390
declaneaz ulceraia [3]. Un alt factor

etiologic este refluxul duodenal. Acidoza
sever i deficitul alcalin cu deprimarea
secreiei sunt factori, atribuii apariiei
defectelor mucoasei. Rolul steroizilor i
prostoglandinelor este controversat. Interesul
ctre aceast patologie a crescut n ultimii 15
ani din cauza ratei nalte de mortalitate.
Un alt factor important este atribuit
factorului microbian
nsui termenul ulcer de stres
reprezint o entitate care poate cuprinde i
alte patologii: gastrit eroziv, gastrit
hemoragic
eroziv,
ulceraii
acute
gastroduodenale, leziuni acute de mucoas.
Dificulti de diagnostic apar cnd
pacientul prezint un ulcer duodenal sau
gastric preexistent i o gastrit hemoragic
sau cnd hemoragia sau perforaia apare i n
alte situaii clinice. Boala ulceroas i
hemoragiile din ulceraii acute au
manifestri
sau
complicaii
diferite.
Ulceraiile acute de stress cu multiple
eroziuni superficiale sunt localizate n
regiunea fundic a stomacului.
Harvey Cushing a operat peste 2000
pacieni cu tumori ale creierului, micornd
mortalitatea de la 50 la doar 8%. Ca
cercettor el a descris boala Cushing,
reflexul Cushing i ulcerul Cushing [4].
Examenul endoscopic stabilete o
ngroare considerabil a mucoasei la cteva
ore de la traumatism la majoritateae
pacienilor examinai. Angiografia poate fi
folosit n cazurile de incertitudine
endoscopic de diagnostic [5]. Ali autori
indic ca metode de diagnostic radiografia
baritat [6].
Mai multe studii au demonstrat
eficiena att al inhibitorilor de pomp de
protoni ct i a antagonitilor de receptori
anti histaminici-h2 administrate preoperator.
Au fost comparate pH-ul intragastric, nivelul
gastrinei (PGE2) i incidena ulcerelor de
stres n toate grupele cercetate. S-a ajuns la
concluzia eficacitii nalte a ambelor
preparate n scderea secreiei gastrice i a
nivelului seric de gastrin. Cheia profilaxiei
acestei complicaii este meninerea ph-ului
intragastric normal [7]. La pacieni selectai,
cerbina R. et al.
cu o hemoragie continu se poate administra
vasopresin sau se poate tenta embolizare
vascular [5]. Tratamentul chirurgical este
urmat de o mortalitate nalt. Vagotomia,
piloroplastia pot fi recomandate ca operaii
de prim pas n hemoragiile din ulcerele de
stres. n cazul hemoragiilor repetate, dup
aceste operaii, se preconizeaz o
gastrectomie total [8].
CONCLUZII
n
cazul
traumatismelor grave
craniocerebrale, boli cerebro-vasculare,
intervenii chirurgicale majore, fracturile de
old, bazin, inclusiv operaii majore, stri de
oc, septicemii se recomand tratament
antiulceros indiferent de prezena sau
absena
antecedentelor
anamnestice
ulceroase. n cazul apariiei HDS se
recomand
tratamentul
conservator,
efectuarea EDS att pentru apreciarea
evoluiei leziunilor hemoragice dar i pentru
realizarea
hemostazei
endoscopice.
Tratamentul chirurgical al ulcerelor Cushing
hemoragice trebuie rezervat n cazul eecului
tratamentului conservator sau tratamentul
endoscopic sau pentru complicaiile
perforative.
interese
BIBLIOGRAFIA
1. Grebenev AL, Sheptulin AA Considerations
on the classification of peptic ulcer. Klin Med
(Mosk). 1989; 67(1): 142-145.
2. Chapman ML. Peptic ulcer: a medical
perspective. Med Clin North Am. 1978; 62: 3951.
3. Selezneva MG, Kolobov SV, Zarat'iants OV,
Shevchenko VP, Zarat'iants GO, Ozeritski
AV Acute erosive gastropathies. Arkh Patol.
2010; 72(5): 57-60.
4. Wijdicks EF. Cushing's ulcer: the eponym and
his own. Neurosurgery. 2011; 68(6): 16951698.
5. Baum S, Stein GN, Usbaum M, Chait A.
Selective arteriography in the diagnosis of
Ulcerele Cushing
hemorrhage in the gastrointestinal tract. Radiol
Clin North Am. 1969; 7(1): 131-134.
6. Stein GN, Martin RD, Roy RH,Finkelstein
AK.
Evaluation
of
conventional
roentgenografic tehniques for demonstration
of duodenal ulcers craters. Am J Roentgenol
Radium Ther Nucl Med. 1964; 91: 801-807.
391
7. Pilkington KB, Wagstaff MJ, Greenwood JE.

Prevention of gastrointestinal bleeding due to
stress ulceration: a review of current literature.
Anaesth Intensive Care. 2012; 40(2): 253-259.
8. Sale TA. Successful treatment of a perforated
Rokitansky-Cushing ulcer. Arch Dis Child.
1956; 31(157): 233-235.
392
cerbina R. et al.
CASE REPORT
393
SUPERIOR MESENTERIC ARTERY SYNDROME - AN

UNUSUAL CAUSE OF DUODENAL OBSTRUCTION
Sahu SK , Singh PK, Ray J, Uniyal M, Sharma C,
Sekhar C, Kapruwan H, Sachan PK
Department of General Surgery
Himalayan Institute of Medical Sciences
SUPERIOR MESENTERIC ARTERY SYNDROME - AN UNUSUAL CAUSE OF
DUODENAL OBSTRUCTION. (Abstract): Superior mesenteric artery (SMA) arising from aorta
at the level of first lumbar vertebra usually takes an angular downward course from ventral
surface of aorta. It is through this vascular angle that the 3rd part of duodenum passes at the level
of 4th lumbar vertebra. Fat and lymphatics around SMA maintains the angle at 25 to 60 with a
mean of 450 and provide protection against duodenal compression. In Superior Mesenteric Artery
Syndrome, the SMA-aorta angle in narrowed down to 7 to 22 with a mean of 80 leading to
entrapment of the transverse part of duodenum between the artery and the vertebral column and
aorta with resultant partial or complete duodenal obstruction. We report a case of Superior
Mesenteric Artery Syndrome which was diagnosed by CECT abdomen. Duodeno-jejunostomy
was done to treat this condition.
KEY WORDS: SUPERIOR MESENTERIC ARTERY; DUODENUM;
MESENTERIC ARTERY SYNDROME; DUODENO-JEJUNOSTOMY.
SUPERIOR
RUNNING HEAD: Superior mesenteric artery syndrome

HOW TO CITE: Sahu SK, Singh PK, Ray J, Uniyal M, Sharma C, Sekhar C, Kapruwan H, Sachan PK [Superior
mesenteric artery syndrome - an unusual cause of duodenal obstruction]. Jurnalul de chirurgie (Iai). 2012; 8(4): 393-396.
INTRODUCTION
Superior mesenteric artery (SMA)
arising from aorta at the level of first lumbar
vertebra usually takes an angular downward
course from ventral surface of aorta.
It is through this vascular angle that
the 3rd part of duodenum passes at the level
of 4th lumbar vertebra.
Fat and lymphatics around SMA
maintains the angle at 25 to 60 with a
mean of 45o and provide protection against
duodenal compression.
In Superior Mesenteric Artery
Syndrome, the SMA-aorta angle is narrowed
down to 7 to 22 with a mean of 8o leading
to entrapment of the transverse part of
duodenum between the artery and the
vertebral column and aorta with resultant

partial or complete duodenal obstruction.
SMA-aorta distance is also reduced to
2 -8 mm (normal range 10 to 28 mm) at the
level of 4th lumbar vertebra in Superior
Mesenteric Artery Syndrome. [1-4].
CASE REPORT
A 58 year old female was admitted
with history of upper abdominal discomfort,
recurrent bilious vomiting containing
undigested food material and significant
weight loss since last 8 months.
The symptoms used to disappear when
the patient used to lie in left lateral or prone
position. For the similar complaints she was
repeatedly hospitalized and managed

Correspondence to: Shantanu Kumar Sahu, MS, Associate Professor,
Department of General Surgery
Himalayan Institute of Medical Sciences
Swami Ram Nagar, Post- Doiwala, Dehradun
Uttarakhand, 248140, India.
Phone: 0091 (0) 94 12 93 38 68
Email: lntshantanu@yahoo.co.in
394
conservatively for the last 8 months at local

hospitals.
On
examination
patient
was
dehydrated and malnourished with a weight
of 45 kg.
Examination of abdomen revealed
epigastric distension with a visible peristalsis
moving from left to right and no palpable
mass.
Routine
investigation
revealed
Hemoglobin 12 mg/dL, total leukocyte count
8000/mm3. Renal function tests were within
normal limits. Upper GI endoscopy after
gastric lavage revealed a normal study upto
2nd part of duodenum. Sonography of
abdomen was normal.
Oral and IV contrast enhanced- CT
scan of abdomen was planned which
revealed dilatation of stomach and
duodenum upto 3rd part and narrowing of 3rd
and 4th part of duodenum.
The angle between superior mesenteric
artery and aorta was 20 confirming superior
mesenteric artery syndrome (Fig. 1).
B
Fig. 1 CT scan
A: CECT abdomen showing dilatation of stomach and duodenum

up to 3rd part and narrowing of 3rd and 4th part of duodenum.
B: CECT abdomen showing the 20 angulation between superior
mesenteric artery and aorta along with the duodenal compression
confirming superior mesenteric artery syndrome.
Exploratory laparotomy revealed

superior mesenteric artery compression of
the 3rd part of duodenum with dilatation of
proximal duodenum and stomach.
Lysis of ligament of Treitz along with
side to side duodenojejunostomy with the 3rd
part of the duodenum and a loop of jejunum
Sahu SK. et al.

was done. Patient had an uneventful post
operative recovery (Fig. 2, 3).
DISCUSSION
Superior Mesenteric Artery Syndrome
(SMAS) was first described in literature by
von Rokitansky in 1861 on autopsy studies.
The largest and most complete study of this
disease was published by Wilkie in 1927,
based on 75 cases.
Chronic
duodenal
ileus,
arteriomesenteric duodenal compression,
gastromesenteric ileus, aortomesenteric
artery compression, duodenal vascular
compression, Wilkies syndrome and Cast
syndrome are the various alternative
nomenclatures given to this entity [3-7].
Reviews of literatures have reported
the incidence of this entity in the range of
0.0130.53%. Females are affected more
commonly than males with the age of
presentation ranging between 10-39 years.
This condition has been reported at the
extremes of age with the youngest patient
being a 35-week gestational age newborn in
whom the diagnosis was made prenatally,
and the oldest patient a woman over 90 years
of age.
Lack or loss of retroperitoneal and
periduodenal fat pads is attributed to this
acute angulation resulting in the duodenal
clamping.
Severe wasting diseases such as burns,
cancer and endocrine diseases; severe
injuries such as head trauma; spinal trauma,
deformities like scoliosis and application of
a body cast; dietary disorders such as
anorexia
nervosa
or
malabsorptive
syndromes; and the postoperative states are
associated with this entity.
Anatomical deformities resulting in
this entity includes a high insertion of the
duodenum at the ligament of Treitz, a
congenitally low origin of the superior
mesenteric artery and compression of the
duodenum caused by peritoneal adhesions,
which are a results of duodenal malrotation.
A surgical intervention which reduces
the width of the aortomesenteric angle
includes bariatric surgery, scoliosis surgery,
Superior mesenteric artery syndrome

ileoanal pouch anastomosis, and aortic
aneurysm disease as well as its repair is
associated with this entity [8-17].
Fig. 2 Intraoperative view
Exploratory laparotomy showing superior mesenteric artery

compression of the 3rd part of duodenum along with dilatation of
the proximal duodenum
Fig. 3 Intraoperative view
Duodenojejunostomy with the 3rd part of proximal duodenum and a

loop of jejunum done in the SMA syndrome
Postprandial upper abdominal pain and

fullness, voluminous bilious vomiting and
rapid weight loss are the most characteristic
symptoms of presentation of superior
mesenteric artery syndrome. Certain postural
adjustments like left lateral, knee chest or
prone position may relieve these abdominal
symptoms.
Epigastric distension and a tympanitic
and tender upper abdomen are usually
present. Laboratory findings will show
evidence of dehydration and electrolyte
abnormalities [4,7].
Plain abdominal radiography may
suggest the diagnosis if it shows a dilatation
395
of the first and second portions of the

duodenum, with or without gastric dilatation.
Barium studies may show abrupt
vertical and oblique compression of the
mucosal folds; antiperistaltic flow of barium
proximal to the obstruction, producing toand-fro movement; delay of 4 to 6 hours in
transit through the gastroduodenal region
and relief of obstruction when the patient is
placed in a position (prone or knee-chest).
Contrast enhanced CT scan abdomen
and MRI abdomen is helpful in estimation of
the actual aortomesenteric gap as well as
visualization of the retroperitoneal and
mesenteric fat and the level of duodenal
compression. Selective SMA arteriography
against a barium-filled duodenum will
demonstrate the extrinsic compression and
measure the aortomesenteric angle and the
distance from the aorta [17].
Conservative management includes
rest to GI tract, fluid and electrolyte
resuscitation, parenteral nutrition and lying
in left decubitus or knee chest position.
Efforts to induce weight gain with high
calories liquid diet in left decubitus or knee
chest position have been tried with varying
results.
Aggressive nutritional support using a
nasojejunal tube placed past the point of
obstruction via endoscopic or radiographic
guidance may be necessary if the patient
does not tolerate or achieve adequate oral
intake.
Surgery is indicated if there is a long
history of vomiting, progressive weight loss,
pronounced dilatation and stasis of the
duodenum.
Open or laparoscopic approach can be
adopted with equal success. Loop duodenojejunostomy from the third portion of the
duodenum to the jejunum is the procedure of
choice with 80% success rate.
Gastro-jejunostomy,
Rouxen-Y
duodeno-jejunostomy, anterior transposition
of the third part of the duodenum above the
SMA and lysis of ligament of Treitz
(Strongs operation) and mobilization of
duodenum have been tried with varying
results [8,18,19].
396
Sahu SK. et al.
None to declare
REFERENCES
1. Plea A, Constantinescu C, Crumpei F,
Cotea E. Superior mesenteric artery syndrome:
an unusual case of intestinal obstruction. J
Gastrointestin Liver Dis. 2006; 15(1): 69-72.
2. Applegate GR, Cohen AJ. Dynamic CT in
superior
mesenteric
artery
syndrome.
J Comput Assist Tomogr. 1988; 12: 976-980.
3. 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.
4. 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.
5. Von
Rokitansky
C.
Lehrbuch
der
pathologischen Anatomie.Vienna: Braumuller
& Seidel. 1861.
6. Wilkie DP: Chronic duodenal ileus. Am J Med
Sci. 1927; 173: 643-649.
7. Ahmed AR, Taylor I. Superior mesenteric
artery syndrome. Postgrad Med J. 1997; 73:
766-768.
8. Ylinen P, Kinnunen J, Hockerstedt K. Superior
mesenteric artery syndrome. A follow up study
of 16 operated patients. J Clin Gastroenterol
1989; 11: 386-391.
9. Elbadawy MH. Chronic superior mesenteric
artery syndrome in anorexia nervosa. Br J
Psychiatry. 1992; 160: 552-554.
10. McClenathan JH. Hyperthyroidism as a cause
of superior mesenteric artery syndrome. Am J
Dis Child. 1988; 142: 685-686.
11. Milner EA, Cioffi WG, McManus WF,

Pruitt BA Jr. Superior mesenteric artery
syndrome in a burn patient. Nutr Clin Pract.
1993; 8: 264-266.
12. Philip PA. Superior mesenteric artery
syndrome in a child with brain injury. Case
report. Am J Phys Med Rehabil. 1981; 70:
280-282.
13. Ramos M. Recurrent superior mesenteric
artery syndrome in a quadriplegic patient.
Arch Phys Med Rehabil. 1975; 56: 86-88.
14. Roth EJ, Fenton LL, Gaebler-Spira DJ, Frost
FS, Yarkony GM.Superior mesenteric artery
syndrome in acute traumatic quadriplegia:case
reports and literature review. Arch Phys Med
Rehabil. 1991; 72: 417-420.
15. Cohen LB, Field SP, Sachar DB. The superior
mesenteric artery syndrome: the disease that
isn't, or is it? J Clin Gastroenterol. 1985; 7:
113-116.
16. Strong EK. Mechanics of arteriomesenteric
duodenal obstruction and direct surgical attack
upon etiology. Ann Surg. 1958; 148: 725-730.
17. Hearn JB. Duodenal ileus with special
reference to superior mesenteric artery
compression. Radiology. 1966; 86: 305-310.
18. Gustafasson L, Falk A, Lukes PJ, Gam Klour,
Diagnosis and treatment of superior
mesenteric artery syndrome. Br. J Surg. 1984;
71: 499-501.
19. Neto PRF, Paiva RDA, Filho AL, Queriroz
FLD, Noronha T. Superior mesenteric artery
compression syndrome - case report. J
Coloproctol. 2011; 31(4): 401-404.
CAZURI CLINICE
397
EFECTELE MEGALIPOSUCIEI CU ULTRASUNETE

ASUPRA INDICELUI DE MAS CORPORAL I
CONCENTRAIEI SERICE DE LEPTIN LA FEMEILE
OBEZE PREZENTARE DE CAZ
Laura Maria Curic1, , F. Bassetto2, Carmen Vulpoi3
1) Clinica de Chirurgie Plastic i Reconstructiv
2) Clinica de Chirurgie Plastic i Reconstructiv
Universitatea de Medicin i Farmacie Padova
3) Clinica de Endocrinologie
THE EFFECTS OF ULTRASOUND-ASSISTED MEGALIPOSUCTION ON BODY MASS
INDEX AND SERIC LEPTIN LEVEL IN OBESE WOMEN - CASE REPORT (Abstract):
INTRODUCTION: Numerous studies in the literature shows that liposuction has a functional role
(removal of large quantities of fat would lead to an increase lipase activity, leading to a continued
reduction in body weight, linked to an inhibition of the hunger center through a feedback
mechanism). Nowadays, liposuction is performed not only for aesthetic reasons, but also in
therapy to improve quality of life of obese patients. CASE REPORT: We exemplify the effects of
the surgical removal of subcutaneous adipose tissue by ultrasound-assisted megaliposuction
(UAM) on body mass index (BMI) and seric leptin level in a 53 years old premenopausal obese
women. UAM reduced both parameters in the first six months after surgery, without further
important changes in the following six months. Leptin levels transiently increased after UAM and
then declined according to fat mass reduction. Leptin levels were directly associated with BMI,
except postoperative inflammatory phase. Only one minor complication was noted, a burn which
was solved favorably. CONCLUSIONS: The results are consistent with existing data in literature
and in addition is a response to the dilemmas and conflicting statements about this issue.
KEY WORDS: OBESITY; ULTRASOUND-ASSISTED-MEGALIPOPLASTY; LEPTIN;
BODY MASS INDEX
SHORT TITLE: Ultrasound assisted megalipoplasty
Megaliposucie cu ultrasunete
HOW TO CITE: Curic ML, Bassetto F, Vulpoi C. [The effects of ultrasound-assisted megaliposuction on body mass index
and seric leptin level in obese women- case report]. Jurnalul de chirurgie (Iai). 2012; 8(4): 397-402.
INTRODUCERE
Obezitatea este o afeciune complex,
multifactorial, o condiie medical grav ca
rezultat al unui ctig persistent n greutate
pe seama esutului adipos (aportul de energie
depind consumul). n ultimele decade ea a
devenit una din cele mai frecvente boli de
nutriie din lume, avnd amploarea unei
pandemii, conform raportului OMS 2011,
fiind considerat boala secolului XXI [1].
Chirurgia bariatric este o metod eficient

de tratament a obezitii morbide i
reprezint opiunea terapeutic cea mai
adecvat pentru aceti pacieni [2].
Numeroase studii din literatur,
demonstreaz c liposucia clasic i
variantele sale moderne au i un rol
funcional (extragerea unei importante
cantiti de esut adipos ar duce la
accentuarea activitii lipazei, ducnd printr-

Adresa de coresponden: Dr. Laura Maria Curic
Doctorand Universitatea de Medicin i Farmacie Gr T Popa Iai
Clinica de Chirurgie Plastic i Reconstructiv
Str. Pictorului, nr. 3, 700321, Iai, Romania
e-mail: lauracuric2004@yahoo.com.
398
un mecanism de feedback, la o continu

reducere a greutii corporale, legat i de o
inhibare a centrului foamei) [3-9].
PREZENTARE DE CAZ
Raportm cazul unei paciente n vrst
de 53 de ani, care a fost supus tehnicii de
megaliposucie cu ultrasunete (UAM) la
Clinica de Chirurgie Plastic a Spitalului
Universitar Civil din Padova [10].
Pacienta aflat n premenopauz, a fost
diagnosticat
cu
obezitate
morbid,
complicat cu HTA, tratat farmacologic cu
diuretice i inhibitori de enzim de
conversie,
un
grad
uor
de
hipercolesterolemie fr nivel sczut al
HDL-colesterolului i un DZ tip 2
noninsulinonecesitant tratat prin ajustarea
dietei.
Pacienta nu a prezentat oscilaii
semnificative ale greutii corporale (> 20%)
n ultimele 6 luni premergtoare internrii.
n urm cu 3 ani pacienta a suferit un
banding gastric, cu scdere ponderal de
41%, care nu s-a meninut n timp (dilataia
rezervorului gastric).
Pacienta a refuzat alte intervenii de tip
bariatric i s-a adresat chirurgului plastician
la indicaia echipei interdisciplinare care se
ocup de tratamentul obezitii, n vederea
asocierii UAM.
Pacienta nu prezenta contraindicaii
pentru aceast tehnic (risc anestezic mic) i
a semnat un formular de consimmnt
informat nainte de operaie.
La luarea n eviden a pacientei au
fost efectuate msurtorile antropometrice
cu pacienta n ortostatism, cu mbrcminte
uoar, fr pantofi.
nlimea a fost determinat cu o
precizie de 0,01 m cu ajutorul unui
stadiometru montat la perete, iar greutatea
corporal a fost determinat cu o precizie de
0,05 kg cu ajutorul unui cntar calibrat.
Ulterior s-a determinat IMC.
Determinarea cantitativ a leptinei n
ser a fost efectuat n cadrul Laboratorului
Clinic al Spitalului Civil din Padova. Pentru
aceast determinare s-a utilizat kitul ELISA
specific DRG International, Mountainside,
Curic ML. et al.

NJ,
n
funcie
de
instruciunile
productorului.
Aceti parametri au fost determinai n
pre i postoperator la 1-3 zile, 1-6 luni i
1an.
S-a utilizat ca tehnic operatorie
UAM, tehnica superwet, care a fost
practicat sub supravegherea Prof. Dr. F.
Bassetto.
n dimineaa operaiei s-a fcut
desenul preoperator. S-au marcat cu un
marker cutanat negru zonele int i cu un
marker rou toate depresiunile i zonele de
aderen, zone unde trebuie evitat
lipoaspiraia (Fig. 1).
Fig. 1 Aspect preoperator:

93 kg, IMC = 40,7 kg/m2
n sala de operaie s-a realizat

antisepsia tegumentelor cu o soluie
nonalcoolic (Cetramid) cu pacienta n
poziie de ortostatism. Dup inducerea
anesteziei generale i intubaiei orotraheale
pe masa de operaie, pacienta a fost aezat
n decubit dorsal pe un pat special pentru
chirurgia bariatric, acoperit de cmpuri
sterile. Dup finalizarea lipoaspiraiei
regiunilor dorsale, bolnava este reaezat n
decubit ventral, tehnica utilizat fiind
aceeai.
Raportul infiltrat/aspirat corespunde
indicaiilor tehnice ale acestei metode, avnd
o valoare de 0,8. Att esutul adipos
superficial ct i cel profund au fost
ndeprtate din zone ca flancuri, olduri,
coapse, fese, abdomen, cantitatea de
lipoaspirat ajungnd la 13 litri. Intervenia a
durat 150 minute, iar durata total de
aplicare a energiei ultrasonice a fost de 90
minute. Cu ajutorul ultrasunetelor s-au
aspirat 44 ml/min.
399
n postoperator s-a realizat o bun

analgezie peridural, continu, cu anestezice
locale n doze similare normoponderalilor n
vederea mobilizrii precoce a pacientului i
pentru ca durerea s nu interfereze cu
respiraia. Pacienta a beneficiat de
antibiprofilaxie i antiinflamatoare.
Profilaxia complicaiilor respiratorii sa realizat printr-o fizioterapie respiratorie
agresiv combinat cu oxigenoterapia pe
masc i administrarea de anti-H2, sond de
aspiraie gastric i poziie semieznd
pentru profilaxia pneumoniei de aspiraie.
Profilaxia bolii tromboembolice s-a
realizat prin utilizarea terapiei anticoagulante, a manetelor cu compresiune
intermitent a gambelor i mobilizarea precoce
a pacientei. O atenie deosebit a fost acordat
profilaxiei leziunilor de decubit i infeciilor
tegumentare care apar extrem de rapid la
aceti pacieni.
Tabel I. Valorile IMC, greutii corporale i a
concentraiei serice de leptin
IMC
(kg/m2)
Greutatea
(kg)
Leptin
(g/mL)
PREOPERATOR
40,7
93
34,5
ZIUA 1
39,4
90
39,5
ZIUA 3
38,1
87
31,6
LUNA 1
37,7
86
29,1
LUNA 6
36,4
83
28,7
1 AN
36,4
83
28,6
Fig. 2 Aspect postoperator la 6 luni:

83kg, IMC=36,4 kg/m2
Igiena a fost riguroas n special la

nivelul pliurilor cutanate, iar modificarea
poziiei n pat s-a fcut periodic, evitnd o

presiune prelungit pe aceleai teritorii.
Suportul nutriional trebuie avut n
vedere la toi pacienii obezi, cunoscndu-se
faptul c acetia au un metabolism accelerat.
n cazul prezentat nutriia enteral s-a reluat
rapid, n a-4-a zi postoperator.
La externare, n ziua 10 postoperator,
pacienta a fost informat cu privire la stilul
de via pe care trebuie s l respecte. La
domiciliu a purtat mbrcminte special
elastocompresiv timp de 45 zile, a efectuat
edine de limfodrenaj (3 ori/sptmn, 1
lun) i edine de endermologie (15-20
tratamente de cte 45 minute de 2
ori/sptmn, 3luni) din ziua 15
postoperator.
Rezultatele obinute nainte i dup
UAM sunt raportate n Tabelul I.
Beneficiile estetice aduse de aceast
metod pot fi observate imediat postoperator
i se menin i la distan (Fig. 2).
Trebuie menionat faptul c nu s-au
nregistrat
complicaii
sistemice.
Complicaia local de arsur a fost un
incident de tehnic operatorie, survenit ca
urmare a micrilor prea superficiale ale
sondei de ultrasunete, pacienta fiind una din
primele paciente operate cu aceast tehnic.
Arsurile de contact ntre sond i
tegument, la nivelul locurilor de introducere
ale sondei, au fost evitate prin utilizarea unor
teci de rcire i protecie. Din fericire,
incidena acestor complicaii scade n mod
semnificativ cu experiena, fapt argumentat
de studii recente [11].
Rata complicaiilor UAM este mai
mic dect n cazul chirurgiei bariatrice. n
plus, natura acestor complicaii este mai
mult de ordin estetic i mai puin de ordin
medical, complicaiile majore fiind foarte
rare [12].
Aceste complicaii apar de cele mai
multe ori pe perioada curbei de nvare a
tehnicii care este suficient de lung.
La controalele postoperatorii repetate a
fost evaluat gradul de satisfacie al pacientei,
aceasta declarndu-se foarte satisfcut de
rezultatul obinut i dorind s recomande
aceast intervenie i altor persoane.
400
Indicele de mas corporal se reduce

cu 4,3 Kg/m2 la 6 luni i rmne constant la
1 an postoperator.
Greutatea corporal n preoperator a
fost de 93 kg, depind valoarea greutii
ideale cu 42 kg. Dac greutatea corporal nu
prezint o scdere important n prima zi
postoperator (90 kg), ea fiind puin
corelabil cu valoarea volumului de
lipoaspirat ndeprtat, devine semnificativ
ncepnd cu ziua 3 postoperator (87 kg).
Scderea ponderal continu i se
stabilizeaz la 6 luni de la operaie, pe
msur ce scade edemul postoperator.
Valorile obinute la 6 luni se menin
constante i la 1 an postoperator (83 kg),
pacienta pierznd n greutate 10 kg.
n prima zi postoperator s-a putut
observa o cretere semnificativ a
concentraiei serice de leptin comparativ cu
perioada preoperatorie (cu 5 ug/ml).
Modificrile au fost foarte rapide i de
scurt durat (acest cretere dispare n ziua
3 postoperator).
DISCUII
Majoritatea leptinei circulante este
produs de esutul adipos alb; se poate deci
specula c aceste creteri ale nivelelor de
leptin se datoreaz provenienei lor din
grsime. Metodologia utilizat nu ne permite
s facem diferena dac aceast cretere se
datoreaz creterii nivelelor de leptin din
circulaia
general
datorit
rupturii
adipocitelor sau dac este consecina sintezei
active.
Rezultate asemntoare au fost
publicate i de Luca Bussetto i echipa sa
(studiu efectuat n aceeai clinic i de
aceeai echip) [4,5]. Extrapolnd i la
celelalte rezultate obinute de acesta,
creterea factorilor proinflamatori (TNF-,
IL-6, rezistin) n paralel cu scderea
factorilor antiinflamatori (adiponectin)
sugereaz mai mult existena unei reacii
inflamatorii coordonate dect eliberarea
mecanic pasiv a produilor grsoi n
snge.
Creterea concentraiilor de leptin n
contextul fazei acute de rspuns la stress a
Curic ML. et al.

fost deja descris n faza precoce
postoperatorie dup chirurgia major
[13,14]. n inflamaie valoarea seric a
leptinei crete semnificativ la 12 ore, iar
dup 24 ore scade i ramne la nivele
relative constante n urmtoarele 32-96 ore
[15,16].
Maruna arat c leptina crete fa de
normal i creterea se coreleaz cu TNF- i
IL-6, dar nu se coreleaz cu indicele de mas
corporal [15]. Rezultatele studiului nostru
sunt similare. Astfel valorile postoperatorii
crescute ale leptinei dispar n ziua 3
postoperator i se stabilizeaz la valori mai
mici dect cele din preoperator.
n faza postoperatorie imediat valorile
leptinei nu se coreleaz cu valorile IMC care
ncep s scad imediat dup operaie.
n faza tardiv de recuperare dup
UAM (1 lun 1an), reacia inflamatorie
acut observat n perioada precoce
postoperatorie dispare rapid i majoritatea
concentraiilor de adipocitokine revin la
valorile de baz sau chiar la un nivel uor
mai sczut conform studiului efectuat de
Luca Bussetto.
Am observat o stabilizare a
concentraiei de leptin la valori mai mici
dect valorile de baz (din preoperator) la 1
lun, la 6 luni i 1 an dup operaie pe
msur ce pacienta a sczut n greutate
(pierdere de mas grsoas prin liposucie).
Scderile de la 1 an nu sunt ns
semnificative comparativ cu cele de la 6
luni.
Numeroase studii arat c la subiecii
sntoi exist o puternic corelaie pozitiv
ntre IMC i leptin, corelaie care se pierde
n inflamaie [17-19].
Creterea valorilor leptinei n perioada
imediat postoperatorie sugereaz un
comportament al leptinei similar proteinelor
de faz acut. Sinteza leptinei n perioada
postoperatorie are majoritar surs extraadipocitar, la nivelul celulelor inflamatorii
sau adipocitul poate fi stimulat i poate
crete n condiii de inflamaie sinteza de
leptin.
Relaia semnificativ ntre concentraia
de leptin seric i procentul de grsime
corporal
sugereaz
c
adipocitele
semnalizeaz creierului despre dimensiunea
depozitelor adipoase, rezultnd n scderea
apetitului i creterea cheltuielilor de
energie, care, mpreun, va duce la pierderea
n greutate.
S-a observat c oamenii care nu dispun
de aceast protein au obezitate sever,
apetit crescut foarte mult i rat metabolic
redus [20]. Mai mult dect att, n contrast,
majoritatea persoanelor obeze au nivelul
circulant de leptin ridicat, care nu induce
rspunsurile
ateptate
(de
exemplu,
reducerea ingestiei de alimente i creterea
cheltuielilor de energie), sugernd existena
unei rezistene la leptin la subiecii obezi
hiperleptinemici [21,22].
Cnd un obez ncearc s slbeasc (n
cazul
nostru
cu
ajutorul
UAM),
hipotalamusul percepe scderea de leptin i
stimuleaz apetitul. Scderea concentraiei
de leptin o dat cu reducerea esutului
adipos, reprezint semnale pentru sistemul
hipotalamic care stimuleaz centrul foamei
i cresc aportul alimentar n vederea
rectigrii greutii anterioare.
Pierderea n greutate indus prin diet,
poate provoca reacii de adaptare ale
organismului pentru a-i rectiga greutatea
i ar trebui s fie luat n considerare n
managementul de lung durat al pacientelor
obeze supuse UAM, sugernd necesitatea
instituirii unui program pentru meninerea
greutii. Controlul activitii biologice a
leptinei prin modificarea dietei poate
reprezenta o strategie practic pentru
tratamentul obezitii [23,24].
CONCLUZII
UAM are efecte metabolice importante
(reducerea concentraiei serice de leptin
corelat
cu reducerea masei adipoase)
asociate celor de ordin morfologic,
mbuntind calitatea vieii pacientei care a
fost atent selecionat i care i-a meninut o
greutate corporal constant pe parcursul
unui an, fiind o pacient pe deplin
compliant.
UAM poate fi practicat n asociere cu
chirurgia bariatric n tratamentul obezitii
401
morbide sau poate reprezenta o alternativ

fiabil atunci cnd pacienii refuz acest tip
de chirurgie.
interese.
BIBLIOGRAFIE
1. Flynn MA, Mc Neil DA, Maloff B, et al.
Reducing obesity and related chronic disease
risk in children an youth: a synthesis of
evidence
with
best
practice
recommendations. Obes Rev. 2006 (Suppl 1):
7-66.
2. Gastrointestinal Surgery for Severe Obesity:
National Institutes of Health Consensus
Development Conference Statement. Am J
Clin Nutr. 1992; 55:615S619S.
3. Arner P. Not all fat is alike. Lancet 1998;
351:1301-1302.
4. Busetto L, Bassetto F, Zocchi M, et al. The
effects of the surgical removal of
subcutaneous adipose tissue on energy
expenditure and adipocytokine concentrations
in obese women. Nutrit Metab Cardiovasc
Dis. 2008; 18:112-120.
5. Busetto L, Bassetto F, Nolli ML. Metabolic
effects of Liposuction-Yes or No?. NEJM.
2004; 351:1355-1357.
6. Giugliano G, Nicoletti G, Grella E et al. Effect
of liposuction on insulin resistance and
vascular inflammatory markers in obese
women. Br J Plast Surg. 2004; 57:190-194.
7. Klein S, Fontana L, Young VL, et al. Absence
of an effect of liposuction on insulin action
and risk factors for coronary heart disease. N
Engl J Med. 2004; 350:2549-2557.
8. Klein S. The case of visceral fat: argument for
the defense. J Clin Invest. 2004; 113: 15301532.
9. Bastard JP, Jardel C, Bruckert E, et al.
Elevated levels of interleukin-6 are reduced in
serum and subcutaneous adipose tissue of
obese women after weight loss. J Clin
Endocrinol Metab. 2000; 85:3338-3342.
10. Curic L, Bassetto F, Vulpoi C. Actualiti
privind tratamentul chirurgical al obezitii
11. Roustaei N, Masoumi Lari SJ, Chalian M,
Chalian H, Bakhshandeh H. Safety of
ultrasound-assisted liposuction: a survey of
660 operations. Aesthetic Plast Surg.
2009;33(2):213-218.
12. Gonzales-Ulloa. Aesthetic Plastic Surgery Vol. 7 - Body Contouring Surgery. Padova:
Piccin Nuova Libreria, 2003.
402
13. OBrien PE, Brown WA, Smith A, et al.

Prospective study of a laparoscopically placed,
adjustable gastric band in the treatment of
morbid obesity. Br J Surg. 1999; 86:113118.
14. Ristescu I, Grigoras I, Ungureanu D, et al.
Leptina, un nou marker proinflamator si
compozitia corporala Corelatii privind
perioada postoperatorie precoce in chirurgia
majora. Jurnalul de Chirurgie (Iai). 2011;
7(4): 582-595.
15. Maruna P, Grlich R, Frasko R, Haluzk M.
Serum leptin levels in septic men correlate
well with C-reactive protein (CRP) and TNF
but not with BMI. Physiol Res. 2001; 50(6):
589-594.
16. Maruna P, Grlich R, Frasko R, Rosicka M.
Ghrelin and leptin elevation in postoperative
intra-abdominal sepsis. Eur Surg Res. 2005;
37(6): 354-359.
17. Maruna P, Grlich R, Fried M, Frasko R,
Chachkhiani I, Haluzik M. Leptin as an acute
phase
reactant
after
non-adjustable
laparoscopic gastric banding. Obes Surg.
2001; 11(5): 609-614.
18. Maruna P, Grlich R, Frasko R, Haluzk M.
Serum leptin levels in septic men correlate
well with C-reactive protein (CRP) and TNFalpha but not with BMI. Rozhl Chir. 2001;
50(6): 589-594.
Curic ML. et al.

19. Koch A, Weiskirchen R, Zimmermann HW,
Sanson E, Trautwein C, Tacke F. Relevance of
Serum
Leptin
and
Leptin-Receptor
Concentrations in Critically ill Patients.
Mediators Inflamm. 2010;473-540.
20. Heymsfield SB. Greenberg AS, Fujioka K,
Dixon RM, Kushner R, Hunt T. Recombinant
leptin for weight loss in obese and lean adults:
a randomized, controlled, dose escalation trial.
JAMA. 1999; 282:1568-1575.
21. Ann NY, Acad SC. Leptin signaling, adiposity
and energy balance. J Clin Invest. 2002;
967:379-388.
22. Montague CT, Farooqi, IS, Whitehead JP.
Congenital leptin deficiency is associated with
severe early-onset obesity in humans. Nature
1997; 387:903-908.
23. Noorah S., AL-Sowyan. Difference in leptin
hormone response to nutritional status in
normal adult male albino rats. Pak J Biol Sci.
2009; 12:48-52.
24. Minnoci A, Savia G, Lucantoni R, Berselli M,
Calo G, Viberti GC. Leptin plasma
concentrations are dependant on body fat
distribution in obese men. Int Obes Relat
Metab Disord. 2000; 24:1139-1144.
ANATOMIE I TEHNICI CHIRURGICALE
403
TRAPEZUL CEFALOPANCREATIC I TRIUNGHIUL

COLEDOCO-WIRSUNGIAN
S. Suman
Departamentul de chirurgie operatorie i anatomie topografic
Universitatea de Stat de Medicin i Farmacie N. Testemianu Chiinu, Republica Moldova
TRAPEZIUS CEFALOPANCREATIC AND COLEDOCO-WIRSUNGIAN TRIANGLE
(Abstract): Operations by removing the proximal portion of the pancreas remain some of the most
technically complicated. Regards of applied surgical technique, all are based not only on the
targeted anatomy, which are needed to determine the amount of tissue resected but also on the
deep knowledge of surgical anatomy features biliopancreatoduodenale area.
KEY WORDS: TRAPEZIUS; TRIANGLE; BILIO-PANCREATO-DUODENAL AREA
SHORT TITLE: Anatomie cefalopancreatic
Pancreatic head anatomy
HOW TO CITE: Suman S. [Cefalopancreatic trapezius and coledoco-wirsungian triangle]. Jurnalul de chirurgie (Iai).
2012; 8(4): 403-405.
INTRODUCERE
n prezent, interveniile chirurgicale,
cu nlturarea poriunii proximale de
pancreas, rmn a fi unele din cele mai
complicate, att din punct de vedere tehnic
ct i n funcie de evoluia perioadei
postoperatorii. Arsenalul de procedee
chirurgicale
n
patologia
zonei
biliopancreaticoduodenale este variat, ns
practic toate sunt extrem de complicate, cu
risc nalt de complicaii intra- i
postoperatorii
[1].
Conform
datelor
literaturii, numrul complicaiilor dup
duodenopancreatectomii cefalice (DPC)
variaz de la 30% pn la 80%, iar
mortalitatea postoperatorie de la 0 pn la
50% din cazuri [1-4].
Indiferent de procedeul chirurgical
aplicat, n toate interveniile trebuie inut
cont de particularitile structurale i
reperele anatomice necesare la stabilirea
volumului esuturilor excizate. Posibilitatea
efecturii exciziilor pariale pe organele

zonei biliopancreaticoduodenale poate fi
argumentat
prin
particularitile
embriogenetice ale organelor cointeresate i
prin anatomia chirurgical a acestora n
ontogeneza postnatal [5-9].
Obiectivul prezentului studiu const n
stabilirea unor repere care pot facilita
accesul la pancreas, innd cont de
raporturile spaiale intime dintre duoden i
glanda pancreatic.
MATERIAL I METOD
Studiul s-a axat pe analiza materialului
cadaveric
a
20
de
complexe
biliopancreaticoduodenale, prelevate n
Centrul de Medicin Legal al Republicii
Moldova, de la cadavrele persoanelor
decedate n urma diferitelor patologii (cu
excepia tractului digestiv) sau traumatisme,
cu vrsta cuprins ntre 18 i 85 de ani.
Organele zonei biliopancreaticoduodenale s-
O parte din datele din acest articol au fost prezentate n cadrul celei de a XXIV-a Reuniune a chirurgilor din Moldova, Piatra
Neam, 11-13 octombrie 2012.
Adresa de coresponden: Dr. S. Suman
Departamentul de chirurgie operatorie i anatomie topografic
Universitatea de Stat de Medicin i Farmacie N. Testemianu Chiinu,
Bd. tefan cel Mare, Nr. 192, MD-2004, Chiinau, Republica Moldova
Tel.: 00373 (0) 79 43 57 01
e-mail: sumanser@yahoo.com
404
au prelevat n primele 12 ore de la deces. Au

fost efectuate cercetri pe 10 complexe
nefixate i, respectiv, 10 fixate n soluie de
formol de 10%, timp de 15 zile.
Segmentul retro- sau intrapancreatic al
coledocului (dup caz) a fost studiat
suplimentar pe 134 de obiecte organe ale
zonei respective, fixate n soluie de formol
10%, la fel, timp de 15 zile. Ca metode s-au
utilizat disecia anatomic i seciuni
orizontale de tipul histotopogramelor,
efectuate
prin
organele
zonei
biliopancreaticoduodenale.
Fig. 1 Reprezentarea schematic a trapezului

cefalopancreatic i triunghiului
coledoco-wirsungian
D1 duoden orizontal superior; D2 duoden descendent; D3 duoden

orizontal inferior; pV papilla Vateri; VP vena porta; VL vena
lienalis; VMS vena mezenterica superior; APM axul portomezenteric; W canalul Wirsung;
1 triunghiul superior; 2 triunghiul mediu; 3 triunghiul inferior;
4 baza mare (medial); 5 baza mic (lateral); 6 latura inferioar;
7 latura superioar.
REZULTATE
Suprafaa
anterioar
a capului
pancreatic amintete de forma unui trapez
(Fig. 1).
Limitele acestui spaiu trapezoid sunt:
latura superioar corespunde marginii
inferioare a segmentului duodenal superior
(DI), latura inferioar a trapezului imaginar
coincide cu segmentul duodenal inferior
(DIII), latura lateral coincide cu marginea
medial a duodenului descendent (DII). Ea
poate fi denumit i baza mic a trapezului
Suman S.
cefalopancreatic. Baza larg a trapezului
corespunde liniei (axului) porto-mezenterice.
Aadar, spaiul patrulater, cu limitele
sus-menionate, a fost denumit trapezul
cefalopancreatic.
n limitele trapezului se deosebesc trei
triunghiuri isoscele superior, mediu i
inferior (triunghiurile respective pot fi
denumite i proximal, mediu i distal).
n limitele triungiurilor mediu i
inferior nu se proiecteaz formaiuni
anatomice importante, ns n limitele
triunghiului superior se proiecteaz elemente
anatomice superficiale i profunde:
- superficiale artera pancreatoduodenalis superior anterior;
- profunde coledocul intrapancreatic
(poate fi retropancreatic) i ductul
Wirsung.
Apexului triunghiului superior i
corespunde papila Vater (Brevet de invenie
eliberat de AGPI, seria O, nr. 3726/1777).
DICUII
Relaiile celor mai
importante
formaiuni anatomice ale capului pancreatic
se
observ
n
limitele
trapezului
cefalopancreatic. Acesta prezint un
instrument de orientare n anatomia capului
pancreatic, reper major anatomic n tehnica
operatorie de excizie parial a capului de
pancreas. Arhitectura vascular i raporturile
anatomice
complexe
ale
zonei
biliopancreaticoduodenale, determin n
mare msur posibilitile mobilizrii i
stabilirea volumului de excizie a caput
pancreas, cu pstrarea circulaiei sangvine a
duodenului. Jonciunea biliopancreatic i
respectiv, papila duodenal mare, se
proiecteaz la vrful triunghiului superior
din limitele trapezului cefalopancreatic.
CONCLUZII
Cunoaterea
limitelor
trapezului
cefalopancreatic i ale triunghiului coledocowirsungian
faciliteaz
interveniile
chirurgicale n aceast complex zon
chirurgical.
Anatomie cefalopancreatic
405
Autorul nu declar nici un conflict de
interese.
BIBLIOGRAFIE
1. Veligotsky NN, Veligotsky AN, Obuobi RB,
Oakley D. [Actual problems of surgery of
diseases of the pancreaticoduodenal area]
Harkivska hirurgichna. 2001; 10(1): 70-73.
2. Ershov VV, Rybinsk AD, Anikin AV.
[Improved pancreatodigestive anastomoses in
pancreatoduodenal resection]. Khirurgiia
(Mosk). 2006; 1: 38-43.
3. Zykov A, Nikitichenko S. [Diagnosis and
treatment of cancer of the major duodenal
papilla] Khirurgiia (Mosk). 1989; 7: 25-28.
4. Kozlov IA, Kubyshkin VA. [Pancreatic head
resection in chronic pancreatitis] Khirurgiia
(Mosk). 2004; 11: 64-69.
5. Nagai H. Configurational anatomy of the
pancreas: its surgical relevance from
ontogenetic
and
comparative-anatomical
viewpoints. J Hepatobil Pancreat Surg. 2003;
10: 4856.
6. Gockel I, Domeyer M, Wolloscheck T, et al.

Resection of the mesopancreas (RMP): a new
surgical classification of a known anatomical
space. World Journal of Surgical Oncology.
2007; 5(44): 18.
7. Sakamoto Y, Nagai M, Tanaka N, et al.
Anatomical segmentectomy of the head of the
pancreas along the embryological fusion
plane: A feasible procedure ? Surgery. 2000;
128(5): 822-831.
8. Talbota ML, Foulisb AK, Imriea CW. Total
dorsal pancreatectomy for intraductal papillary
mucinous neoplasm in a patient with pancreas
divisum. Pancreatology. 2005; 5: 285-288.
9. Kubyshkin VA, Kozlov IA. [Anatomical
conditions of performance for proximal
pancreas resections]. Khirurgiia (Mosk). 2004;
5: 10-15.
406
Suman S.
ARC PESTE TIMP
407
FISTULE CHOLCYSTO-DUODNALE
E. Christide
Revista de Chirurgie 1938: 7-8/41: 579-585
La malade E.N. ge de 43 ans,

marie, habitant Turnu Mgurele, entre le 10
Dcembre 1936 dans notre service, pour des
douleurs dans lhypochondre droit et dans
lpigastre, irradies dans tout labdomen et
surtout dans lpaule droite; ces douleurs
taient accompagnes de nauses et de
vomissements qui la calmaient. Ces
phnomnes datent depuis deux ans;
dernirement ils se sont accentus et, en
mme temps, la malade a observ la
prsence de quelques calculs de la grosseur
dune noisette, limins par les selles.
Rien de particulier dans les
antcdents et lexamen des autres
appareils et systmes.
Lexamen de labdomen met en
vidence un point cystique douloureux, sans
aucun emptement ou autre modification de
cette rgion.
Examens de laboratoire: lure dans le
sang : 0,33gr ; la glycmie 0,88gr ;
lexamen de lurine normal; examen
radiologique: la cholcystographie aprs
liode ttragnoste est ngative.
Aprs la prparation propratoire, on
intervient le 18 dcembre 1936 avec le
diagnostic de cholcystite calculeuse et on
fait une hmi-cholcystectomie bivalve.
Incision Sprengel droite. A louverture de la
cavit abdominale, on trouve une vsicule
biliaire petite, rtrcie sous le rebord
antrieur du foie, couverte dadhrences
duodno-cholcystiques, contenant des
calculs. On dfait autant que possible ces
adhrences. On sectionne la vsicule en
long, de sorte quelle est dfaite en deux
valves: une valve duodnales sur laquelle on
constate une perforation qui faisait
communiqu la vsicule avec la seconde
portion du duodnum, ayant la grosseur dun

pois de lentille, par laquelle passe facilement
une pince Kocher, et une autre valve soushpatique. On explore le canal cystique et on
constate quil est impermable. Avec la
valve duodnale on bouche la fistule du
duodnum par une double suture
srosreuse. Au moment o lon enlve une
pince place sur le pdicule cystique- dans le
voisinage immdiate du choldoque- une
vague de bile apparat dans la plaie. On
draine avec un paquet de mches de gaze
lendroit o la vsicule a t sectionne,
entre le duodnum et le bord infrieur du
foie. On ne pose ni des ligatures vasculaires,
ni sur le cystique, ces lments ntant pas
distinctement visible dans la plaie.
Evolution post-opratoire.
- Le 9 Janvier 1937: le pansement est
trs imbib de bile, ictre conjonctival. On
fait un tubage duodnal Melzer-Lyon.
- Le 10 Janvier 1937: tubage, injection
de Campolon*. Les selles se colorent.
- Le 16 Janvier 1937: la fistule se
ferme spontanment, pour se rouvrir le 21
Janvier. Le 22 Janvier on fait une
cholangiographie avec du Lipiodol. Le 29
Janvier la malade rentre chez elle la
maison avec la fistule biliaire qui continue
scrter jusquau 22 Mars 1937. Quelques
temps aprs, elle commence ressentir des
douleurs locales accompagnes de fivre;
elle entre lhpital de Turnu-Mgurele, o
on lui fait une incision au niveau de
lancienne fistule par laquelle il scoule de
la bile, rtablissant de cette manire la
fistule, qui se ferme au bout de 20 jours.
Au mois de Mai 1937 apparaissent
deux bourgeons charnus qui scrtent un
liquide sro-purulent, sans aucun autre
408
symptme gnral. Cet tat persistant, la

malade se fait interner nouveau dans notre
service, au mois de Novembre 1937. On y
procde une radiographie aprs une
injection de Lipiodol sur ce trajet, qui
montre une fistule borgne externe de peu
dtendue.
On fait lexcision du trajet fistuleux.
Gurison. A cette occasion on fait aussi une
radiographie gastro-duodnale de contrle.
On constate que le duodnum est normal.
Les fistules cholcysto-duodnales ont
t dcrites par Cruveilhier en 1852. Il
distingue trois varits de fistules: les
cholcysto-duodnales, les plus frquentes,
les cholcysto-coliques et les cholcystogastriques, plus rares.
Symptmes.
Delhorme,
Dalsace,
Thoyer, Bazat et Cadet (Paris), prsentent
dans une communication faite la Socit de
Radiologie de France, le 13 Janvier 1931, un
cas de fistule duodno-biliaire souponne
cliniquement et vrifie loccasion dun
examen radiologique.
Dumont,
qui
a
cit
cette
communication dans le Journal de Chirurgie,
Tome 37, p. 234, considre le cas comme
extrmement rare, tant donn quil na
trouv dans la littrature que deux cas,
diagnostiqus cliniquement et confirms par
un examen radiologique extrmement
intressant. Les signes cliniques peuvent
passer inaperus car, dans les antcdents de
lilus biliaire, ces lsions passent souvent
insouponnes.
Cependant Chiray et Pavel dans leur
trait sur la Vsicule biliaire, considrent
comme un signe pathognomonique- le
vidage brusque et massif de lintestin
(Chauffard)et,
dune
manire
concomitante, la disparition dune tumeur
vsiculaire ou pri-vsiculaire.
Dans notre cas, la prsence des calculs
assez gros dans les selles nous a orients
vers le diagnostic dune lithiase vsiculaire
ouverte dans le tube digestif.
Traitement.
Hartmann
dans
la
Chirurgie des Voies Biliaires page 113,
donne deux observations des fistules
cholcysto-duodnales (FCD).
Dans la premire observation on a

trouv, lintervention, une FCD et un
calcul dans le conduit cystique. On a spar
la vsicule du duodnum, on a rpar la
brche duodnale, on a fix la vsicule la
paroi
abdominale,
cholcystostomie,
gurison.
Dans le deuxime cas la FCD admette
le petit doigt, la vsicule tait sclreuse sans
calculs. On a rpar la perforation duodnale
en
deux
plans,
en
faisant
une
cholcystectomie. Gurison.
Lecne dans le trait de thrapeutique
chirurgicale, page 346, indique dans le cas
de FCD la suture de duodnum et la
gastroentrostomie immdiate.
La technique que nous avons utilise
dans notre cas, la section de la vsicule en
deux moitis et lemploi dune de ces
moitis pour rparer la brche duodnale, est
notre avis- une garantie de plus pour le
succs de lintervention et pour viter des
complications ultrieures dans le sens des
cicatrices stnosantes du duodnum.
DISCUSSION
St. Jianu: cite un cas dans lequel il a
pos, par examen radiologique le diagnostic
de FCD. La fistule tait la consquence dun
ulcre duodnale, perfor dans la vsicule
biliaire.
Il sagit dune malade qui entre dans le
service du professeur Iacobovici pour des
troubles digestifs. La malade prtend avoir
t opre dans un Sanatorium de
Transylvanie o on lui aurait fait une gastroentro-anastomose. Cependant elle a
continu souffrir..
En examinant la malade, on constate
une cicatrice mdiane sus-ombilicale. A
lexamen radiologique, jai constat
lestomac augment de volume, prsentant
les caractres habituels de la stnose
pylorique bnigne; lvacuation gastrique
commenait trs tard. Vingt-quatre heures
aprs, la radiographie (Fig. 1) montre le
baryum dans le clon ascendant et la portion
initiale du clon transverse. En mme temps,
on voit le bulbe duodnal rempli de baryum.
Le bulbe communique au sommet avec une
409
seconde cavit rempli de baryum, qui a

laspect de la vsicule biliaire (flche noire).
Fig. 1 Radiographie au baryum

(transit so-gastro-duodnal)
Le baryum dans le clon ascendant et la portion initiale du clon

transverse; le bulbe duodnal rempli de baryum et communique
avec une seconde cavit rempli de baryum - vsicule biliaire
(flche noire).
Fig.2 Radiographie au baryum

(transit so-gastro-duodnal)
Administrant la malade deux jeunes dufs et en faisant une

radiographie vingt minutes aprs, on constate que la vsicule a
vacu le baryum et quelle est remplie dair (flche noire
suprieure)
En effet en administrant la malade

deux jeunes dufs et en faisant une
radiographie vingt minutes aprs, on
constate que la vsicule a vacu le baryum
et quelle est remplie dair (flche noire
suprieure) (Fig. 2). On ne constate aucune
anastomose gastro-jjunale. Le duodnum
est petit, rtrci, comme on le voit dans les
anciens ulcres sclreux.
La malade a t opre par le
professeur Iacobovici, qui lui a fait une
gastrectomie avec anastomose gastrojjunale et elle a quitt le service, gurie.
Blassian: Jai assist mon matre
LAgrg Nasta lopration dun cas
analogue: notre malade avait une vsicule
biliaire ratatine et contenant deux calculs;
elle communiquait par son fond avec le
duodnum, grce un trajet long de 1,1/2,2
cm et du diamtre dun crayon. La difficult
consistait dans le fait que nous ne
connaissions pas la permabilit de voies
biliaires extra-hpatique, et nous craignions
que la seule communication hpatointestinale ne se fit par le cholcyste et la
fistule.
Notre avis est que, dans de pareils cas,
cest justement cette permabilit qui
constitue le point le plus important et le plus
dlicat, puisque cest delle que dpend la
conduite du chirurgien.
Ce nest quaprs une exploration
minutieuse de lhpato-choldoque et
seulement aprs stre assur par
cathtrisme de sa parfaite permabilit, que
mon matre, a fait une cholcystectomie, en
sectionnant au pralable le trajet fistuleux
biliaire le plus prs possible du cholcyste
quon devait extirper, en le liant et en
lenfouissant en bourse comme un
appendice. Le malade a parfaitement guri.
En conclusion, nous croyons que, sans
nous assurer en premier lieu de la parfaite
permabilit
de
lhpato-choldoque
jusquau duodnum, il nest pas prudent
dextirper une pareille fistule, tant donn
que dans certains cas (lorsque lhpatocholdoque est obstru), elle peut constituer
la seule voie de drainage hpato-intestinale.
410
G.Gatoschi: Il est certain quun

diagnostic clinique prcis est difficile
poser dans de tels cas; cependant, je crois
que dans le cas prsent par le Docteur
Christide, si on avait fait au patient un
examen complet de lestomac et du
duodnum, comme je le fais dhabitude pour
tout examen cholcystographique (que la
cholcystographie soit positive, ou quelle
soit ngative), il est certain que cette fistule
cholcysto-duodnale aurait t mise en
vidence avant lintervention et quelle
naurait plus constitu une surprise durant
lopration. Aujourdhui quand nous avons
notre
disposition
tant
de
moyens
dinvestigation, il serait dsirer quon
pratiqut ces examens radiologiques mme
dans les cas o nous avons toute la certitude
dun diagnostic, pour mettre le chirurgien
labri de toute surprise et le malade hors de
tout danger qui pourrait survenir dans une
pareille intervention.
De pareils cas sont rares, et
personnellement, je nen connais que trois:
deux cas prsents la Socit de
Radiologie Mdicale de France entre 19351936, et un cas que jai observ dans le
service de la Ire Clinique Chirurgicale de
Iassy, et que jai publi dans la Presse
Mdicale No 104 en 1936, avec le
professeur Vl. Buureanu, tous ces cas tant
diagnostiqus avant lintervention.
Dans ce dernier cas il sagissait dun
patient qui sest prsent pour des troubles
gastriques. A lexamen radiologique de

lestomac, on constate que les canaux
biliaires extra-hpatiques et la vsicule
biliaire sont compltement remplis par la
substance de contraste; en mme temps, on
trouve aussi un ulcre duodnal sur la face
postrieure du bulbe.
Le diagnostic clinique tait celui
dulcre
duodnal;
le
diagnostic
radiologique confirme lulcre duodnal,
mais en mme temps on dcouvre aussi une
fistule choldoco-duodnale, le malade ne
prsentant aucun symptme clinique du ct
du foie et de la vsicule biliaire (ces fistules
tant trs bien supportes et tolres
longtemps par les malades).
A lintervention on a trouv un ulcre
sur la face postrieur du duodnum perfor
dans le choldoque (fistule choldocoduodnales) et un grand calcul de
cholestrine dans la vsicule biliaire. Etant
donn que ltat gnral du malade tait trs
mauvais et que le malade prsentait une
stnose pylorique spastique trs accentue,
avec des troubles dvacuation de lestomac
qui le mettaient dans limpossibilit de
salimenter, on a fait seulement une gastroentro-anastomose postrieure.
La rsection large de lestomac tait
contre-indique aussi par ltat anatomique
local constat lintervention: on avait
trouv une masse dadhrences tendues, qui
pouvaient difficilement tre dissques.
ARC PESTE TIMP
411
COMENTARIU LA ARTICOLUL
FISTULE CHOLCYSTO-DUODNALE
E. Christide - Revista de Chirurgie 1938; 7-8/41: 579-585
Nicolae M. Constantinescu
Universitatea de Medicin i Farmacie Carol Davila Bucureti
Prezena unei fistule colecistoduodenale este nc i astzi de cele mai

multe ori o descoperire intraoperatorie. Dei
frecvena acestei complicaii a bolii litiazice
este relativ redus (n jur de 2% dup Glenn
[1] ea ar trebui s beneficieze de un
diagnostic preoperator mai mare dect cel
actual care nu depete 1/6 bolnavi [2], i
aceasta datorit mortalitii postoperatorii de
15-22%, mult superioar celei nregistrate n
absena acestei complicaii [2]. Preoperator
indicii importante ne sunt date de
identificarea pneumobiliei, asociat cu un
colecist atrofic i cu prezena de calculi n
CBP, duoden, intestin sau n fecale [1].
Dintre explorrile imagistice ecografia
i colecisto-colangiografia clasic nu sunt
operaionale, n schimb CT asociat cu
tranzitul gastro-duodenal i cu ERCP ne pot
orienta ctre diagnostic [3].
Cauza fistulei bilio-enterice este
litiazic n 90% din cazuri [2] i se datorete
mecanismului de compresiune ulcerativ
descris de Lannelongue nc din sec XIX.
Cele mai multe fistule bilio-enterale sunt
colecisto-duodenale, dup care urmeaz n
ordinea frecvenei cele colecisto-colice i
colecisto-gastrice [3]. Dei descoperirea unei
fistule colecisto-duodenale n timpul unei
colecistectomii laparoscopice impunea pn
nu demult conversia, sunt chirurgi. care au
reuit sutura soluiei de continuitate din
peretele
duodenului
prin
mijloacele
chirurgiei mini-invazive [4].
Polul biliar al fistulei impune
colecistectomia, efectuat cu dificultate
datorit
proceselor
sclero-inflamatorii,
consecutive puseelor de colecistit care au
Adresa de coresponden: Prof. Dr. N.M. Constantinescu
Universitatea de Medicin i Farmacie Carol Davila Bucureti
e-mail: nae_constantinescu@yahoo.com
premers instalarea fistulei. Este obligatorie

explorarea CBP datorit procentului crescut
n care o fistul bilio-enteral se nsoete cu
prezena calculilor n canalul hepato-coledoc
[5]. De regul colecistectomia se termin
printr-un drenaj biliar extern. Polul duodenal
al fistulei ine cont de starea peretelui
duodenal i de mrimea orificiului fistulos
iar chirurgul are la dispoziie: avivarea
marginilor cu sutur transversal n 2
planuri, patch cu seroas de jejun,
anastomoz
duodeno-jejunal
lateroterminal pe ans n Y Roux. n cazul unui
duoden II strmtorat se poate executa o
gastroentero-anastomoz.
Articolul pe care l comentez i
discuiile pe care le-a suscitat la Societatea
de Chirurgie din Bucureti n urm cu trei
sferturi de secol ne aduc n memorie 4 din
marii chirurgi ai primei jumti a sec XX.
Astfel n spatele lui Christide l vedem pe
ingeniosul Ernest Juvara, chiar dac la ora
aceea nu mai era n via, bolnavul prezentat
de St.Jianu a fost rezolvat de Iacob
Iacobovici, cazul prezentat de Blassian a fost
operat de Traian Nasta iar cel comentat de
Gh. Gatoschi a fost operat de Vladimir
Buureanu la Iai.
Observaia clinic a lui Christide are
ca particulariti istoricul care precizeaz
eliminarea de calculi prin fecale, semn care
nu este patognomonic pentru fistul- i apoi
maniera n care a folosit perete din colecist
pentru a acoperi defectul duodenal. Pentru
polul biliar nu a fcut nici o manevr de
identificare i ligatur a canalului cistic,
motiv care explic biliragia postoperatorie,
care a durat cu intermiten patru luni i
412
jumtate. Actualmente cazul ar fi beneficiat

mult mai devreme de o papilo-sfincterotomie
endoscopic.
n cazul prezentat de tefan Jianu era
vorba de o fistul ulceroas colecistoduodenal ntre fundul colecistului i
genunchiul superior duodenal, la care
gastrectomia cu anastomoz gastro-jejunal
a pus n repaus fistula de contactul cu
alimente, lucru pe care nu-l reuise GEA
efectuat anterior i care se dovedise
nefuncional.
Bolnavul prezentat de Blassian i care
a fost operat de Traian Nasta este un caz
tipic de fistul colecisto-duodenal de
origine litiazic. Este important maniera n
care operatorul i-a luat toate msurile de
precauie privind permeabilitatea papilei,
nainte de a face colecistectomia i de a
desfiina comunicarea colecisto-duodenal.
Cazul operat la Iai de Vladimir
Buureanu este un exemplu de tactic
operatorie. Deci era vorba de un bolnav cu
stenoz piloric ulceroas decompensat,
care prezenta o fistul coledoco-duodenal
i un mare calcul n colecist. Scoaterea din
ocluzie i reechilibrarea bolnavului prima,
motiv pentru care i s-a practicat doar o GEA

posterioar ca prim timp operator.
Fistulele bilio-enterale pun i astzi
probleme de diagnostic i de conduit
privind tactica i tehnica chirurgical, care
trebuiesc adaptate fiecrui caz n parte.
BIBLIOGRAFIE
1. Glenn F, Reed C, Grafe W. Biliary enteric
fistula. Surg Gynecol Obstetr. 1981; 153: 527531.
2. Duzgun AP, Ozman PP, Ozer MV, Coskun F:
Internal biliary fistula due to cholelithiasis: a
single centre experience. World J Surg. 2007;
13(34): 4606-4609.
3. Yamashita H, Chijiiwa K, Ogawa Y, Kuroki S,
Tanaka M. The internal biliary fistulareappraisal of incidence, type, diagnosis and
management of 33 consecutive cases. Hep
Pancr Bil Surg. 1997; 10: 143-147.
4. Oka M, Yoshimoto Y, Ueno T, Yoshimura K,
Maeda Y, Tangoku A. Treatment of
cholecysto-duodenal fistula by laparoscopy.
Surg Laparos Endosc Percutan Tech. 1999;
9(3): 213-216.
5. Juvara I, Gavrilescu S. Fistulele biliodigestive. In: I. Juvara, D. Setlacec, D.
Rdulescu, . Gavrilescu, redactori, Chirurgia
cilor biliare extrahepatice. Bucureti: Editura
Medical; 1989. p. 163-168.
RECENZII
413
A XXXIV-A REUNIUNE A CHIRURGILOR DIN MOLDOVA

IACOMI-RZEU
Piatra Neam, 11-13 octombrie 2012
n perioada 11-13
octombrie 2012 s-a
desfurat la Piatra
Neam
a XXXIV-a
Reuniune a Chirurgilor
din Moldova IacomiRzeu, organizat de
Societatea Romn de
Chirurgie, Academia de
tiin e
Medicale,
Academia Oamenilor de tiin din
Romnia, Clinica I Chirurgie U.M.F. Gr.T.
Popa Iai, Colegiul Medicilor Neam , la
care au participat peste 200 de chirurgi din
toat ara i din Republica Moldova.
Nivelul tiin ific ridicat a fost atins
prin tematica bine aleas (terenul n
chirurgie, iatrogenie, chirurgie de urgen ,
chirurgie oncologic, chirurgie minim
invaziv, chirurgie digestiv) i, mai ales,
prin participarea unor somit i ale lumii
chirurgicale (N. Angelescu, M. Beuran,
Fl. Popa, E. Brtucu, N.M. Constantinescu,
S. Constantinoiu, C. Copotoiu, M.R.
Diaconescu, N. Dnil, I. Georgescu,
t. Georgescu, N. Iordache, L. Kiss,
R. Neme, D. Sabu, V. Srbu, C. Diaconu,
V. Unc, Cr. Lupacu, G. Rojnoveanu,
R. Scerbina).
Deschiderea oficial a reuniunii a
cuprins, pe lng mesajele de bun venit din
partea autorit ilor locale, care au sus inut
efectiv desfurarea manifestrii i au
apreciat activitatea chirurgilor, i patru
conferin e importante pentru momentul
actual: Genomul poporului romn n
viziunea lui George Emil Palade
(N.M. Constantinescu), Omul lumii moderne
ntre progres i disperare (V. Rzeu),
Chirurgul
astzi
(Fl.
Popa),
Mari personalit i chirurgicale i politica
(M.R. Diaconescu).
n sec iunea Iatrogenie i terenul n
chirurgie s-au prezentat 5 conferin e
magistrale i 9 lucrri, care au dezbtut acest
capitol actual, delicat i foarte important.
n sec iunea chirurgie de urgen au
fost sus inute 4 conferin e privind actualit i
n politraumatisme i 15 lucrri referitoare la
hemoragii digestive superioare, ocluzii
intestinale, traumatisme i sepsis abdominal,
ulcere de stress, infarctul enteromezenteric,
cancerul colorectal operat n urgen ,
traumatisme duodenale, colonice, sarcin
abdominal ectopic, ileus biliar etc.
Sesiunea de chirurgie oncologic a
cuprins 20 de lucrri pe diverse teme de
cercetare fundamental n oncologie, tehnici
de chirurgie oncologic, carcinoame
hepatocelulare, cancere de rect, adenocarcinomul de endometru, chimioterapia
intraperitoneal, neoplasmul de col uterin,
cancerul de sn, tumori retroperitoneale,
cancerul de esofag.
O sesiune special a fost dedicat
chirurgiei pancreasului, care a dezbtut
pancreatitele acute i cronice, complica iile
lor, tehmici de pancreatectomie, tumori
pancreatice. O alt sesiune interesat a vizat
chirurgia minim invaziv i a cuprins 4
conferin e i 22 lucrri privind abordul
laparoscopic al chistului hidatic hepatic,
apendicita acut, limfangioamele chistice
abdominale, herniile i eventra iile, tumorile
benigne de ovar, obezitatea, chirurgia
single port, pancreatita, suprarenalectomia
laparoscopic, chirurgia bariatric i
chirurgia robotic a cancerului rectal.
414
De un real interes s-au bucurat

sesiunile de chirurgie digestiv (12
conferin e i lucrri), cea de cazuri clinice
deosebite (10 lucrri) i, nu n ultimul rnd,
cea Varia (22 lucrri), care a oferit
participan ilor posibilitatea de a face
schimburi de idei n domeniile cele mai
diverse ale patologiei chirurgicale.
Sesiunea de postere a cuprins 12
lucrri, din care trei au fost premiate.
Discuiile academice dup fiecare

lucrare, participarea tuturor centrelor
universitare,
organizarea
impecabil,
ambiana plcut a evenimentelor sociale au
garantat reuita acestei manifestri devenit
tradiional
pe
scena
evenimentelor
tiinifice din ara noastr.
La plecare participan i au promis c
vor reveni cu plcere la a XXXV-a Reuniune
a Chirurgilor din Moldova.
Prof. Dr. Eugen Trcoveanu
RECENZII
415
MANAGEMENTUL SELECTIV NONOPERATOR AL

LEZIUNILOR VISCERALE ABDOMINALE LA PACIENTUL
POLITRAUMATIZAT
Mircea Beuran, Ionu Negoi
Editura Academiei Romne, Bucureti, 2012; ISBN: 978-973-27-2221-3
Monografia aprut
recent
la
Editura
Academiei Romne i
propune i reuete s
evalueze indica iile,
siguran a, limitele i
factorii asocia i cu
eecul managementului
non-operator
al
leziunilor traumatice
abdominale, n cadrul complex al pacientului
politraumatizat.
n zilele noastre trauma reprezint una
din primele 5 cauze de morbiditate i
mortalitate la adultul tnr, mai important
dect bolile cardiovasculare i cancerul, iar
politraumatizatul rmne n continuare o
provocare permanent pentru echipa
multidisciplinar din cauza complexit ii
lezionale deosebite.
Monografia este, de fapt, un studiu
prospectiv care evalueaz pe statistica
bogat a Spitalului Clinic de Urgen
Floreasca, pe perioada ultimilor trei ani,
dac managementul selectiv nonoperator al
leziunilor viscerale abdominale poate fi
aplicat n condi ii de siguran la pacientul
politraumatizat.
n acelai timp, studiul analizeaz
factorii prognostici de eec al tratamentului
nonoperator la pacientul politraumatizat i
analizeaz complica iile precoce i tardive
pe care le antreneaz laparatomia
nonterapeutic la aceti bolnavi.
Studiul are criterii de includere i de
excludere foarte clare, o fi de cercetare, un
design clar i o analiz statistic a datelor
performant.
Cartea este structurat n 10 capitole,

primul fiind dedicat metodologiei studiului.
n capitolul 2 este prezentat istoria ngrijirii
pacientului traumatizat n decursul timpului,
analizndu-se aceast pandemie pn n
prezent, n lume, n Europa i n ara noastr.
n rile Uniunii Europene, la fiecare 2
minute moare o persoan n urma unui
traumatism i anual sunt ngrijite 60.000.000
persoane n urma acestor situa ii.
Chirurgia de traum a evoluat
permanent n decursul istoriei ctigndu-se
o mare experien n timpul rzboaielor i
reorganizndu-se n zilele noastre pentru a
face fa leziunilor epocii moderne.
Capitolul 3 analizeaz epidemiologia
traumatismelor. Studiul epidemiologic i cel
al mecanismului lezional sunt abordate prin
prisma experien ei bogate acumulate,
particularizat prin analiza grupului de
studiu constituit n Spitalul Clinic de
Urgen Floreasca. Actualmente, 5,8
milioane de oameni sunt anual victime ale
unui traumatism, iar n 2020 sunt ateptate
8,4 milioane decese pe an din cauza
traumatismelor.
Capitolul 4 descrie din toate punctele
de vedere mecanismul lezional cinetica n
traume. Trecerea n revist a scorurilor
traumatice (capitolul 5) i detalierea
managementului
ini ial
prespitalicesc
(capitolul 6) i spitalicesc ini iat n UPU
(capitolul 7), cu eviden ierea rolului
investiga iilor
imagistice
performante
(capitolul 8) fundamenteaz capitolul
referitor
la
managementul
selectiv
nonoperator
al
leziunilor
viscerale
abdominale prin contuzie (capitolul 9),
416
convingtor
ilustrat
prin
cazuistica
personal.
Lucrarea reprezint rezultatul unei
munci de echip, al unei activiti academice
deosebite, care poart amprenta profesorului
Mircea Beuran.
Cartea se adreseaz studenilor,
medicilor tineri, rezidenilor i chirurgilor
practicieni, medicilor de la SMURD i UPU
care se confrunt cu aceast pasionant, dar
dificil patologie a politraumatiza ilor.
Bazat pe o bogat experien
chirurgical complex i pe studiul unei
bibliografii recente, manualul conceput n
stil european este uor de parcurs datorit
manierei concise, ordonate i clare, a
iconografiei bogate.
Apariia acestei cri, unice n

domeniu, reprezint un eveniment editorial
deosebit,
mbogind
literatura
de
specialitate, fiind util tuturor specialitilor
din echipa multidisciplinar de urgen , n
momentul n care aceast specialitate devine
din ce n ce mai imprtant n practica
medical curent.
Prof. Dr. Eugen Trcoveanu

NR 4 Tot

Încărcat de

Informații document

Titlu original

Drepturi de autor

Formate disponibile

Partajați acest document

Partajați sau inserați document

Opțiuni de partajare

Vi se pare util acest document?

Este necorespunzător acest conținut?

Drepturi de autor:

Formate disponibile

NR 4 Tot

Încărcat de

Drepturi de autor:

Formate disponibile

i

Jurnalul de Chirurgie (Iai), 2012, Vol. 8, Nr. 4

Jurnalul de chirurgie este o revist electronic, cu acces liber (Open

Viorel Scripcariu (Iai)

ntreaga responsabilitate a opiniilor exprimate n articolele Jurnalului de chirurgie revine autorilor.

Jurnalul de Chirurgie (Iai), 2012, Vol. 8, Nr. 4

Jurnalul de Chirurgie (Iai), 2012, Vol. 8, Nr. 4

Jurnalul de chirurgie (Iai) octombrie-decembrie 2012; vol. 8; nr. 4

Jurnalul de Chirurgie (Iai), 2012, Vol. 8, Nr. 4

ANATOMIE I TEHNIC CHIRURGICAL

ARC PESTE TIMP

Jurnalul de Chirurgie (Iai), 2012, Vol. 8, Nr. 4

Jurnalul de chirurgie [Journal of Surgery] (Iai) October-December 2012; vol. 8; no. 4

Jurnalul de Chirurgie (Iai), 2012, Vol. 8, Nr. 4

ANATOMY AND SURGICAL TECHNIQUE

ARCH BEYOND TIME

NEWS AND BOOK REVIEWS

Jurnalul de Chirurgie (Iai), 2012, Vol. 8, Nr. 4

GEORGE EMIL PALADE - INGREDIENTELE UNUI GENIU

Pe 19 noiembrie 2012 s-au mplinit

Mama savantului, Constana Cantemir

Jurnalul de Chirurgie (Iai), 2012, Vol. 8, Nr. 4

n aceast a doua etap, pe terenul

George Emil Palade ingredientele unui geniu

Jurnalul de Chirurgie (Iai), 2012, Vol. 8, Nr. 4

Claude i Christian de Duve pentru

Jurnalul de Chirurgie (Iai), 2012, Vol. 8, Nr. 4

cercettori, director de granturi, militant

1. Palade GE. Autobiography In: Anca Michaela

Jurnalul de Chirurgie (Iai), 2012, Vol. 8, Nr. 4

CANCERUL DE RECT PRINCIPII DE DIAGNOSTIC I

Managementul modern, actual al

Received date: 03.08.2012

Jurnalul de Chirurgie (Iai), 2012, Vol. 8, Nr. 4

Aniei MG. et al.

Adenopatia n cancerul de colon

Jurnalul de Chirurgie (Iai), 2012, Vol. 8, Nr. 4

tratament chirurgical, la 5,6% n grupul

Jurnalul de Chirurgie (Iai), 2012, Vol. 8, Nr. 4

chirurgia radical dup 6-8 sptmni.

Aniei MG. et al.

Fig. 1. Arborele decizional n tratamentul cancerului de rect

Pentru tumori T1N0 este indicat

- pentru tumori evaluate prin endoscopia

Adenopatia n cancerul de colon

Jurnalul de Chirurgie (Iai), 2012, Vol. 8, Nr. 4

colo-anal) i tratament neoadjuvant se

Jurnalul de Chirurgie (Iai), 2012, Vol. 8, Nr. 4

Gradul 2 - excizia mezorectului n

Aniei MG. et al.

Fig 2. Arbore decizional n tratamentul cancerului de rect amlar mijlociu i inferior

Adenopatia n cancerul de colon

Jurnalul de Chirurgie (Iai), 2012, Vol. 8, Nr. 4

Postoperator, rspunsul la tratamentul

schimbri importante. Ecografia endorectal

Jurnalul de Chirurgie (Iai), 2012, Vol. 8, Nr. 4

4. The Royal College of Pathologists Working

Aniei MG. et al.

Adenopatia n cancerul de colon

Jurnalul de Chirurgie (Iai), 2012, Vol. 8, Nr. 4

34. Quirke P, Morris E. Reporting colorectal

Jurnalul de Chirurgie (Iai), 2012, Vol. 8, Nr. 4

Aniei MG. et al.