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Sesiune Medici Comunicri orale

Physicians Session Oral Communications


Stadializarea local a cancerului rectal: rolul actual al rmn
F. Bauer
Munich, Germania
Odat cu apariia sistemelor de gradient puternice i cu antene de suprafa de rezoluie ridicat, a crescut importana imagisticii cu rezonan magnetic (IRM) n
stadializarea cancerului rectal. Superioritatea IRM fa de ecografia endorectal, modalitatea de stadializare folosit cel mai frecvent pentru stadializarea
pacienilor cu tumori rectale, const n faptul c aceasta, pe lng peretele intestinal, vizualizeaz i anatomia pelvian nconjurtoare. Avantajul crucial al IRM nu
este stagingul T exact, ci evaluarea corect a relaiei topografice a tumorii cu fascia mezorectal. Aceast fascie este cel mai important reper anatomic pentru
evaluarea fezabilitii exciziei mezorectale totale, procedur care a devenit standard operatoriu pentru rezecia cancerului situat n segmentele rectale mediu i
inferior. n prezent, IRM este singura modalitate imagistic de acuratee ridicat pentru prognozarea posibilitii de a obine o margine de rezecie liber de
tumori, oferind astfel informaii importante pentru planificarea unei strategii terapeutice eficiente, mai ales pentru pacienii cu cancer rectal avansat.
n cadrul prelegerii se va discuta i despre: raiuna stagingului, stadializarea clasic, stadializarea modern, resatadializare dup RCT i calitatea stadializrii.

Recuperarea ameliorat se poate face n caz de urgen sau de ocluzie colic?


Enhanced Recovery Protocol after Colectomy: Feasible in Emergency and in Colonic Obstruction?
A. Venara, P. A. Colas, J. Barbieux, J. B. Philippe, M. F. Talbot, A. Hamy
Centre Hospitalier Universitaire, Chirurgie Visceral, Angers, Frana
Enhanced Recovery Protocol after Colectomy: Feasible in Emergency and in Colonic Obstruction?
Introducere: Reabilitarea ameliorat i-a artat eficacitatea i fezabilitatea n chirurgia colic programat. Chirurgia n urgen poate s fie un obstacol n
compliana acestui protocol. Scopul acestei prezentri este de a analiza fezabilitatea i eficacitatea acestui tip de protocol n urgen i n caz de ocluzie colic.
Material i metod: 167 de pacieni consecutiv operai de o rezecie colorectal au fost introdui n acest studiu retrospectiv monocentric, pe o durat de 24 de
luni. Grupele de pacieni operai n urgen (U) i fr urgen (SU) au fost comparate. ntr-un al doilea timp, pacienii operai n urgen au fost mprii ntr-un
grup de pacieni n ocluzie (O) i un grup de pacieni fr ocluzie (SO).
Resultatele: Media de complian a protocolului a fost de 77.8% i a fost diferit ntre grupurile U i SU. Etapele preoperatorii i peroperatorii difereau cel mai
mult, datorit imposibilitii de pregtire a pacienilor i a faptului c anestezitii de urgen nu sunt implicai sistematic n recuperarea rapid. Nu exist diferen
ntre cele dou grupuri n ceea ce privete reluarea tranzitului sau a morbiditii severe.
Douazeci i opt de pacieni au fost operai n urgen, printre care 17 au fost in ocluzie colic. Compliana global la protocol nu a diferit ntre grupul O i SO.
Morbiditatea, durata relurii tranzitului i durata spitalizrii nu au fost semnificativ diferite.
Concluzie: Reabilitarea ameliorat nu provoac creterea morbiditii n urgen.
n caz de ocluzie, aceasta poate fi aplicat i pare s aib tendina de a diminua durata relurii tranzitului.

Aim: Enhanced recovery protocols after colorectal surgery are safe and effective. Emergency surgery could be an obstacle in the compliance with the protocol.
The aims were to assess (i) the feasibility and effectiveness of protocols in cases of emergency surgery, and (ii) the feasibility and efficiency of protocols in cases
of colon obstruction caused by tumor. Methods: This retrospective monocentric study included all consecutive patients undergoing colorectal resection during a
2-year period. Patients undergoing colon decompression with endoscopic stent or diverting stoma and patients needing postoperative intensive care were
excluded. Results: Apart from the rate of obesity, there was no difference between the groups of patients undergoing elective or emergency surgery. The median
of the overall compliance with the protocol was 77.8% and was higher in elective surgery during the pre, per and postoperative course (p<0.001, p<0.001 and
p=0.004). Apart from overall morbidity (p<0.007) and length of stay (p=0.002), there was no difference between the two groups regarding the postoperative
course, especially with regards to severe morbidity (p=0.22), postoperative ileus (p=0.08) or anastomotic leakage (p=0.26). Urgent resection in cases of colon
obstruction caused by tumors allowed 61% of compliance with the protocol and was not significantly different to urgent resection in cases of other indications.
There was also no significant difference regarding the postoperative course, such as anastomotic leakage (p>0.1), severe morbidity (p=0.1) or length of stay
(p=0.4). Interestingly, there was no significant difference in the rate of postoperative ileus between the 2 groups (p=0.054). Conclusion: Enhanced recovery
protocol seems to be feasible and effective in patients undergoing emergency surgery.

Congresul Naional de Chirurgie 2016 01 - 04 iunie 2016 Centrul Internaional de Conferine Sinaia
National Congress of Surgery 01 - 04 June 2016 Sinaia International Conference Center
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Sesiune Medici Comunicri orale


Physicians Session Oral Communications

Factori de predicie ai recidivelor tumorale retroperitoneale


Predictive Factors for Retroperitoneal Tumor Recurrences
Angela Mdlina Lazr, E. Brtucu, N. D. Straja
Institutul Oncologic Prof. Dr. Al. Trestioreanu / Universitatea de Medicin i Farmacie Carol Davila, Clinica de Chirurgie I, Bucureti, Romnia
Tumorile retroperitoneale reprezint un grup heterogen de neoplazii rare, insuficient nelese i dificil de gestionat din punct de vedere terapeutic. Rezecia
chirurgical radical este singura terapie cu potenial curativ; totui, i dup o chirurgie extensiv ratele de supravieuire ale pacienilor sunt reduse, n vreme ce
recidivele locoregionale sunt frecvente i n final inoperabile. Obiectivul studiului prezent a fost identificarea unor factori de predicie ai recidivelor
retroperitoneale, cu scopul de a depista aceste cazuri n stadii operabile.
Pacieni i metode: Am realizat un studiu prospectiv i retrospectiv pe un grup de 125 de pacieni cu tumori retroperitoneale pe o perioad de 15 ani. Am analizat
detaliat efectul factorilor legai de tipul tumoral, pacieint i terapiile administrate asupra ratelor de recidiv locoregional tumoral.
Rezultate: Rezecabilitatea tumoral complet a fost de 47%. Aproximativ jumtate din paceinii operai radical au dezvoltat recidive locoregionale, dar
consemnarea acestora nu a fost asociat cu reducerea supravieuirii pacienilor. Doar unele tipuri histopatologice de tumori retroperitoneale i anumite conduite
terapeutice au asociat mai frecvent recurene neoplazice, iar suprinderea acestora precoce a fcut posibil prelungirea supravieuirii pacienilor.
Concluzii: Semnificaia prognostic negativ a recurenelor locoregionale de la tumorile retroperitoneale considerate a fi operate radical este de mult
recunoscut. Totui, pn in prezent, lipsete o descriere adecvat a factorilor asociai recidivelor tumorale dup rezeciile chirurgicale considerate complete,
ceea ce reflect o insuficient nelegere a biologiei acestor tumori i care explic neomogenitatea mare de atitudini chirurgicale, dar i eficiena redus pe
termen lung a terapiilor.

Retroperitoneal tumors represent a heterogeneous group of rare neoplasms, insufficiently understood and difficult to manage therapeutically. Radical surgical
resection represents the only therapy of curative intent; however, even after extended surgery, patient survival rates are low while locoregional recurrences are
frequent and finally become inoperable. The aim of the current study was the identification of predicting factors of tumor recurrences in order to identify these
cases in operable stages.
Patients and Methods: A retrospective and prospective study was conducted on a group of 125 patients with retroperitoneal tumors during a period of 15 years.
We analyzed the effect of factors related to tumor type, patient and delivered therapies on tumor locoregional recurrence rates in detail.
Results: Complete tumor surgical resectability was of 47%. Approximately half of the radically operated on patients developed locoregional recurrences, but the
record of this event has not been associated to lower patient survival rates. Only certain retroperitoneal histopathologic tumor types and surgical approaches
associated neoplastic recurrences more frequently but their precocious detection increased patient survival.
Conclusions: The negative prognostic significance of locoregional recurrences from retroperitoneal tumors regarded as being radically resected has been
acknowledged for a long time. However, currently, there is a lack in an adequate description of the factors that are associated to tumor recurrences after surgical
resections regarded as complete, that reflects insufficient understanding of the biology of these tumors and explains the important inhomogeneity in surgical
approaches, as well as the long-term low efficiency of therapies.

Experiena spitalului sf. constantin n chirurgia citoreductiv combinat cu hipec


The St. Constantin Hospitals Initial Experience with CRS-HIPEC
B. Moldovan (1), D. Pocrea (1), Luminia Cmpeanu (2), Andreea Moldovan (3), C. C. Rad (1), Svetlana Enache (4)
(1) Spitalul Sf. Constantin, Secia de Chirurgie General, Braov, Romnia
(2) Spitalul Sf. Constantin, Secia de Anestezie i Terapie Intensiv, Braov, Romnia
(3) Spitalul Sf. Constantin, Secia de Boli Infecioase, Braov, Romnia
(4) Spitalul Sf. Constantin, Secia de Chirurgie Vascular, Braov, Romnia
Introducere: Chirurgia citoreductiv (CRS) n combinaie cu chimioterapia intraperitoneal (HIPEC) reprezint o tehnic rspndit n tratamentul carcinomatozei
peritoneale, o tehnic asociat cu morbiditate i mortalitate ridicat. Am efectuat un studiu retrospectiv, experiena Spitalului Sf. Constantin, subliniind
rezultatele bune obinute att din punct de vedere al citoreduciei ct i oncologic.
Material i metod: ntre iunie 2013 i februarie 2016, la un numr de 46 pacieni cu vrsta medie de 55,54 ani i un minim de 34 ani, s-au practicat 50 de
intervenii de chirurgie citoreducional combinat cu HiPEC (4 cazuri de reHIPEC).
Rezultate: Rezecia CCR-0 s-a realizat la 26 din 50 de pacieni, CCR-1 n 16 din 50 de cazuri i CCR-2 n 8 din 50 de cazuri, cu un timp operator mediu de 560
minute (ntre 400-620 minute). Durata medie de spitalizare a fost de 9 zile (4 zile n cazul operaiei de citoreducie tumoral laparoscopic combinat cu Hipec).
Rata morbiditii a fost de 30% cu WHO de grad 3 i 4 morbiditate 2 cazuri/50, rata mortalitii fiind 0 la 30 zile. Cu o urmrire postoperatorie de 11,8 luni, rata de
supravieuire a fost de 62%. Originea gastrointestinal n contrast cu originea ovarian a carcinomatozei peritoneale i un index PCI mai mare de 19 ne-a artat
un prognostic mai nefavorabil.
Concluzii: n centrele oncologice de referin s-a demonstrat c, chirurgia citoreducional combinat cu HIPEC pot reduce morbiditatea i mortalitatea, alturi de
un manegement multidisciplinar corect n ceea ce privete selecia pentru aceast procedur. Experiena noastr n ceea ce privete aceast procedur
(CRS-HIPEC) confirm aceste studii legate de managementul carcinomatozei peritoneale.

Introduction: Cytoreductive surgery (CRS) in combination with hyperthermic intraperitoneal chemotherapy (HIPEC) is a spreading technique for the treatment of
Congresul Naional de Chirurgie 2016 01 - 04 iunie 2016 Centrul Internaional de Conferine Sinaia
National Congress of Surgery 01 - 04 June 2016 Sinaia International Conference Center
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Sesiune Medici Comunicri orale


Physicians Session Oral Communications
peritoneal carcinomatosis, a technique that is associated with high morbidity and mortality rates. We report retrospectively the experience of St. Constantin
Hospital Brasov, underlining the good results obtained in terms of both reduction of complications and oncologic outcome.
Methods: Between June 2013 and February 2016, 46 patients with a mean age of 55.54 years, underwent 50 CRS-HIPEC combined procedures.
Results: CCR-0 resection was achieved in 26/50 of patients, CCR-1 in 16/50 of patients and CCR-2 in 8/50 of patients, with a mean operative time of 560 minutes
(range 400-620 minutes). Median hospital stay was 9 days (4 days in laparoscopic HIPEC-20 days). Total morbidity rate was 30%, with WHO grade 3 and 4
morbidity rate 2/50 and the 30 days mortality was 0. With a median follow up of 11.8 months, the overall survival (OS) rate was 62%. Gastrointestinal (GI) origin in
contrast with ovarian origin and peritoneal cancer index (PCI) higher than 19 showed a worst prognosis in terms of both OS and Progression Free Survival (PFS).
Conclusions: In a referral surgical oncology center, CRS-HIPEC related perioperative mortality and morbidity can be reduced with a multidisciplinary patient
management and a correct patient selection for this procedure. Our single center retrospective series confirm the advantage in PFS and OS of the combined
treatment CRS-HIPEC in the management of peritoneal carcinomatosis.

Tehnici de comunicare n echipa chirurgical


Communication Skills in the Surgical Team
G. C. Duu, Elena Stircu, F. Svulescu
Spitalul Universitar de Urgen Militar Central, Chirurgie II, Bucureti, Romnia
Echipa chirurgical are datoria de a asigura i de a promova un mediu de lucru pozitiv, care mbuntete performanele echipei i maximizeaz rezultatele
pentru sigurana pacientului.
Obiectivul studiului: Lucrarea urmrete cele mai importante atribute care sunt critice pentru dezvoltarea unei echipe de nalt performan, cum sunt
membership-ul i leadership-ul. Astfel, membrii unei echipe chirugicale trebuie s se simt angajai i implicai ntr-un scop comun.
Lucrarea evideniaz faptul c, ntr-un mediu interpersonal sigur, membrii echipei nu trebuie s ezite n a-i exprima punctele de vedere, s se provoace pozitiv
unul pe altul, s ridice anumite probleme fr team de ridicol sau atacuri personale. De asemenea, trebuie s se simt n siguran pentru a discuta despre erori
i greeli.
Material i metod: Conform literaturii cercetate, un mod simplu de a reflecta asupra performanei este de a rspunde la ntrebrile:
- Ce am fcut bine?
- Ce ar putea fi fcut mai bine?
- Ce ar trebui s nu mai facem?
- Ce ar trebui s continum s facem?
Rezultate: Abilitile de comunicare sunt o component cheie a practicii n chirurgie; ele pot fi predate, nvate, mbuntite, iar acest lucru va maximiza
performana i plcerea n practica clinic.
Concluzii: Problemele de comunicare interprofesional reprezint cauza principal a multor erori medicale.
Protocoale de comunicare structurate, cum ar fi SBAR, sunt proiectate pentru o comunicare eficient i complet.

The surgical team has the duty to ensure and promote a positive work environment that improves team performance and maximizes patient safety outcomes.
The study goal: The study follows the most important attributes that are critical to the development of high performance teams, such as the membership and
leadership. Thus, surgical team members should feel committed and involved in a common purpose.
The paper points out that, in a safe interpersonal environment, team members should not hesitate to express their views, to challenge each other positively, to
raise certain issues without fear of ridicule or personal attacks and also to feel safe to discuss errors and mistakes.
Material and method: According to the literature researched, a simple way to reflect the performance is to answer the questions:
- What did I do well?
- What could be done better?
- What should we not do?
- What should we keep doing?
Results: Communication skills are a key component of surgical practice; they can be taught, learned, improved, and this will maximize performance and
enjoyment in clinical practice.
Conclusions: Inter-professional communication problems are the main cause of many medical errors.
Structured communication protocols such as SBAR are designed for effective and complete communication.

Congresul Naional de Chirurgie 2016 01 - 04 iunie 2016 Centrul Internaional de Conferine Sinaia
National Congress of Surgery 01 - 04 June 2016 Sinaia International Conference Center
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Sesiune Medici Comunicri orale


Physicians Session Oral Communications

Tuberculoza abdominal - o problem de diagnostic i tratament


Abdominal Tuberculosis - A Diagnostic and Therapeutic Challange
N. Vlad (1), Ionela Negoi (2), I. A. Morar (2), N. Dnil (1), C. Lupacu (3), D. Andronic (1)
(1) Spitalul Clinic Judeean de Urgene Sf. Spiridon / Universitatea de Medicin i Farmacie Gr. T. Popa, Clinica I Chirurgie, Iai, Romnia
(2) Spitalul Clinic Judeean de Urgene Sf. Spiridon, Clinica I Chirurgie, Iai, Romnia
(3) Spitalul Clinic Judeean de Urgene Sf. Spiridon / Universitatea de Medicin i Farmacie Gr. T. Popa, Clinica II Chirurgie, Iai, Romnia
Introducere: Tuberculoza abdominal reprezint infecia provocat de Mycobacterium tuberculosis la nivelul peritoneului, tubului digestiv, mezourilor i
ganglionilor limfatici abdominali. Tuberculoza abdominal apare la pacienii cu un nivel socio-economic sczut, imunodeprimai i alcoolici. Asocierea cu
tuberculoza pulmonar nu este obligatorie. Tuberculoza abdominal are manifestri clinice, modificri imagistice i de laborator nespecifice, motiv pentru care
diagnosticul este dificil de stabilit.
Material i metod: Am efectuat un studiu retrospectiv pe o perioad de 10 ani la pacienii cu tuberculoz abdominal diagnosticai n Clinica I Chirurgie. n
aceast perioad au fost 18 pacieni (5 femei i 14 brbai) cu vrsta cuprins ntre 19 i 80 ani. Am analizat localizarea, metodele de diagnostic, tratamentul i
evoluia ulterioar.
Rezultate: Au fost 11 cazuri de tuberculoz peritoneal, 6 cazuri de tuberculoz intestinal i un caz de tuberculoz ganglionar. apte pacieni s-au internat n
urgen cu suspiciunea de abdomen acut chirurgical. La 11 pacieni diagnosticul s-a stabilit prin laparoscopie cu biopsie, iar n 7 cazuri a fost nevoie de
laparotomie asociat cu alte gesturi chirurgicale. Asocierea cu tuberculoza pulmonar s-a confirmat doar la 39% din cazuri. Am avut un caz de deces.
Concluzii: Tuberculoza abdominal rmne o realitate chirurgical, dei suntem n secolul XXI. Laparoscopia cu biopsie este o metod sigur de diagnostic i
favorizeaz prognosticul prin nceperea precoce a tratamentului specific. Complicaiile tuberculozei abdominale impun intervenii chirurgicale n urgen, iar
prognosticul uneori este nefavorabil.

Background: Abdominal tuberculosis is caused by the Mycobacterium tuberculosis infection of the peritoneum, digestive tract and lymphnodes in the abdomen.
Patients are usually with low socioeconomic level, immunosuppressed and alcoholics. Pulmonary tuberculosis is not necessarily present. The non-specific clinic,
imagistic and lab data make the diagnosis difficult.
Material and Method: Retrospective study on 10 years interval of the abdominal tuberculosis patients admitted in First Surgical Clinic St. Spiridon Hospital Iai.
There have been 18 patients (5 female and 14 male) with age between 19-80 years. We analyzed the clinicopathological data, diagnostic methods, treatment and
follow-up.
Results: 11 cases had peritoneal tuberculosis, 6 cases intestinal tuberculosis, and 1 case of lymphnodes tuberculosis. 7 patients have been admitted in emergency
for acute abdomen. 11 patients had the diagnosis established by laparoscopic biopsy, 7 cases needed laparotomy and other surgery. Associated pulmonary
tuberculosis has been confirmed in only 39% cases. One patient died.
Conclusions: Abdominal tuberculosis is still present in the XXIst century. Laparoscopic biopsy is a good diagnostic method and favors a good outcome by
hastening specific drugs treatment. Complicated abdominal tuberculosis needs emergency surgery, sometimes with grim prognosis.

Vascularizaia i particulariti de cretere pentru neoplaziile retroperitoneale


Retroperitoneal Tumors Vascularization and Growth Particularities
Angela Mdlina Lazr (1), E. Brtucu (1), N. D. Straja (1), Cecilia Tihoan (2), Antoaneta Magdalena tefnescu-Winterlik (2)
(1) Institutul Oncologic Prof. Dr. Al. Trestioreanu / Universitatea de Medicina i Farmacie Carol Davila, Chirurgie I, Bucureti, Romnia
(2) Spitalul Clinic de Urgen Sfntul Pantelimon, Serviciul de Anatomie Patologic, Bucureti, Romnia
Tumorile retroperitoneale, primitive sau secundare, se remarc printr-un comportament similar de dezvoltare insidioas i agresiv i prignostic asociat nefast.
Dimensiunile deosebite pn la care aceste neoplazii se dezvolt sugereaz existena unor factori locali anatomici favorizani pentru acestea. Obiectivul studiului
a fost analiza particularitilor de dezvoltare a tumorilor retroperitoneale, cu investigarea caractersticilor de vascularizaie tumoral, factorilor facvorizani pentru
aceasta, dar i stabilirea semnificaiei prognostice a simptomatologiei pacienilor.
Pacieni i metode : Am condus un studiu retropectiv i prospectiv pe o perioad de 15 ani pe un grup de pacieni operai de neoplazii retroperitoneale primitive
i secundare. Am analizat datele obinute din buletinele de examen histopatologic i descrierilor operatorii, dar i imagistice pentru a identifica caracteristici de
dezvoltare tumoral, dar i corelaia acestora cu simptomatologia paceinilor.
Rezultate: Tumorile retroperitonale s-au caracterizat prin dimensiuni deosebite. O dimensiune tumoral mai mare nu a semnificat i o rezecabilitate mai redus.
n schimb, rata de dezvoltare tumoral a avut semnificaie prognostic. Anumite tipare ale vascularizaiei neoplazice au asociat agresivitate sporit, implicarea
unor structuri vasculare mai mari i rspunsuri mai slabe la terapii.
Concluzii: n general, se consider c o tumor voluminoas presupune o vascularizaie mai bogat i o rezecabilitate redus. De asemenea, simptomatologia
nespecific i insidioas a pacinilor cu neoplazii retroperitoneale nu a condus pn n prezent la diferenieri prognostice. Discrimninarea unor profiluri
difereniate de dezvoltare tumoral la nivelul spaiului retroperitoneal i a factorilor determinani pentru acestea va permite o terapie particularizat, mai eficient
i pentru aceste neopalzii aparent monocrome.

Primitive as well as secondary retroperitoneal tumors are remarkable by their uniform behavior of silent but aggressive development and associated precarious
prognosis. The important dimensions of these neoplasms suggest the existence of propitious local anatomic factors for them. The aim of this study was to
Congresul Naional de Chirurgie 2016 01 - 04 iunie 2016 Centrul Internaional de Conferine Sinaia
National Congress of Surgery 01 - 04 June 2016 Sinaia International Conference Center
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Physicians Session Oral Communications
analyze the growth particularities of retroperitoneal tumors with the investigation of tumor vascularization characteristics, factors favoring it, as well as the
determination of the prognostic significance of tumor symptomatology.
Patients and Methods: We conducted a retrospective and prospective study on a group of patients operated on for primitive and secondary retroperitoneal
tumors along a period of 15 years. We analyzed data obtained from histopathologic examination bulletins, operative and imagistic descriptions in order to identify
tumor development characteristics as well as their correlation to patient symptoms.
Results: Retroperitoneal tumors have been characterized by important dimensions. However, a bigger tumor dimension did not also signify a lower resection rate.
Instead, tumor growth rate has been of prognostic significance. Certain neoplastic vascularization patterns associated an increased aggressiveness, the
involvement of more important blood vessels and poorer results to therapies.
Conclusions: Usually, a voluminous tumor is regarded as having a richer vascularization and being of lower surgical resectability. Also, the unspecific and silent
symptoms of retroperitoneal tumor patients have not led to prognostic differentiations yet. The discrimination of differentiated tumor growth patterns in
retroperitoneal space and their favoring factors will enable a particularized, more efficient therapy for these apparently monochromous neoplasias.

Tratamentul cu radiofrecven al bolii varicoase. Experiena Clinicii Chirurgie a Spitalului Sf. Constantin Braov
The Treatment of Varicose Veins of the Limb Using VNUS Closure Technique. The St. Constantin Hospital
Experience
B. Moldovan (1), D. Pocrea (1), Luminia Cmpeanu (2), Andreea Moldovan (3), C. C. Rad (1), Svetlana Enache (4)
(1) Spitalul Sf. Constantin, Secia de Chirurgie General, Braov, Romnia
(2) Spitalul Sf. Constantin, Secia de Anestezie i Terapie Intensiv, Braov, Romnia
(3) Spitalul Sf. Constantin, Secia de Boli Infecioase, Braov, Romnia
(4) Spitalul Sf. Constantin, Secia de Chirurgie Vascular, Braov, Romnia
Introducere: Boala varicoas a membrelor inferioare beneficiaz de multiple abordri terapeutice, dintre care, tehnica de ablaie endovenoas cu radiofrecven
VNUS este procedura minim invaziv de elecie n clinica noastr, n tratamentul insuficienei venoase safene.
Metoda: Tratamentul bolii varicoase are 2 obiective: cel fiziopatogenic - tratarea refluxului safen prin termoablaie i cel estetic-dispariia pachetelor varicoase
inestetice, ce necesit adesea gesturi complementare: scleroterapie, mici flebectomii sau nsilri transfixiante. Prezentm experiena Clinicii Chirurgie din cadrul
Spitalului Sf. Constantin n 270 cazuri la care s-a practicat tratamentul minim invaziv prin termoablaie endovenoas cu radiofrecven, tehnica VNUS. 270
pacieni au beneficiat de ablaie endovenoas prin radiofrecven ecoghidat fr incizii, la 162 pacieni s-a augmentat intervenia prin scleroterapie cu
Aethoxysclerol i/sau nsilri supraetajate cu fire transfixiante pentru pachete nesistematizate.
Rezultate: Rezultatele chirurgicale au fost excelente, cu o spitalizare medie de 20 ore datorat n general anesteziei generale. n 3 cazuri s-au semnalat leziuni
termice tegumentare n general la nivelul plicii geniculare sau pe coaps, tratate conservator. Rezultatele estetice au fost de asemenea favorabile, 35 de cazuri
necesitatnd scleroterapie de completare postoperator.
Concluzie: Tehnica VNUS este o alternativ binevenit a unor proceduri invazive, cum e cea de stripping venos, aceasta putndu-se aplica att pe vena safen
intern ct i pe vena safen extern i alte vene superficiale ale membrelor inferioare.

Introduction: The treatment of varicose veins of the limb benefits of multiple therapeutic approaches. The VNUS closure technique is the main procedure in our
surgical dept. in the treatment of the saphenous insufficiency.
Method: The treatment of varicose veins has 2 objectives: the fiziopathogenic one - the approach of the saphenous reflux by thermoablation and 2, the esthetic
one - the disappearance of the inestetic varicose veins that needs, beside the VNUS closure, complementary gesture: sclerotherapy, flebectomy or transphixiant
sutures. We present the experience of the St Constantin Hospital with the miniinvasive treatment of varix using VNUS closure technique in 270 patients.
Between 2011-2016, 270 patients underwent VNUS closure technique for uni/bilateral varix, echo-guided, scareless surgery. In 162 cases we augmented the
procedure by using sclerotherapy with Aethoxysclerol l and/or by transphixiant sutures.
Results: Surgical results were excellent, with an average hospitalization of 20 hours due to general anesthesia. In 3 cases thermal injuries to the skin were
reported, treated conservative. The results have been favorable aesthetically, 35 cases requiring completion with sclerotherapy surgery.
Conclusion: VNUS technique represents a welcome alternative to invasive procedures, like that of venous stripping, and may be applied on both saphenous vein
internal and external, and other superficial veins of the legs.

Congresul Naional de Chirurgie 2016 01 - 04 iunie 2016 Centrul Internaional de Conferine Sinaia
National Congress of Surgery 01 - 04 June 2016 Sinaia International Conference Center
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Sesiune Medici Comunicri orale


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Consideraii diagnostice i terapeutice asupra fistulelor postoperatorii ale tractului digestiv


Diagnostic and Therapeutic Consideration Over Postoperative Digestive Fistula
V. A. Porojan, Oana Ilona David, Elena Violeta Radu, I. S. Coman, A. R. Stoian, M. Paraschiv, V. T. Grigorean
Spitalul Clinic de Urgen Prof. Dr. Bagdasar-Arseni, Secia de Chirurgie General, Bucureti, Romnia
Introducere: Fistula digestiv este una din cele mai redutabile complicaii ale chirurgiei abdominale, fiind nsoit de o rat crescut a mortalitii, n ciuda
progreselor tehnice nregistrate n ultimii ani.
Material i metod: Lotul a inclus 51 de pacieni din Clinica de Chirurgie General a Spitalului Clinic de Urgen Bagdasar-Arseni, ce au dezvoltat o fistul
digestiv postoperatorie. Studiul se ntinde pe o perioad de 4 ani (01.01.2012-31.12.2015). Au fost analizate repartiia pe vrst i sexe a pacienilor, tipul
patologiei iniiale (benign/malign), comorbiditile i statusul nutriional, caracterul interveniei chirurgicale (de urgen/programat), modalitile de realizare a
suturilor digestive, semnele clinice revelatorii, localizarea fistulelor, modalitatea de tratament i rezultatele.
Rezultate: Pacienii inclui n lot au avut vrste cuprinse ntre 23 i 85 de ani, remarcndu-se o preponderen a sexului masculin (34/51). Fistulele au fost
imprite n 6 categorii: eso-gastro-duodenale (14), enterale (13), colonice (17), biliare (4), multiple (3). La 25 de pacieni s-a optat pentru tratamentul conservator
(debit mic al fistulei, bine captat de ctre tubul de dren), n timp ce la restul de 26 s-a intervenit chirurgical, de cele mai multe ori acest lucru fiind impus de
apariia semnelor de peritonit. Mortalitatea global a fost de 33% (17/51), mai mare n lotul pacienilor tratai chirurgical (14/26).
Concluzii: Decizia terapeutic trebuie luat n funcie de un ansamblu de factori, operaia fiind impus n general de peritonita ce determin un sepsis greu de
controlat, responsabil de rata crescut a mortalitii la pacienii cu reintervenie.
Cuvinte cheie: fistule digestive postoperatorii, tratament conservator, tratament operator

Introduction: Digestive fistula is one of the most feared complications of abdominal surgery, with a high rate of mortality despite the technical progresses in
recent years.
Method: The group included 51 patients with postoperative digestive fistula form Bagdasar-Arseni General Surgery Clinic. The study covers a period of 4 years
(01.01.2012 31.12.2015). There were analyzed: sex and gender distribution, the type of the initial pathology (benign/malign), comorbidities and nutritional status,
whether the surgical intervention was performed in emergency or as programed intervention, type of digestive sutures, revealing clinical signs, fistula localization,
treatment and results.
Results: The patients were between 23 and 85 years old, in majority males (34/51). Fistulae were divided into 6 categories: eso-gastro-duodenal (14), enteral (13),
colonic (17), biliary (3) and multiple (3). Conservative treatment was used for 25 patients (decision made based on the small amount of fluid produced by the
fistula and also on the high efficiency of the peritoneal drainage) while surgical treatment was performed for the other 26, in most cases surgical intervention
being imposed by the occurrence of signs of peritonitis. Global mortality was 33% (17/51), higher for the surgical treated patients (14/26).
Conclusions: Therapeutic decision must be taken according to a multitude of factors, the surgical intervention being mandatory in case of general peritonitis with
sepsis leading to a high rate of mortality in patients suffering reintervention.
Keywords: postoperative digestive fistula, conservative treatment, surgical treatment

Patologia chirurgical ginecologic pediatric (atrezie de vagin, duplicaie de vagin, agenezie de col uterin)
Pediatric Gynecological Pathology (Vaginal Atresia, Vaginal Duplications, Cervical Agenesis)
C. Tica, F. D. Enache, A. Tiron, G. Panait, Iulia Dreptu, Cosmina Beliu
Spitalul Clinic Judeean de Urgen Sf. Apostol Andrei, Secia de Chirurgie Pediatric, Constana, Romnia
Afeciunile ginecologice pediatrice chirurgicale sunt puin cunoscute i rar ntlnite n practica zilnic.
Materiale i metode: Articolul nostru analizeaz 3 cazuri ntlnite n ultimii ani n ceea ce privete dificultile de diagnostic i rezolvarea terapeutic, ct i
urmrirea acestora pe termen lung.
Rezultate: Pentru toate cele trei cazuri, diagnosticul a fost dificil, necesitnd o palet larg de investigaii, mai ales imagistice. Managementul terapeutic a trebuit
s in cont att de aspectul anatomic, ct i de cel funcional.
Concluzii: Abordul acestui tip de patologie este dificil, existnd dificulti att de diagnostic, ct i de tratament. Managementul terapeutic necesit o echip
multidisciplinar: chirurg pediatru, ginecolog, pediatru, endocrinolog i neonatolog, n cazul malformaiilor congenitale aparente, descoperite n perioada
neonatal. Urmrirea pe termen lung este esenial, pn n momentul maturizrii, acordndu-se atenie perioadei de adolescen, cnd se definitiveaz funciile
organelor sexuale.

Gynaecological paediatric pathology is little known and rare in the daily practice.
Materials and Methods: Our article examines three cases encountered in recent years in terms of solving the difficulties of diagnosis and therapeutics, and their
long-term tracking.
Results: For all three cases, the diagnosis was difficult, requiring a wide range of investigations, especially imaging. Therapeutic management had to consider
both the anatomic appearance and functional.
Conclusions: The approach of this type of pathology is difficult; there are difficulties in both diagnosis and treatment. The therapeutic management requires a
multidisciplinary team: paediatric surgeon, gynaecologist, paediatrician, endocrinologist and neonatologist for the apparent congenital anomalies discovered in
the neonatal period. Long term follow up is essential, until maturity, with an emphasis on the period of adolescence, when the functions of sexual organs are
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finalized.

Tulburrile menstruale ale adolescentelor


Menstrual Disorders of Adolescent Girls
V. Cristea (1), A. Petrea (1), M. Dnil (1), A. Charkaoui (2), D. Bejan (2)
(1) Universitatea Dunrea de Jos, Clinica de Chirurgie Pediatric, Galai, Romnia
(2) Spitalul Clinic de Urgen Pentru Copii Sf. Ioan, Clinica de Chirurgie i Ortopedie Pediatric, Galati, Romnia
Momentul esenial al pubertii este apariia primei menstruaii (menarha), care survine n mod normal ntre 11 i 14 ani.
Ciclurile neregulate sunt frecvente n primele luni de dup menarh, fiind de obicei lungi, de 30-45 zile. Tot n aceast perioad ciclurile sunt anovulatorii (cteva
luni, mai rar ani).
n majoritatea cazurilor, dup prima menstr sau dup cteva menstre repetate apar dereglri ale ritmului, duratei i cantitii menstrelor. Ritmul ciclurilor este
neregulat, apar cicluri de 4 sptmni care alterneaz cu cicluri de 5-6 sptmni sau mai lungi, pn la 3 luni. Durata menstrelor poate fi variabil, de la 3-4 zile
normal, la 1-2 zile sau menstre prelungite 5-7 zile. Menstrele pot fi, de asemenea, modificate cantitativ: uneori reduse la cteva picturi, alteori abundente, mai
rar.
Himenul neperforat. Foarte rar se ntlnete imperforarea himenului: membrana himenal nu are orificiile ei obinuite pe unde se scurge sngele menstrual. Fata
simte dureri mari n abdomenul inferior, se baloneaz, poate prezenta febr. Aceste suferine dureaz 3-4 zile, menstra nu apare i tulburrile dispar, ca s
reapar n luna urmatoare. Sngele menstrual neputnd s se scurg din uter i vagin pe care le destinde. Sngele acumulat dup un timp trece parial n
cavitatea abdominal.

The essential moment of puberty is the appearance of the first menstruation (menarche), which occurs normally between 11 and 14 years.
Irregular menstrual cycles are common in the first months after menarche, typically long, 30-45 days. In this period there are anovulatory cycles (a few months,
rarely years).
In most cases, after the first menstrual cycle or the first menses, disorders of the rhythm, timing and quantity of menses appear. The cycles rhythm is irregular,
cycles occur 4 weeks alternating with cycles of 5-6 weeks or longer, up to 3 months. The duration of periods can be variable, normally from 3-4 days, 1-2 days,
5-7 days, prolonged menstruation. Heavy periods can also be modified quantitatively, sometimes reduced to a few drops, sometimes (rarely) abundant.
Non-perforated hymen. We very rarely meet the non-perforated hymen: hymen membrane has holes where the regular menstrual blood drains. The girl feels pain
in the lower abdomen, is bloated, there may be fever. Those symptoms last for 3 to 4 days, menstrual cycle does not appear and the disorders disappear, only to
reappear next month. The menstrual blood being unable to flow from the uterus and vagina, it relaxes them. The collected menstrual blood passes partially into
the abdominal cavity.

Elemente de patologie ovarian chistic la fetie


Elements of Cystic Ovarian Pathology in Girls
A. Zavate (1), O. Ciobanu (1), I. Purcaru (2), J. Kamel (2), Alexandra Groza (2), C. Sabetay (2)
(1) Universitatea de Medicin i Farmacie, Clinica de Chirurgie Pediatric, Craiova, Romnia
(2) Spitalul Clinic Judeean de Urgen, Secia de Chirurgie Pediatric, Craiova, Romnia
Introducere: Patologia anexial la fetie aproape de vrsta pubertii determin tot mai frecvent forme ale abdomenului acut sau cronic, n special la pacientele
cu disfuncii ale ciclului menstrual, corelat cu tulburri de cretere i de apariie a caracterelor sexuale secundare. Dac aceast patologie este frecvent la vrsta
pubertii, exist cazuri diagnosticate i la vrste mici.
Materiale i metode: Autorii comunic un numr de 89 de cazuri cu patologie chistic ovarian, unele dintre ele manifestnd simptome de abdomen acut, altele
cu simptomatologie cronic. Examinarea clinic corelat cu explorrile imagistice au fost cele mai importante n stabilirea diagnosticului.
Rezultate i concluzii: Rezultatele au fost bune, urmrirea pacientelor incluznd terapie social adresat lor, dar i familiei.

Introduction: Ovarian pathology in girls close to puberty causes more frequent forms of chronic or acute abdomen, especially in patients with menstrual
dysfunction correlated with growth disorders and the appearance of secondary sexual characteristics. If this pathology is common in puberty, there are, however,
some cases diagnosed at early ages.
Materials and Methods: The authors communicate a number of 89 cases with cystic ovarian pathology, some of them showing symptoms of acute abdomen,
while others presenting chronic symptoms. Clinical examination correlated with imaging explorations were the most useful in establishing the right diagnosis.
Results and Conclusions: The results were good by tracking patients, including social therapy addressed to them and their family.

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Abordul laparoscopic n patologia anexial la copil


Laparoscopic Approach in Adnexal Pathology in Pediatric Population
Carmen Iulia Ciongradi, I. Srbu, S. G. Aprodu
Spitalul de Urgen pentru Copii Sf. Maria, Secia de Chirurgie Pediatric, Iai, Romnia
Scop: Scopul lucrrii este de a prezenta experiena autorilor n tratamentul laparoscopic al afeciunilor anexiale n populaia pediatric.
Materiale i metode: Au fost analizate retrospectiv foile de observaie ale pacienilor cu afeciuni ovariene sau tubare, ce au beneficiat de tratament minim invaziv
n clinica autorilor, n perioada august 2012 - decembrie 2015.
Rezultate: Au fost identificai un numr de 24 de pacieni, cu vrste cuprinse ntre 4 luni i 15 ani, ale cror diagnostice au inclus: dou cazuri de chistadenom
seros ovarian, un caz de torsiune a trompei uterine secundare unui hidrosalpinx, zece cazuri de torsiune de ovar (dintre care trei pe ovar tumoral - teratom
ovarian i dou torsiuni antenatale de ovar), chisturi ovariene simple n zece cazuri i un caz de endometrioz. n patru cazuri de torsiune ovarian a fost
necesar ovariectomie, incluznd cele trei cazuri de torsiune pe ovar tumoral. Am identificat i dou cazuri de torsiune antenatal de ovar ce au necesitat
ovarectomie la vrsta de 4, respectiv 6 luni. Timpul operator a variat ntre 35 i 145 de minute, cu o medie de 70 de minute. n niciun caz nu a fost necesar
conversia, dar n trei dintre pacieni a fost necesar, pentru extragerea unor piese mari de excizie, efectuarea unei minilaparotomii Pfannensteil. Nu am identificat
complicaii intra i postoperatorii.
Concluzii: Considerm c abordul laparoscopic al patologiei anexiale n populaia pediatric este o procedur eficient, sigur i tehnic posibil, asigurnd
prezervarea esutului ovarian non tumoral i astfel a fertilitii, aparent fr a asocia riscuri crescute. Pe lng aceasta, accesul minim invaziv asigur, comparativ
cu chirurgia deschis, o mai bun vizualizare anexial, alturi de reducerea durerii postoperatorii, precum i o recuperare rapid.

Aim: To present our early experience regarding the laparoscopic treatment of adnexal pathology in pediatric population.
Materials and Methods: We retrospectively review the records of our patients with ovarian or tubal disease, treated in our department by laparoscopic
procedures between August 2012 and December 2015.
Results: Our series includes 24 patients aged 4 months to 15 years, diagnosed with ovarian serous cyst adenoma in two cases, tubal torsion due to a hydrosalpinx
in one case, ten cases of ovarian torsion (three with associated ovarian teratoma and two with prenatal torsion), simple ovarian cyst in 10 cases and one case of
endometriosis. Four cases of ovarian torsion needed ovariectomy; in three of them a tumor was found. Two cases of fetal ovarian torsion were prenatally
diagnosed and required excision of the ovary at 4, respectively 6 month. The operative time varied between 35 and 145 minutes, with a mean operative time of
78 minutes. The conversion rate was zero, but in three cases, a small Pfannenstiel laparotomy was needed for the extraction of some large specimens. We didnt
find any intra or postoperative complication.
Conclusions: The laparoscopic approach of the adnexal pathology in pediatric population is technically feasible and a safe procedure, providing the preservation
of the non-tumoral ovarian tissue and thus of the fertility, with no apparent risk of increasing the morbidity. Also, minimal invasive surgery is associated with
better visualization of the adnexal, less postoperative pain and quicker recovery.

Tumori ale organelor genitale interne (maligne i benigne) pe o perioad de 4 ani (2012 - 2015)
Internal Genitalia Tumors (Malignant and Benign) for a Period of 4 Years (2012 to 2015)
E. Boia, C. Popoiu, V. David, Maria Corina Stnciulescu, A. Pal
Spitalul Clinic de Urgen pentru Copii Louis urcanu, Clinica de Chirurgie Pediatric, Timioara, Romnia
Tumorile ovariene se ntlnesc rar la copii, iar simptomatologia i patologia sunt diferite fa de adult. Neoplasmele ovariene au o inciden de 2.6 din 100.000
de fete/an. Cele mai ntlnite formaiuni tumorale ovarie la copil sunt benigne dar, prin agresivitatea lor crescut, tumorile maligne ovariene reprezint o
provocare imens pentru terapeut. n perioada 2012 - 2015, au fost internate un numr total de 71 de paciente cu tumori ale organelor genitale interne. Vrsta
pacientelor a fost cuprins ntre <1 an i 17 ani. Au fost un numr de 40 chisturi de ovar simple, 6 teratoame, 23 alte tumori. Tratamentul a fost chirurgical la un
numr de 40 de paciente, dintre care 12 au avut nevoie de tratament de urgen. n 16 cazuri s-a intervenit laparoscopic, iar n 24 de cazuri prin abord deschis.
S-a practicat chistectomia simpl la 18 cazuri, ablaia tumorii ovariene n 3 cazuri, ovarectomie la 19 cazuri. n 8 cazuri ovarectomia a fost necesar pentru necroza
ovarului torsionat. n cazul unei paciente de 11 ani cu teratom ovarian gigant stng s-a descoperit intraoperator un teratom la ovarul controlateral, practicndu-se
excizia acestuia cu pstrarea esutului ovarian indemn. La 30 de paciente s-a preferat tratamentul nonchirurgical al chistului folicular simplu, evoluia fiind
favorabil la 28 dintre ele. Concluzii: Patologia tumoral ovarian este o afeciune frecvent la fetie, n special n perioada postmenarh. Chisturile ovariene
simple sunt cea mai frecvent patologie, dei mult mai rare, tumorile ovariene solide pun probleme majore de diagnostic i tratament corespunztor.

Ovarian tumors are rare in children and the symptoms and pathology are different from the adult. Ovarian neoplasms have an incidence of 2.6 per 100,000
girls/year. The most common ovary tumor formation in children is benign, but the increased aggressiveness of malignant ovarian tumors represents a huge
challenge for the therapist. Between 2012 and 2015, a total of 71 patients with tumors of internal genitalia were hospitalized. Patients age was between <1 year to
17 years. There were a total of 40 simple cysts of the ovary 6 teratomas, 23 other tumors. Surgical treatment was a total of 40 patients of which 12 needed
emergency treatment. In 16 cases we used the laparoscopic approach and in 24 cases by open approach. Simple cystectomy was practiced in 18 cases of ovarian
tumor ablation in 3 cases, 19 cases oophorectomy. In 8 cases oophorectomy was required for the necrosis of the twisted ovary. In the case of an 11 year old with
ovarian teratoma was discovered giant intraoperative left a teratoma ovary controlaterala, practicing its excision with ovarian tissue preservation urge. For 30
patients we preferred non-surgical treatment of simple follicular cyst, the evolution being favorable in 28 of them. Conclusions: Ovarian tumor pathology is a
common condition in girls, especially postmenarcheal. Simple ovarian cysts are the most common pathology, although more rare, solid ovarian tumors pose
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major problems for diagnosis and appropriate treatment.

Abordarea torsiunilor de anex n chirurgia pediatric


Adnexal Torsion Management in Pediatric Surgery
S. Ionescu, M. Mocanu, B. Andrei, Beatrice Bunea, Teodora Luchita, Daniela Pavel
Spitalul Clinic de Urgen pentru Copii Maria Sklodowska Curie, Secia de Chirurgie Pediatric, Bucureti, Romnia
Obiectiv: Descrierea metodelor de tratament folosite pentru rezolvarea cazurilor de torsiune de ovar n Clinica de Chirurgie Pediatric a Spitalului MS Curie
Material i metode: Lucrarea este un studiu retrospectiv efectuat ntre anii 2007-2016, n care s-au analizat metodele de diagnostic, durata simptomatologiei
naintea prezentrii, vrsta, prezena sau absena unei patologii asociate i metodele de tratament aplicate la pacientele cu torsiune de anex.
Rezultate: n perioada menionat, au fost 45 de paciente la care s-a stabilit diagnosticul de torsiune de anex. Acestea s-au prezentat la spital n regim de
urgen cu durere abdominal, lipotimie, vrsturi cu o evoluie premergatoare de 3 (medie) zile, avnd vrsta ntre 3 luni i 21 ani (medie 11.14 ani ). n 30 dintre
cazuri torsiunea anexei a fost asociat cu prezena unei patologii a ovarului sau a trompei, respectiv chiste seroase sau hematice - 17, teratoame sau chiste
dermoide - 10, ovar polichistic - 2, malformaie de tromp uterine - 1 caz. ntr-un caz, torsiunea anexei s-a datorat hernierii n canal peritoneo vaginal perisistent.
Tratamentul conservator a fost posibil n 9 cazuri, restul necesitnd anexectomie, pe cale deschis sau laparoscopic.
Concluzii: Torsiunea de anex este o patologie relativ rar n populaia pediatric, dar afecteaz toate grupurile de vrst i necesit un diagnostic diferenial
amnunit. Cel mai frecvent se asociaz cu alte afeciuni ale ovarului sau trompei. Tratamentul chirurgical reprezint o urgen i are ca obiectiv detorsionarea. n
funcie de patologia asociat i viabilitatea anexei dup detorsionare se practic chistectomie/biopsie ovarian/anexectomie.

Objective: To describe the methods of treatment used for dealing with adnexal torsion in Pediatric Surgery Hospital MS Curie
Material and Methods: This paper is a retrospective study conducted between 2007-2016 in which we have analyzed the methods of diagnosis, duration of
symptoms before presentation, age, presence or absence of associated pathologies and treatment methods applied in patients with torsion of the appendix.
Results: In the mentioned period, there were 45 patients in which the diagnosis of torsion of the appendix. They were presented to hospital emergency with
abdominal pain, faintness, vomiting evolving preceding 3 (average) days, aged between 3 months and 21 years (mean 11.14 years). In 30 of the cases twisting
Annex was associated with this pathology of the ovary or fallopian or serous cysts or hematic - 17, teratomas or dermoid cyst - 10, - 2 polycystic ovary, fallopian
tube malformations of 1 case. In one case, twisting Annex was due herniation in peritoneo vaginal canal perisistent. Conservative treatment was possible in 9
cases, the rest requiring anexectomy, open or laparoscopic.
Conclusions: Torsion Annex is a relatively rare pathology in the pediatric population, but affects all age groups and requires a thorough differential diagnosis.
Most commonly associated with other disorders of the ovary or tube. Surgical treatment is urgent and aims detorsioning. In function of the viability and the
associated pathology practice after the detorsioning one may carry out cystectomy/ovarian biopsy/anexectomy.

Corp strin intraperitoneal restant postoperator 16 luni


16 Months Postoperative Intraperitoneal Foreign Body
S. Pun (1), I. Negoi (2), I. Tnase (2), B. Stoica (2), Anca Ricu (2), B. Gapar (1), M. Beuran (3)
(1) Spitalul Clinic de Urgen Floreasca, Clinica Chirurgie II, Bucureti, Romnia
(2) Spitalul Clinic de Urgen Floreasca, Secia de Chirurgie General, Bucureti, Romnia
(3) Spitalul Clinic de Urgen Floreasca, Clinica Chirurgie III, Bucureti, Romnia
Catalogat ca iatrogenie, corpul strin intraperitoneal poate fi retenionat timp ndelungat fr a produce manifestri clinice importante pn cnd procesul
inflamator asociat produce efecte directe asupra organelor vecine.
Prezentarea cazurilor singulare - de altfel, destul de rare - duce la posibilitatea ulterioar a diagnosticrii mai rapide a unor astfel de situaii, cu evitarea din timp a
unor complicaii majore.
Este prezentat cazul unei paciente histerectomizate cu 16 luni nainte i care a dezvoltat postoperator o tumor n etajul abdominal inferior stng, care a ajuns la
dimensiuni de 13/11/10 cm pn cnd s devin palpabil, fr alt simptomatologie alarmant pentru pacient. Investigaiile paraclinice nu au putut preciza tipul
tumorii evideniate n firida colic stng, posterior dar laparotomia exploratorie a evideniat prezena unui material textil de 35/35/1 cm n mijlocul unui abces cu
1000 ml puroi cremos (n condiiile particulare ale unei hemoleucograme preoperatorii normale), situat printre ansele ileale terminale, cu aglutinarea inflamatorie
a apendicelui cecal la nivelul abcesului - a fost necesar enterectomia segmentar ileal i apendicectomia pentru ndeprtarea corpului strin i a abcesului
inter-ileal. Evoluia postoperatorie a fost simpl, fr complicaii digestive la 6 luni de la operaie.
Retenia intraperitoneal a unui corp strin dup intervenii chirurgicale de anvergur poate fi de lung durat, chiar n lipsa unui tablou dramatic
clinico-paraclinic pentru un timp ndelungat.

A case of a woman with a previous hysterectomy is presented to expose a remnant textile foreign body left intraperitoneal for 16 months after surgery - a 35/35/1
cm textile material was removed from a 1000 ml interileal abscess and segmentary enterectomy was necessary along with apendectomy. Smooth postoperative
evolution was noticed even after 6 months from the removal.
Large textile foreign body can be retained inside the peritoneal cavity after previous surgery with no major symptomatology for the patient, even for a long period
of time.
10

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Invaginaie jejunal pe esut pancreatic ectopic - cauz rar de ocluzie intestinal
Jejunal Intussusception in Ectopic Pancreatic Tissue - Rare Cause of Intestinal Obstruction
M. Prcoveanu, M. Munteanu, L. Vasile, Anca Ruxanda, . Dina, A. C. Munteanu, Valentin Crstea, Nicoleta Pogoran, C. Du, D. Dranceanu
Spitalul Clinic Judeean de Urgen, Clinica Chirurgie III, Craiova, Romnia
Introducere: Pancreasul ectopic este o anomalie congenital relativ rar, definit ca esut pancreatic aflat la distan de pancreas i care nu are legturi
anatomice, vasculare sau nervoase cu acesta. Cel mai frecvent, pancreasul ectopic se afl la nivelul stomacului, duodenului i jejunului. El este asimptomatic i
devine clinic evident doar atunci cnd apare inflamaia, sngerarea, obstrucia sau degenarere malign la nivelul su.
Material i metod: Prezentm cazul unei paciente n vrst de 46 de ani, apendicectomizat n antecedente, internat prin serviciul de urgen cu semne clinice
i simptome de ocluzie intestinal nalt. Radiografia abdominal descrie nivele hidroaerice pe intestin subire, localizate n flancul stng. Se intervine chirurgical
de urgen sub anestezie general.
Rezultate: Intraoperator se constat primele anse jejunale destinse n amonte de o invaginaie produs pe o tumor subseroas de jejun. Se efectueaz
enterectomie segmentar cu evoluie postoperatorie favorabil. Rezultatul histopatologic a fost de pancreas ectopic jejunal.
Concluzii: Diagnosticul de pancreas ectopic este greu de pus preoperator, de cele mai multe ori descoperirea pancreasului ectopic fiind ntampltoare, cu ocazia
altor intervenii chirurgicale sau n cazul n care esutul pancreatic ectopic dezvolt complicaii de tip obstructiv, inflamator sau hemoragic. Dezvoltarea
subseroas a esutului pancreatic face grea diferenierea intraoperatorie a acestuia de tumorile stromale intestinale care au o frecven mult mai mare.

Introduction: Ectopic pancreas is a relatively rare congenital anomaly, defined as pancreas tissue, remote from the pancreas and with no anatomic, vascular or
nervous connection to it. Most commonly, ectopic pancreas lies in the stomach, duodenum and jejunum. It is asymptomatic and becomes clinically evident only
when inflammation, bleeding, obstruction or malignant degeneration occur.
Material and method: We present the case of a patient aged 46, admitted through the emergency room with clinical signs and symptoms of high bowel
obstruction. Abdominal radiography shows hidroaeric levels on the the small intestine, located in the left flank. Emergency surgery is performed under general
anesthesia.
Results: Intraoperatively it is discovered that the first jejunal loops relaxed upstream of an invagination tumor produced on a subset of the jejunum. Segmental
enterectomy is performed with favorable postoperative evolution. Histopathological result was jejunal ectopic pancreas.
Conclusions: The diagnosis of ectopic pancreas is difficult to be put preoperatively; most of the times the discovery of ectopic pancreas is made by chance,
during other surgeries or if the ectopic pancreatic tissue develops obstructive, inflammatory or hemorrhagic complications. Subseries development of pancreatic
tissue makes its intraoperative differentiation difficult from the intestinal stromal tumors which have a much higher frequency.

Impactul empiemului cu cultur pozitiv asupra toracotomiei i decorticrii


The Culture-Positive Empyema Impact on Thoracotomy and Decortication
L. Kiss (1), R. Kiss (1), M. Save (2), D. Roiban (1), M. Faur (1)
(1) Spital Clinic Judeean de Urgen, Secia de Chirurgie I, Sibiu, Romnia
(2) Spital Clinic Judeean de Urgen, Secia de Anestezie i Terapie Intensiv, Sibiu, Romnia
Rezumat: Empiemul pleural se definete prin acumularea de secreie pleural n cavitatea pleural, aprnd de obicei n asociere cu pneumonia comunitar
(colecie paropneumonic).
Scopul: Acest studiu are ca scop aprecierea eficacitii toracotomiei i decorticrii (T/D) n obinerea reexpansionrii pulmonare la pacienii aflai n stadiul III al
empiemului i aprecierea impactului empiemului cu cultur pozitiv asupra rezultatelor decorticrii.
Metoda: Studiul de faa este retrospectiv, cuprinznd pacienii nostri tratai cu T/D, pe o perioad de 12 ani (2002-2014).
Rezultate: Au fost identificai 107 pacieni dintre care 86% de sex masculin
Durata medie de spitalizare a fost 12 zile.
n 86% din cazuri s-a obinut expansiune pulmonar complet. Nu au fost decese postoperatorii.
n 56 de cazuri (52%), cultura pleural a fost pozitiv, aceast categorie de pacieni avnd o durat mai lung a drenajului pleural (n medie 11 zile) cu extreme
ntre 4-111 fa de 5 zile medie (interval 3-28 zile) pentru cazurile cu culturi negative (p=0.0004).
Cazurile cu culturi pozitive au evoluat cu mai multe complicaii (p=0.0008) cu o durat de spitalizare mai lung (media 11 zile fa de media de 7 zile p=0.0002)
Concluzia: Toracotomia i decorticarea sunt folosite cu reexpansionarea pulmonar n majoritatea cazurilor. Empiemele cu culturi pozitive au fost asociate cu
evoluii nefavorabile.

Abstract: Pleural empyema, defined as the accumulation of pus in the pleural cavity, occurs most commonly in association with community acquired pneumonia
(parapneumonia effusion).
Aims: This study aimed to assess the efficacy of thoracotomy and decortication (T/D) in achieving lung re-expansion in patients with stage III empyema and assess
the impact of culture-positive empyema on the outcome of decortication.
Methods: This is a retrospective study of our patients treated with T/D over a 12-year period (2002-2014).
Results: A total of 107 consecutive patients were identified.
87% of our cases were male.
The mean length of hospital stay was 12 (range 3-45) days.
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In 86% of the cases we achieved full lung re-expansion.
There were no postoperative deaths.
In 56% (52%) of cases, the pleural cultures were positive, these patients had a larger duration of pleural drainage (mean of 11 days) range 4-111 versus mean of 5
days, range 3-28 days, for negative culture (p=0.0004), more complications (p=0.0008) and larger length of hospital stay (mean of 11 days versus mean of 7 days)
(p=0.0002).
Conclusion: Thoracotomy and decortication is safe with lung re-expansion in the majority of patients. The empyema with positive culture was associated with
worst outcomes.

Simularea - component a curriculei de pregtire n chirurgie


Simulation as Part of Train the Trainer Curricula in Surgery
Clin Tiu (1), A. Negoi (1), W. Korb (2), Susanne Kotzsch (2), Eszter Fenyhzi (2), F. M. S. Margallo (3), Luisa F. Snchez Peralta (3), B. Pagador (3), J. Sandor (4),
G. Wber (4)
(1) Fundaia Medis, Cercetare, Cmpina, Romnia
(2) University of Applied Sciences, Research Center "Life Science & Engineering", Research Group Innovative Surgical Training Technologies, Lepzig, Germania
(3) Centro de Ciruga de Mnima Invasin "Jess Usn", Cercetare, Cceres, Spania
(4) Semmelweis University, Department of Surgical Research and Techniques, Budapesta, Ungaria
Obiective: n perioada actual se constat c n rile europene lipsete ideea unei abordri comune a principiilor de formare n chirurgie. Principalul obiectiv al
proiectului european SurgTTT, cofinanat prin Programul Erasmus Plus este s mbunteasc pregtirea n specialitile chirurgicale, reducnd diferenele de
standardizare la nivel paneuropean. n acest sens, proiectul caut s defineasc profilul profesional al formatorului n chirurgie pe baza unei curricule n msur
s fie aplicat n mod similar n mai multe ri. O platform online n mai multe limbi va fi pus la dispoziia consultanilor.
Material i metod: Un chestionar transnaional a fost pus la baza redactrii unui program de pregtire care s in cont de nevoile educatorilor. Profilul
profesional al formatorului n chirurgie a fost considerat ca avnd cea mai mare importan n abordarea curriculei. S-a pornit de la rolurile specifice ale
formatorului descrise de ctre Scottish Doctors n 2009. Din perspectiva categoriei de dezvoltare a resurselor, cel mai mult accent s-a pus pe importana n
cretere a simulatoarelor i a nvmntului la distan. Dezvoltarea acestor teme reprezint aportul Fundaiei Medis n elaborarea unui curs ce are co-autori n
rndul partenerilor din Germania, Spania i Ungaria.
Rezultate: n etapa de validare, acest curs urmeaz s fie prezentat unor module de cte apte participani n fiecare dintre rile participante n proiect. Ulterior,
n funcie de interesul obinut, cursul va fi propus tuturor centrelor de formare.
Concluzii: Acest proiect definete o serie de competene ce trebuie dobndite de ctre profesionitii din domeniul sntii care sunt dedicai formrii
profesionale a rezidenilor din specialitile chirurgicale.

Objective: Nowadays a common European approach of surgical training based on a unique strategy and similar principles among the EU countries are still
missing. The main objectives of the European Project SurgTTT, co-founded by the Erasmus+ Program is to improve specialty training in surgical specialties and to
reduce lacking standardization on the pan-European level. Thus, the main objective of the project is to define the professional profile of surgical trainers by
designing and testing the most suitable curricula. Another objective is broadening the scope of application of this professional profile to a European level through
the development of an open multilingual online learning platform for consultants.
Material and methods: The project is based on a transnational survey of the national frameworks for specialty training and needs assessment for designing a TTT
program. The professional profile for a surgical trainer was designed in order to develop a curriculum and teaching materials. We adapted The roles of the
medical teacher published by the Scottish Doctors as a model for our special requirements of teaching in surgical education. In the field of Resource Developer
the increasing potential of Simulation and Distance Learning act with higher priority. Courses with target group will follow in every participant countries.
Results: After the final validation procedure, this TTT five-day course will be dedicated to surgical consultants (bottom-up approach) and also to medical structures
and organizations (top-down approach).
Conclusions: This work defines a set of competences to be acquired by this health professionals devoted to training the surgical residents.

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Metode actuale n tratamentul prolapsului genital


Modern Methods in the Treatment of Genital Prolapse
Simona Niculescu (1), M. Burniche (1), D. Niculescu (2)
(1) Spitalul Clinic de Obstetric-Ginecologie Elena Doamna, Secia de Obstetric-Ginecologie, Iai, Romnia
(2) Spitalul Clinic Judeean de Urgene Sf. Spiridon, Secia de Chirurgie General, Iai, Romnia
Rezumat: Tratamentul diferitelor tulburri de static pelviperineal asociate sau nu cu incontinena urinar de efort (I.U.E.), beneficiaz n ultimii ani de indicaii i
tehnici noi prin utilizarea diferitelor dispozitive protetice de polipropilen, special concepute i amplasate prin procedee minim invazive.
Material i metod: n iulie 2007-iulie 2015, n serviciile menionate au fost rezolvate 165 de cazuri cu diferite tulburri de static pelvin. La bolnavele cuprinse n
lot, s-au practicat izolat sau asociat diferite procedee n funcie de diagnostic, simptomatologie, tipul prolapsului, vrsta, situaia anatomic local i existena sau
nu a vieii sexuale. Astfel s-au realizat: - Uretrocistopexie cu bandelet sau dispozitiv n hamac, cu patru brae transobturator - 82 cazuri; - Colposuspensie
posterioar sacrosciatic sau refacerea planeului ridictorilor anali - 35 cazuri; - Colpopromontopexie abdominal n 48 cazuri dintre care 28 cu histerectomie
sau rezecia colului uterin restant. Acestui procedeu i s-au asociat 6 cazuri implant de plas polipropilenic la nivelul ridictorilor anali i n 11 cazuri bandelet
suburetral transobturatorie pe cale vaginal pentru I.U.E. Calea abdominal de abord permite corecta scheletizare a organelor genitale interne i a vaginului
ntors n deget de mnu cu evitarea lezrii ureterovezicale iar fixarea promontorial a domului vaginal cu dispozitiv de polipropilen asigur meninerea
rezultatelor n timp.
Rezultate: n general, toate cazurile au avut evoluie postoperatorie imediat simpl cu meninerea a trei hematoame ce au impus evacuare chirurgical i 3
cazuri de necroz de mucoas vaginal, unul impunnd suprimarea dispozitivului implantat. Rezultatele anatomice i funcionale la distan au fost bune.
Concluzii: n concluzie, utilizarea bandeletelor, plaselor i dispozitivelor de polipropilen n corectarea diferitelor tulburri de static pelviperineal, prezint
avantaje legate de relativa uurin de execuie scurtarea perioadei de spitalizare i rezultate foarte bune ce se menin n timp.
Cuvinte cheie: prolaps genital, tratament actual

Introduction: To support through personal experience the use on a large scale of the modern techniques of correction of the pelvic floor disorders by
polypropylene prosthetic device. To specify the technical details regarding the correct placement of prostheses in feminine genital prolapse. Show the personal
casuistry in order to highlight the indications, technique and results of the types of surgeries. Plead for expending the modern techniques in pelvic-perineal floor
dysfunctions.
Material and methods: The study was performed between July 2007 and July 2015 in the Hospital Of Obstetrics-Gynecology Iasi, Third Clinic, on 165 cases with
different pelvic floor dysfunctions. Different procedures were practiced, isolated or associated, on the patients in the lot depending on symptoms, the prolapse
type and degree, age, local anatomical situation and the existence or absence of sexual life. Thus, there were performed strip urethrocystopexy or hammock
device, with four arms transobturator in 82 cases, the sacrisciatic posterior colposuspension or the anal levator floor restoration - 35 cases, abdominal colpopexy
in 48 cases, 20 of witch with hysterectomy or resection of residual cervix. In 6 cases a polypropylene mesh implant has been associated with this procedure at
anal elevator level, and in 11 cases the doctors used a suburethral transobturator vaginal strip for stress urinary incontinence (SUI). The abdominal approach
allows the correct path of skeletonization of the internal genital and also of the vagina which is turned inside-out like a glove finger, avoiding damage on the
ureters and bladder. The vaginal vault is secure to the promotory with a polypropulene device and it ensures the results are maintained in time.
Results: The treatment of the different pelvic-perineal floor disorders that are associated or not with stress urinary incontinence has lately benefited from new
indications and techniques by using different prosthetic devices made of polypropylene which are especially conceived and placed through minimally invasive
procedures. Generally, all the cases had and immediate simple postoperatory evolution with only two haematomas that required surgical evacuation and 3 cases
of vaginal mucosa necrosis, one of them requiring the removal of the device implanted. The anatomical and functional results were good.
Conclusions: The use of strips, nets and polypropylene devices in correcting different pelvic floor disorders shows certain advantages as it is relatively easy to
implement, the hospitalization period is shortened and there are very good results that pass the test of time.
Key words: genital prolapse, current treatment

Congresul Naional de Chirurgie 2016 01 - 04 iunie 2016 Centrul Internaional de Conferine Sinaia
National Congress of Surgery 01 - 04 June 2016 Sinaia International Conference Center
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13

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Physicians Session Oral Communications

Rolul actual al inelului gastric ajustabil n chirurgia bariatric


The Current Role of Adjustable Gastric Band in Bariatric Surgery
M. Ionescu (1), R. Mirica (1), R. Iosifescu (1), O. Ginghin (1), Clarisa Brlog (1), R. Munteanu (2), N. Iordache (1)
(1) Spitalul Clinic de Urgen Sf. Ioan, Chirurgie General, Bucureti, Romnia
(2) Spitalul Euroclinic, Regina Maria, Chirurgie General/Bariatric, Bucureti, Romnia
a. Stabilirea rolului actual al inelului gastric, al indicaiilor realiste ale acestuia, al modalitilor de evitare a eecurilor ct i a eventualelor posibile alternative de
nlocuire ale acestui procedeu n viitor.
b. Am analizat literatura de specialitate i procedurile efectuate n clinica noastra. Am nregistrat aproximativ 244 de intervenii chirurgicale de inel gastric ajutabil
dintr-un total de aproximativ 2100 proceduri de chirurgie a obezitii.
c. n ultimii 10 ani, montarea de inel gastric ajustabil, cndva al 2-lea cel mai practicat procedeu de chirurgie laparoscopic bariatric, a pierdut teren continuu n
clinica noastr.
Acest fapt a fost cauzat att de reconsiderarea mecanismelor de aciune ale acestui tip de chirurgie n sensul obinerii nu numai de scdere ponderal ct i de
rezolvarea comorbiditilor metabolice dar i din princina consolidrii poziiei gastrectomiei longitudinale. Astfel, a aparut o rearanjare a ierarhiei celor mai
practicate procedee, cu bypass gastric pe cale s piard prima poziie n favoarea gastric sleeve dar i a scderii majore a montrilor de inele gastrice.
d. Primele 2 cele mai practicate procedee (gastric sleeve i gastric bypass) sunt foarte eficiente dar invazive n sensul modificrilor anatomice ireversibile, fapt
care pentru unii pacieni reprezint motive de refuz ale acestor proceduri iar pe de alt parte sunt pacieni care doresc o scdere ponderal mai mic. Locul
inelului tinde s fie acaparat de sus, referindu-ne la IMC-uri mari, de ctre gastric sleeve iar de jos, IMC ce in de supraponderal i nu de obezitate, de ctre
balonul intragastric.

a. Establishing the current role of the gastric band, the realistic indications, ways of avoiding failures and possible eventual replacement alternative of this
procedure in the future.
b. We analyzed the literature and procedures performed in our clinic. We recorded about 244 gastric band procedures out of a total of approx. 2100 obesity
surgery procedures.
c. In the last 10 years adjustable gastric band, someday the 2nd most practiced method of laparoscopic bariatric surgery is losing ground continuously in our
clinic.
This was caused both by reconsidering the mechanisms of action of this type of surgery in the sense of obtaining not only weight loss and resolution of metabolic
comorbidities but also by consolidate position of the gastric sleeve. Thus, emerged a rearrangement of the hierarchy, the gastric bypass procedures are about to
lose the first position in favor of gastric sleeve and a major decrease of gastric bands.
d. The first 2 most practiced procedures (gastric sleeve and gastric bypass) are very effective but invasive in terms of anatomical irreversible changes, which for
some patients is grounds for refusal of these procedures and on the other hand there are patients who want a smaller weight loss. Place of the gastric band
tends to be monopolized from the top, referring to bigger BMI, by gastric sleeve and from bottom, BMI related to overweight and not to obesity, by intragastric
balloon.

Probleme de diagnostic i tratament n infarctul enteromezenteric


Acute Occlusion of the Superior Mesenteric Artery - Problems of Diagnosis and Treatment
M. Prcoveanu, M. Munteanu, L. Vasile, Anca Ruxanda, . Dina, Camelia Rduleu, A. C. Munteanu, V. Crstea, Alina Gugila, D. Dranceanu
Spitalul Clinic Judeean de Urgen, Clinica Chirurgie III, Craiova, Romnia
Introducere: Infarctul enteromezenteric este o afeciune grav, care ridic probleme deosebite n ceea ce privete diagnosticarea sa n fazele incipiente ale bolii.
n momentul n care tabloul clinic al bolii se contureaz i diagnosticul este uor de susinut, apar dificultile de tratament, deoarece n acest etap, leziunile de
necroz intestinal sunt extinse i insoite de sepsis, ceea ce face ca intervenia chirurgical s nu poat aduce beneficii prea mari.
Material i metod: n studiu au fost inclui un numa de 23 de pacieni internai prin serviciul de urgen, n perioada 2011-2014, cu diagnosticul de infarct
enteromezenteric.
Rezultate: Durerea abdominal este semnul cardinal al tabloului clinic, ea fiind prezent n proportie de 95,65% din cazuri. Rectoragiile, semn clinic important n
orientarea diagnosticului, au fost prezente doar n 34% din cazuri. n 39,13% din cazuri diagnosticul a fost susinut de CT abdominal care a evideniat absena
fluxului sangvin la nivel mezenteric. n restul cazurilor, diagnosticul a fost stabilit prin corelarea datelor clinice i radiologice, arteriografia de arter mezenteric
superioar fiind indisponibil n serviciul de urgen.
Din cele 23 de cazuri de infarct enteromezenteric, 16 au fost produse prin ocluzie arterial mezenteric, 6 prin tromboza de ven mezenteric i 2 cazuri prin
ischemie acut mezenteric non-ocluziv. S-a practicat enterectomia segmentar n 12 cazuri (52,18) iar n 11 cazuri (47,82%) s-a efectuat doar laparotomie
exploratorie.
Concluzii: Mortalitatea global n infarctul enteromezenteric este n continuare foarte ridicat i singura modalitate de a o reduce rmne o diagnosticare cat
mai precoce a bolii.

Acute occlusion of the superior mesenteric artery is a serious disease that raises particular problems in terms of its diagnosis in the early stages of the disease.
When the clinical picture of the disease is emerging and the diagnosis is easier to sustain difficulties appear in treatment because in this stage, the lesions of
14

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intestinal necrosis are extended and accompanied by sepsis.
The study included a total of 23 patients admitted through the emergency room, in 2011-2014, with the diagnosis of acute occlusion of the superior mesenteric
artery
Abdominal pain is the cardinal sign of the clinical picture, being present in a proportion of 95,65% of cases. Rectoragy signs are important in guiding clinical
diagnosis and were present in 34% of cases. In 39.13% of cases the diagnosis of abdominal CT was performed and revealed the absence of blood flow to the
mesenteric. In other cases the diagnosis was established by correlating clinical and radiological data, arteriography of superior mesenteric artery is unavailable in
the emergency room.
Of the 23 cases of acute occlusion of the superior mesenteric artery, 16 were caused by mesenteric arterial occlusion, 6 by mesenteric vein thrombosis and acute
mesenteric ischemia, 2 cases non-occlusive. Segmental enterectomy was practiced in 12 cases (52,18%) and in 11 cases (47.82%) only exploratory laparotomy was
performed. Global mortality was 69, 56%.
Global mortality in acute occlusion of the superior mesenteric artery is still very high and the only way to reduce it remains a diagnosis of the disease as early as
possible.

Gangrena Fournier - particulariti ale tratamentului chirurgical


Fournier Gangrene - Particularities of Surgical Treatment
P. Mustea, A. Costache, Alexandra Agache, O. Mihalache, F. T. Bobirc, D. Georgescu, Cristina-Mihaela Jauca, Andra Brligea, H. Doran, T. Ptracu
Spitalul Clinic Dr. Ioan Cantacuzino, Secia de Chirurgie General, Bucureti, Romnia
Gangrena Fournier reprezint o infecie rapid progresiv cu morbiditate i mortalitate nc ridicat, rezultatele bune obindu-se prin tratament antibiotic i
sistemic de susinere a funciilor vitale, dar mai ales un management chirurgical rapid i agresiv, constnd in debridri i excizii ntinse i repetate.
Obiectiv: Pornind de la experiena Clinicii de Chirurgie General I Juvara a Spitalului Clinic Dr. Ioan Cantacuzino ne propunem s sintetizm particularitile de
diagnostic i de tratament chirurgical care s conduc la vindecarea pacientului. De asemenea dorim s analizm utilitatea indicelui de severitate al gangrenei
Fournier n prognosticul evoluiei postoperatorii.
Metod: Am analizat retrospectiv ntre 1996 i 2015, un numr de 43 pacieni diagnosticai cu gangren Fournier. Toi pacienii au avut diabet zaharat complicat i
neglijat, ct i prezena unor neoplazii asociate la 13 pacieni. Acetia au necesitat ntre 3 i 10 intervenii chirurgicale - debridri, excizii intinse, necrectomii,
incizii de drenaj al fuzeelor supurative, fasciectomii.
Rezultate: Timpul mediu de spitalizare a fost de 17 zile. Au fost 2 decese la pacieni tarai cu multiple boli cardio-vasculare asociate. Indicele de severitate al
gangrenei Fournier poate fi luat n discuie ca element predictiv al mortalitii postoperatorii.
Discuii: Gangrena Fournier reprezint o urgen chirurgical, prima intervenie necesitnd excizii largi, fiind ntotdeauna urmat de alte reintervenii de explorare
a plgii i de completare a exciziilor de pri moi. Aceast agresivitate chirurgical este o necesitate impus de gravitatea patologiei infecioase i obligatoriu
completat de antibioterapie cu spectru larg, ct i de un tratament de terapie intensiv de susinere a funciilor vitale i reechilibrare metabolic.

Necrotizing fasciitis of perineum and external genitalia (Fournier gangrene) is an infection rapidly progressive with morbidity and mortality still high, good results
being obtained by antibiotic therapy and systemic support of vital functions but especially by a surgical management fast and aggressive, consisting in large and
repeated debridement and excision.
Objective: Based on the experience of the General Surgical Clinic I. Juvara, Dr. I. Cantacuzino Clinical Hospital, we intend to summarize the particularities of
diagnosis and surgical treatment to lead us in the healing of the patient. We also intend to analyze the usefulness of Fournier gangrene severity index in
prognosis of postoperative evolution.
Results: We retrospectively analyzed a 20-year period between 1996 and 2015, a total of 43 patients diagnosed with Fournier's gangrene. All patients had
diabetes complicated and neglected and the presence of malignancies was associated in 13 patients. They required between 3 to 10 surgery interventions debridement, large excisions, necrectomy, drainage incisions for recesses and fasciectomy; the average hospitalization time was 17 days. There were 2 deaths in
patients with multiple severe cardiovascular disease related. Fournier gangrene severity index can be taken in discussion as a predictor element of postoperative
mortality.
Discussion: Perineal necrotizing fasciitis is a surgical emergency at presentation, the first intervention requires wide excisions until viable tissue and is always
followed by other exploration re-interventions and by completing the wound excision of soft tissue. This aggressive" surgery is a necessity imposed by the
severity of the infectious pathology and completed compulsory by broad spectrum antibiotics and intensive care supportive treatment and metabolic rebalancing.

Congresul Naional de Chirurgie 2016 01 - 04 iunie 2016 Centrul Internaional de Conferine Sinaia
National Congress of Surgery 01 - 04 June 2016 Sinaia International Conference Center
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15

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Physicians Session Oral Communications

Consideraii tehnice asupra tratamentului laparoscopic n herniile hiatale gigante


Technical Considerations about Laparoscopic Treatment of Giant Hiatal Hernia
N. Dnil (1), M. Costache (1), Mihaela Andronic (1), . O. Georgescu (2), Mihaela Blaj (3), A. Ciumanghel (3), E. Trcoveanu (1)
(1) Spitalul Clinic Judeean de Urgene Sf. Spiridon / Universitatea de Medicin i Farmacie Gr. T. Popa, Clinica I Chirurgie, Iai, Romnia
(2) Spitalul Clinic Judeean de Urgene Sf. Spiridon / Universitatea de Medicin i Farmacie Gr. T. Popa, Clinica II Chirurgie, Iai, Romnia
(3) Spitalul Clinic Judeean de Urgene Sf. Spiridon / Universitatea de Medicin i Farmacie Gr. T. Popa, Clinica de Anestezie i Terapie Intensiv, Iai,
Romnia
Introducere: Hernia hiatal gigant este definit ca acea hernie care conine mai mult de o treime din stomac n sacul herniar. Reprezint n general cam 5-10%
din totalul herniilor hiatale iar distana dintre pilierii diafragmului este adesea peste 5 cm. Tehnica chirurgical laparoscopic este metoda terapeutic cea mai
bun, ns necesit anumite artificii tehnice. Scopul este de a implementa anumite gesturi chirurgicale n tratamentul laparoscopic al acestei entiti.
Material i metod: Este un studiu retrospectiv pe 5 ani ntre ianuarie 2010 i decembrie 2014 realizat n Clinica I Chirurgie a Spitalului Clinic Universitar de
Urgene Sf. Spiridon Iai. n acest studiu au fost inclui un numr de 32 de pacieni dintre care 8 hernii hiatale gigantice. Criteriile de includere au fost: pacieni
cu peste 1/3 din stomac n sacul de hernie, orificul herniar peste 5 cm i pacieni care nu au mai fost operai pentru patologie esogastroduodenal.
Rezultate: Au existat complicaii minore intraoperatorii ce au fost rezolvate (deschiderea pleurei n 4 cazuri cu sutura acesteia i o plag hepatic la care s-a
realizat hemostaza). Postoperator nu au existat complicaii locale, controlul cu substana de contrast fcndu-se ntre ziua 4 i 7 postoperator. A existat un singur
caz de pneumonie lobar ce s-a remis sub tratament medical. Particularitile tehnice au fost cele legate de disecia sacului, nchiderea orificiului i efectuarea
procedeului antireflux.
Concluzii: Un diagnostic precis i bine documentat alturi de folosirea unei tehnici adecvate duce la rezultate foarte bune pe termen lung n herniile hiatele
gigante.

Introduction: Giant hiatal hernia is defined as the hernia that contains more than a third of stomach in hernia sac. Generally represents about 5-10% of hiatal
hernias and diaphragmatic distance between pillars is often more than 5 cm. Laparoscopic surgical techniques are the best approach, but they require some
technical fireworks. The aim is to implement some particular skills in thr laparoscopic surgical treatment of this entity.
Material and methods: It is a 5-year retrospective study between January 2010 and December 2014 conducted in First Surgical Clinic University Emergency
Hospital St. Spiridon Iasi. The study includes a total of 32 patients of which 8 were giant hiatal hernias. Inclusion criteria were patients with more than 1/3 of
stomach in hernia sac, pillar distance more than 5 cm and patients who have not been operated for an esogastroduodenal pathology.
Results: There were minor intraoperative complications that were resolved (opening pleura in 4 cases with its suture and wound liver who achieved hemostasis).
There were no major postoperative complication and local control with contrast being made between the 4th and 7th postoperative day. There was one case of
lobar pneumonia which was resolved under medical treatment. Technical peculiarities were related to sac dissection, closing the defect and making antireflux
procedure.
Conclusions: An accurate and documented diagnosis with the use of appropriate techniques leads to very good long term results of the giant hiatal hernias.

Managementul laparoscopic al herniilor hiatale i BRGE - experiena personal


Laparoscopic Management of Hiatal Hernia and GERD - Personal Experience
R. C. Popescu, Cristina Dan, A. Doa, R. D. Boneagu
Spitalul Clinic Sf. Apostol Andrei, Clinica de Chirurgie General, Constana, Romnia
Obiectivul studiului: Hernia hiatal este o afeciune frecvent ntlnit a zilelor noastre, asociat cu BRGE simptomatic de cele mai multe ori.
Material i metode: Prezentm experiena personal pe ultimii patru ani n tratamentul laparoscopic al herniilor hiatale i BRGE, utiliznd diferite procedee de
fundoplicatur i de cruroplastie cu sau fr protezare sintetic. n cazurile de defect hiatal important, crurorafia a fost nsoit de fundoplicatur Nissen. Au mai
fost practicate hemivalve anterioare sau posterioare, adaptate fiecrui caz n parte.
Rezultate: A fost analizat eficacitatea diferitelor procedee antireflux i a metodelor de cruroplastie, cuantificnd calitatea vieii pacienilor i ameliorarea
simptomatologiei de reflux.
Concluzii: Laparoscopia reprezint actual gold standard terapeutic al herniei hiatale i BRGE n ceea ce privete rezultatul funcional i prevenirea recurenelor.

Objective: Hiatal hernia is a common pathology nowadays frequently associated with symptomatic GERD.
Material and Methods: We present our personal experience in the last four years regarding hiatal hernia repair using different types of antireflux procedures and
cruroplasty with or without mesh reinforcement. In cases of large hiatal defect we performed Nissen fundoplication besides cruroplasty. We also used Dor or
Toupet procedures adapted at each case.
Results: We analyzed the results of different types of antireflux procedures in terms of quality of life of the patients and the efficacy to reduce the GERD symptoms.
Conclusion: Laparoscopic treatment is gold standard in hiatal hernia therapeutical management regarding the functional results and the prevention of recurrence.

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Corpii strini esofagieni - posibiliti diagnostice i provocri terapeutice


Esophageal Foreign Bodies - Diagnostic Possibilities and Therapeutic Challenges
D. Predescu (1), Irina Predescu (2), M. Boeriu (1), I. Vasilache (1), P. Hoar (1), A. Mocanu (1), S. Constantinoiu (1)
(1) Universitatea de Medicin i Farmacie Carol Davila/ Spitalul Clinic Sf. Maria, Chirurgie / Clinica de Chirurgie General i Esofagian, Bucureti, Romnia
(2) Universitatea de Medicin i Farmacie Carol Davila/ Spitalul Clinic Sf. Maria, ORL, Bucureti, Romnia
Ingestia de corpi strini, frecvent ntlnit n serviciile de urgen, rmne o provocare pentru medici n ciuda msurilor preventive i progreselor tehnice datorit
frecvenei i complicaiilor posibile,complicaii grave ce pot ntuneca prognosticul vital sau pot fi surs de morbiditate la distan. Corpii strini esofagieni survin
consecutiv ingestiei (in)voluntare, marea lor majoritate trecnd neobservai. Cel mai frecvent sunt monezi, baterii, ace, obiecte ascuite diverse, alimente, eschile
osoase, cartilagii, buci de plastic, sticl, etc. n ceea ce privete vrsta, cel mai frecvent ingerarea corpilor strini survine la vrste extreme, 70% dintre pacieni
fiind copii precolari i la 25% dintre persoanele n vrst. Semnele clinice uzuale de apel, n absena complicaiilor, sunt: disfagie, hipersialoree, jen cervical
joas i/sau toracic, uneori vomismente. Deloc rar (30%!), se remarc lipsa oricrui semn. Manifestrile de alert, care indic apariia complicaiilor sunt: stare
febril, alterarea strii generale, durere (proiecie verebral/interscapular), mpstare, emfizem cervical subcutanat. Diagnosticul imagistic prin variantele sale
(Rx simpl, tranzit baritat, CT, RMN) rmne veriga esenial n identificarea lezional i decizia terapeutic. Evaluarea endoscopic (rigid sau flexibil) este
obligatorie, permind i gesturi terapeutice. Evolutiv (80-90%) migreaz n stomac fiind eliminai pe ci naturale, la cca. 10-20% este necesar extracie pe cale
endoscopic i doar la 1% din cazuri se impune un gest chirurgical. Tratamentul cazurilor necomplicate este esenial endoscopic fie, de excepie, intervenie
chirurgical pentru extragerea corpului strin. n faa complicaiilor, chirurgia este singura resurs terapeutic credibil. Corpii strini esofagieni reprezint o
urgen frecvent, cu simptomatologie funcional caracteristic ce contrasteaz cu semnele clinice srace, necesitnd ca tratament extracia pe cile naturale n
marea majoritate a cazurilor. Cel mai important tratament rmne prevenia i informarea prinilor cu copii 6 ani.

Ingestion of foreign bodies, common in the emergency services, remains a challenge for physicians despite preventive measures and technical progress due to
the frequency and possible complications, serious complications that can obscure vital prognosis or may be source of morbidity. Esophageal foreign bodies occur
consecutively (in)voluntary ingestion, mostly going unnoticed. The most common are coins, batteries, needles, sharps various objects, foods, dodge bone,
cartilage, pieces of plastic, glass, etc. In terms of age, the most common foreign bodies ingestion occurs at extreme ages, 70% of patients were preschool
children and 25% seniors. Common clinical signs, in the absence of complications, dysphagia, hypersialorrhea, low cervical and/or chest pain, sometimes
vomiting. Not infrequently (30%!), it notes the lack of any sign. Manifestations of alert, indicating the occurrence of complications are pyrexia, general physical
health deterioration, pain (spinal / interscapular projection), pulping, cervical subcutaneous emphysema. Diagnostic imaging and its variants (simple Rx, Barium,
CT, MRI) remains essential to identify the lesion and take therapeutic decision. Endoscopic assessment (rigid or flexible) is mandatory, also allowing therapeutic
action. Evolution is in 80-90% migration to the stomach being eliminated by natural ways, about 10-20% is required endoscopic extraction and only 1% of cases
require a surgery. Treatment of uncomplicated cases is basically endoscopic or, in exceptional cases, surgery to extract the foreign body. In complications phase,
surgery is the only therapeutic resource. Esophageal foreign bodies represent a frequent emergency, with characteristic symptoms that contrasts with poor
clinical signs, treatment requiring in most cases extraction on natural ways. The most important treatment remains prevention and keeping parents with children
6 years informed.

Asociere rar citomegalocvirus-fistul gastrocolic. Prezentarea unui caz clinic


Rare Association Cytomegalovirus-Gastrocolic Fistula. Case Report
C. M. Neacu, S. Nirmaier, T. Bruckner, D. Heinrich, Nadia Skupin
St. Elisabeth Krankenhaus, Chirurgie Visceral, Rodalben, Germania
Obiectiv: Prezentarea unui caz clinic de fistul gastro-colic recidivat asociat infeciei cu citomegalovirus. Citomegalovirus este un beta-herpes virus cu
prezen i simtomatologie semnificativ la pacienii imunosuprimai.
Material i metod: Pacient n vrst de 51 ani, caectic (164 cm, 37 kg); scdere pregnant n greutate (peste 10 kg n ultimele 4 sptmni); scaune diareice
2-3/zi; abuz de nicotin (20-30 igri/zi); n antecedente rezecie gastric Bilroth II pentru ulcer duodenal stenozant (iulie 2000); rezecie gastric atipic i revizia
operaiei Bilroth II cu reconstrucie Y-Roux i rezecie segmentar de colon transvers pentru fistul gastro-colic (dec 2010).
Rezultate: Gastroscopia stabilete diagnosticul de fistul gastro-colic recidivat. Se intervine chirurgical realizndu-se o re-rezecie gastric, rezecie colonic
segmentar, rezecie atipic hepatic i pancreatic. n perioada imediat postoperatorie evoluie favorabil. ncepnd cu ziua a 7-a postoperator: dezorientare
neurologic, pancitopenie sever, hiponatremie, hipocalcemie i alcaloz metabolic.
Rezultatul histopatologic: prezena citomegalovirus n rezectatul gastro-colic; examinarea virusologic atest prezena CMV-DNA serologic.
Terapie intensiv suportiv complex (Ganzyclovir, catecolamin-terapie, transfuzii cu trombocite/eritrocite concentrat; nutriie parenteral). Pacienta este intubat
i ventilat mecanic. Administrare intravenoas de antibiotice (Meronem, Tavanic, Diflucan).
Deces n ziua 14-a postoperatorie.
Concluzii:
- infecia cu citomegalovirus cu implicarea tractului gastrointestinal este comun la pacienii imunosuprimai
- dei descris n literatura de specialitate, asocierea citomegalovirus-fistul enteral este excepional de rar

Aim: We want to present a clinical case of recurrent gastrocolic fistula associated with cytomegalovirus infection. Cytomegalovirus is a beta herpesvirus with
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presence and significant symptoms in immunosuppressed patients.
Material and method: Female patient age of 51 years, with cachexia (164 cm, 37 kg); pronounced weight loss (over 10 kg in the past 4 weeks); diarrhea 2-3/day;
nicotine abuse (cigarettes 15-20/day); in history gastric resection Bilroth II for stenosing duodenal ulcer (July 2000); atypical gastric resection and Bilroth II
operation revision with Y-Roux reconstruction and transverse colon segmental resection for gastrocolic fistula (December 2010).
Results: The gastroscopy sets diagnosis of recurrent gastrocolic fistula. Surgical is practiced gastric re-resection, segmental colon resection, atypical hepatic and
pancreatic resection. Favorable development in the immediate postoperative period. From the 7th postoperative day: neurological disorientation, severe
pancytopenia, hyponatremia, hypercalcemia and metabolic alkalosis.
Histopathological results show the presence of cytomegalovirus in the resected gastrocolic fistula; virusological examination attests the serological presence of
CMV-DNA.
Complex intensive supportive therapy (Ganzyclovir, catecholamintherapy, transfusions of platelets/erythrocytes concentrate, parenteral nutrition). Patient is
intubated and mechanically ventilated. Intravenous antibiotics are administered (Meronem, Tavanic, Diflucan).
Death in the 14th postoperative day.
Conclusions:
-cytomegalovirus infection involving the gastrointestinal tract occurred in immunosuppressed patients
-although described in the literature, association cytomegalovirus-gastrocolic fistula is exceptionally rare

Biliragia postoperatorie - abordul endoscopic, avantaje, indicaii. Experiena personal


Postoperative Billirhagia - Endoscopic Approach, Advantages, Indications from Our Experience
M. Grigoriu (1), D. Vasile (2), C. Lutic (2), C. Budin (2), . Pan (2), C. Oprea (2), I. Scurtu (2), V. Bleanu (2)
(1) Spitalul Universitar de Urgen, Chirurgie I, Bucureti, Romnia
(2) Spitalul Universitar de Urgen, Chirurgie, Bucureti, Romnia
Lucrarea analizeaz prin prisma experienei personale rezultatele abordului endoscopic n tratamentul biliragiei postoperatorii n variate circumstane patologice:
colecistectomia laparoscopic (derapare clipuri, ducte Luschka), chistul hidatic hepatic operat, traumatismele hepatice, etc. Sunt discutate 174 de cazuri tratate
prin endoscopie intervenional n Clinica Chirurgie I a Spitalului Universitar de Urgen Bucureti ntr-o perioad de apte ani, 2008-2015. n funcie de situaia
local, s-a practicat sfincterotomie asociat n cele mai multe cazuri cu protezare papilar folosind stent de plastic de 10 Fr. Rata de succes a fost de 97%,
biliragia s-a oprit n medie la 5,5 zile dup intervenia endoscopic. Nu s-au nregistrat complicaii specifice post ERCP. Toi pacienii au fost re-evaluai clinic,
biochimic i imagistic la trei luni, interval dup care a fost ndepartat proteza biliar.

The paper analyzes the results of our experience in the endoscopic treatment of postoperative billirhagia in various pathological circumstances: after
laparoscopic cholecystectomy (sliding clips, Luschka ducts), hepatic hydatid cyst surgery, liver trauma, etc. We discuss 174 cases treated by interventional
endoscopy in the First Surgical Clinic of the University Emergency Hospital Bucharest in a seven-year period, 2008-2015. Depending on the local situation,
sphincterotomy was practiced in most cases associated with papillary prosthesis using plastic stents (10 Fr). The success rate was 97%, the billirhagia stopped in
5,5 days after the endoscopic procedure. No specific post-ERCP complications were recorded. All patients were re-evaluated clinically, biochemically and by
imaging techniques after a three-month interval, when the biliary prosthesis was removed.

Ce este nou n managementul tratamentului n pancreatita acut sever?


What's New in the Therapeutic Management of Severe Acute Pancreatitis?
Z. J. Kover, L. Pripisi, D. Toma, I. Munteanu, D. Cochior
Spitalul Clinic Ci Ferate Nr. 2, Chirurgie General, Bucureti, Romnia
Managementul clinic n pancreatita acut sever se bazeaz pe cteva elemente cheie: recunoaterea precoce a evoluiei severe, cu rat de mortalitate ridicat;
reechilibrare volemic, susinerea funciilor vitale, monitorizare atent; terapia durerii; eliminarea factorilor favorizani; preveniria i recunoaterea precoce a
complicaiilor; nutriia; abord terapeutic modern; intervenia chirurgical unde este indicat.
Managementul iniial al PAS - faza precoce - este de susinere bazat pe reechilibrare volemic, analgezie i nutriie enteral. Aceti pacieni vor fi tratai n
seciile de terapie intensiv, realizarea profilaxiei antitrombotice. Terapia profilactic antibiotic sistemic pentru complicaiile locale nu este recomandat.
Decontaminarea digestiv selectiv cu antibiotice, care nu se absorb n intestin, prezint anumite beneficii n prevenirea complicaiilor infecioase locale.
Caracteristic fazei trzi n PAS este infectarea esutului pancreatic i peripancreatic necrozat. n aceste cazuri, este acceptat unanim necesitatea interveniei
chirurgicale. Diagnosticul pozitiv de necroz infectat este dat de culturile positive obinute prin CT-FNA. Cnd apar bule de gaz la CT, puncia nu i mai are
rostul.
Chirurgia este considerat gold standard n cazul necrozelor pancreatice infectate. Conduit chirurgical modern: tehnici chirurgicale alternative se dezvolt i
sunt cunoscute ca debridri minim invazive. Tehnicile disponibile sunt: drenaj percutan; abord endoscopic; abord laparoscopic; abord retroperitoneal.
Trendul n prezent: Abord combinat cu step-up philosophy. O combinaie dintre aceste tehnici va fi cheia pentru cea mai bun conduit terapeutic.
Combinarea tehnicilor la acelai pacient va avea rezultate mai bune dect utilizarea unui singur abord.

Principles of conservative therapy


18

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Overview, the clinical management of SAP relies on a number of key points: Early recognition of severe disease, which has a higher mortality; fluid resuscitation
and organ support with appropriate monitoring; pain management; removal of underlying predisposing; prevention and early recognition of complications;
nutrition; novel therapies; surgical intervention where indicated.
The initial management of SAP in early phase is supportive, based on fluid resuscitation, analgesia and enteral nutrition. These patients will be treated in
intensive care units with thrombo-prophylaxis. Prophylaxis of local complications infection by systemic prophylactic antibiotic therapy is not recommended.
Selective digestive decontamination with antibiotics not absorbed from the gut has some benefits.
The main event which characterizes the late phase of SAP is infection of the necrotic peripancreatic and pancreatic tissue. It is universally accepted that surgery is
mandatory in certain pancreatic infections. Accurate diagnosis is represented only by a positive cultures obtained by CT-FNA. When gas bubbles are apparent in
the CT imaging, FNA is no longer needed.
Surgery is considered the gold standard treatment for proven infected pancreatic necrosis. New surgical approach: alternative surgical techniques known as
minimally invasive debridement. Surgical techniques available: percutaneous drainage; endoscopic approach; laparoscopic approach; retroperitoneal approach.
Current trend: Combined approaches with step-up philosophy. Combining them will be the key for defining the best therapeutic option in ANP.
Combinations of techniques in the same patient may prove superior to any single approach.

Tratamentul chirurgical laparoscopic al herniilor hiatale gigante. cu sau fr protez?


Laparoscopic Surgical Treatment of Giant Hiatal Hernia. Mesh - Yes or No?
V. urlin (1), M. Bica (1), S. Rmboiu (1), . Ptracu (1), M. Lazr (1), Mihaela Olteanu (1), S. Bordu (1), M. . Ghelase (2), E. F. Georgescu (1), I. Georgescu (1)
(1) Universitatea de Medicin i Farmacie, Clinica I Chirurgie, Craiova, Romnia
(2) Universitatea de Medicin i Farmacie, Departamentul Sntate Public, Craiova, Romnia
Scop: Analiza datelor din literatur cu privire la tratamentul laparoscopic al herniilor hiatale gigante. Utilizarea sau nu a alloplastiei este o controvers de mare
actualitate.
Discutii: Herniile hiatale gigante sunt definite ca hernii hiatale cu mai mult de 1/3 din stomac n cavitatea toracic. Este cunoscut faptul c procedeul Nissen pe
cale laparoscopic nsotit de refacerea anatomic a orificiului hiatal reprezint o tehnic ce se nsoete nc de o rat ridicat de recidiv. Cu att mai mult n
cazul herniilor hiatale gigante. Utilizarea plaselor rmane ns controversat att ca principiu de tratament ct i n ceea ce privete tipul de plas i tehnic de
plasare a acesteia. Dei nsoit de o rat de recidiv mult diminuat, alloplastia poate fi asociat cu alte complicaii uneori mai grave dect simpla recidiv a
herniei. Astfel, au fost descrise migrarea plasei n esofag, stricturi, disfagie, ulceraii, perforaii.
Concluzii: Desi utilizarea allogrefelor n tratamentul chirurgical laparoscopic al herniilor hiatale gigante este insoit de o rat de recidiv sczut n comparaie cu
procedeul anatomic, acest procedeu poate fi urmat de complicaii postoperatorii redutabile.

Aim: To analyze data in literature regarding laparoscopic treatment of giant hiatal hernia. Using an alloplasty or not is a very current controversy.
Discussion: Giant hiatal hernias are defined as hernias with more than 1/3 of the stomach in the thoracic cavity. Laparoscopic Nissen procedure with anatomic
hiatus repair is known to be associated with high recurrence rate. More so for giant hiatal hernias. Using meshes remains controversial both as a treatment
principle and regarding the type of mesh ant the mesh placement technique. Although it is associated with low recurrence rate, alloplasty can lead to
postoperative complications more serious than hernia recurrence. Mesh migration in the esophagus, strictures, stenosis, ulcerations and perforations were
described.
Conclusion: Although allograft usage in laparoscopic treatment of giant hiatal hernia has a low recurrence rate compared to anatomic procedures, it can be
associated with serious postoperative morbidity.

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Endoscopia i manometria esofagian intraoperatorie n tratamentul chirurgical al acalaziei cardiei


The Intraoperative Upper Endoscopy and Manometry in the Surgical Management of Achalasia
S. Constantinoiu (1), P. Hoar (1), A. Constantin (1), D. Cochior (2), L. Pripisi (2), Rodica Daniela Brl (1), D. Predescu (1), Daniela Dinu (1), F. Chiru (1), A. Caragui (1)
(1) Universitatea de Medicin i Farmacie Carol Davila/ Spitalul Clinic Sf. Maria, Clinica de Chirurgie General i Esofagian, Bucureti, Romnia
(2) Universitatea Titu Maiorescu / Spitalul Clinic Ci Ferate Nr. 2, Chirurgie, Bucureti, Romnia
Introducere: Manometria esofagian i endoscopia sunt explorri complementare, eseniale n diagnosticul i evaluarea postoperatorie a pacienilor cu acalazia
cardiei. Actual, sunt trei metode terapeutice eficiente n acalazie - esocardiomiotomia Heller, dilataia endoscopic cu balon i miotomia endoscopic.
Material i metod: n perioada 2007-2014, am efectuat un studiu retrospectiv pe un lot de 30 de cazuri de acalazie, operate n clinica, la care s-a efectuat
manometrie pre i postoperatorie, alturi de scorul clinic i tranzitul baritat (dintr-un lot de 52 de pacieni operai). n conduita recent (2 ani) am introdus un nou
concept de control terapeutic prin evaluarea i asistarea intraoperatorie endoscopic i manometric, n scopul mbuntirii rezultatului postoperator. Lotul
acestor pacieni este n constituire (10 cazuri pn acum). Tot n constituire este i un lot martor de pacieni. Operaia standard a fost esocardiomiotomia
anterioar Heller, asociat cu hemifundoplicatura tip Dor, clasic sau laparoscopic.
Rezultate: Postoperator am constatat o scdere a valorii presiunii medii a sfincterului esofagian inferior (SEI) (de la 18 mmHg preoperator la 5 mmHg postoperator)
cu ameliorarea semnificativ a relaxrii SEI la deglutiie (de la 57% n preoperator la 99% postoperator), valori corelate cu evoluia clinic i radiologic favorabile.
Nu s-au nregistrat recidive - 2 pacieni cu dureri postoperatorii persistente (peste 3 luni).
Concluzii: Manometria esofagian corobort cu tranzitul baritat i endoscopia reprezint trepiedul gold standard n diagnosticul i stabilirea indicaiei
operatorii din acalazia cardiei. Introducerea curent a evalurii endoscopice i manometrice intraoperatorii poate mbuntii rezultatele postoperatorii.

Introduction: Esophageal manometry and endoscopy are complementary explorations that are essential in the diagnosis and postoperative evaluation of patients
with achalasia. Currently, there are three effective therapeutic methods in achalasia - Heller myotomy, endoscopic balloon dilation and endoscopic myotomy.
Material and Method: Between 2007-2014 weve conducted a retrospective study on a group of 30 cases of achalasia, operated in the clinic and who underwent
pre- and postoperative evaluation using manometry clinical score and barium swallow (from 52 operated patients). Recently (last 2 years), we have introduced a
new concept of therapeutic control using intraoperative endoscopy and manometry, in order to improve functional outcome after surgery. The group of these
patients is in the formation (10 cases so far). Also in the constitution is a control group of patients. Surgical treatment was standard, Heller myotomy, associated
with Dor fundoplication, open or laparoscopic.
Results: Postoperative, we found a significant decrease in the average pressure value of lower esophageal sphincter (LES) (from 18 mmHg preoperative to 5
mmHg postoperatively) with significant improvement in LES relaxation to swallows (from 57% preoperatively to 99% postoperatively), values correlated with the
good outcome evaluated using Eckardt clinical score and barium swallow. No relapses were recorded - there were two patients with persistent postoperative
pain (over 3 months).
Conclusions: Esophageal manometry, barium swallow and endoscopy represents the gold standard in the diagnosis and establishing the surgical indication for
achalasia. Including intraoperative evaluation using endoscopy and manometry could improve the postoperative outcome.

Managementul tumorilor neuroendocrine gastrointestinale


The Management of Gastrointestinal Neuroendocrine Tumors
A. M. Vasilescu (1), E. Trcoveanu (1), C. Lupacu (2), . O. Georgescu (2), N. Dnil (1), C. Bradea (1)
(1) Universitatea de Medicin i Farmacie Gr. T. Popa/ Spitalul Clinic Universitar de Urgene Sf. Spiridon, Clinica I Chirurgie, Iai, Romnia
(2) Universitatea de Medicin i Farmacie Gr. T. Popa/ Spitalul Clinic Universitar de Urgene Sf. Spiridon, Clinica II Chirurgie, Iai, Romnia
Introducere: Managementul tumorilor neuroendocrine gastrointestinale (GINET) este adeseori o provocare.
Materiale i metode: Am realizat un studiu retrospectiv efectuat n Clinica I Chirurgie, Spitalul Clinic Universitar de Urgene Sf. Spiridon, Universitatea de
Medicin i Farmacie Gr. T. Popa Iai n perioada 2004 - 2016. Au fost inclusi toi pacienii diagnosticai i tratai cu GINET.
Rezultate: n aceast perioad am tratat 29 de cazuri cu GINET: gastric = 5 cazuri, duoden = 1 caz, intestin subtire = 6 cazuri, apendice = 12 cazuri, colorectal = 5
cazuri. Vrsta medie a fost de 42 4,365 ani (extreme 20-85 ani). Raportul brbai/femei fost de 10/19. Semnele clinice ale sindromului carcinoid au fost
prezente n 4 cazuri, n restul cazurilor, diagnosticul a fost histopatologic. Am efectuat urmtoarele intervenii chirurgicale: pentru tumorile gastrice - 2 rezecii
atipice, 2 gastrectomii totale i o gastrectomie subtotal; pentru tumora duodenal cu sindrom carcinoid - duodenotomie i ablaia tumorii; pentru tumora
intestinului subire - 2 enterectomii i 4 ileohemicolectomii drepte; pentru tumorile apendiculare - 9 apendicectomii, apendicectomie urmat de hemicolectomie
dreapt n 2 cazuri i ntr-un caz hemicolectomie dreapt ca prim procedur (tumora ileo-ceco-apendicular); pentru tumorile colorectale - 1 hemicolectomie
stng, 1 hemicolectomie dreapt, 1 sigmoidectomie, operaia Dixon n 2 cazuri. Diagnosticul a fost confirmat histopatologic i immunohistochemic n toate
cazurile.
Concluzii: GINETs sunt tumori rare, iar managementul lor este ntotdeauna o provocare. Pentru toate GINET este necesar s se recunoasc semnele clinice ale
sindromului carcinoid. Tratamentul chirurgical agresiv cu excizia leziunii primare este indicat pentru GINET maligne, chiar i n stadii avansate.

Introduction: The management of gastrointestinal neuroendocrine tumors (GINET) is often challenging.


Material and Methods: We made a retrospective study performed in the First Surgical Clinic, St. Spiridon Hospital, Gr. T. Popa University of Medicine and
Pharmacy Iai; from 2004 until 2016. All the patients diagnosed and treated with GINET have been included.
20

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Results: In this period we treated 29 cases with GINET: Gastric = 5 cases, Duodenum = 1 case, Small bowel = 6 cases, Appendix = 12 cases, Colo-rectal = 5 cases.
Mean age in GINET was 42 4.365 years old (range 20-85). Men/Women ratio was 10/19. Clinical signs with carcinoid syndrome were in 4 cases, in the rest of
cases, the diagnosis was histopathologic. We performed the following surgical interventions: For gastric tumors - 2 wedge resections, 2 total gastrectomies and
one subtotal gastrectomy; for duodenal tumor with carcinoid syndrome - duodenotomy and tumor ablation; for small bowel tumors - 2 enterectomies and 4
ileohemicolectomies; for appendix tumors - 9 appendectomies, appendectomy followed by right colectomy in 2 cases and in one case right colectomy as first
procedure (ileo-ceco-appendicular tumor); for colorectal tumors - 1 left hemicolectomy, 1 right hemicolectomy, 1 sigmoidectomy, Dixon in 2 cases. The diagnosis
was confirmed histopathologic and immunohistochemic in all cases.
Conclusions: GINETs are rare tumors, and their management is always challenging. For all GINETs, it is necessary to recognize the clinical signs of the carcinoid
syndrome. Aggressive surgical treatment with excision of the primary lesion is indicated for malignant GINETs, even in advanced stages.

Evaluarea rspunsului inflamator n esofagectomia toracoscopic versus toracotomie


Inflammatory Response Evaluation in Thoracoscopic versus Transthoracic Esophagectomy
N. Dnil (1), M. Costache (1), Mihaela Andronic (1), V. Scripcariu (2), Mihaela Blaj (3), A. Ciumanghel (3)
(1) Spitalul Clinic Judeean de Urgene Sf. Spiridon / Universitatea de Medicin i Farmacie Gr. T. Popa, Clinica I Chirurgie, Iai, Romnia
(2) Institutul Regional de Oncologie / Universitatea de Medicin i Farmacie Gr. T. Popa, Clinica I Chirurgie Oncologic, Iai, Romnia
(3) Spitalul Clinic Judeean de Urgene Sf. Spiridon / Universitatea de Medicin i Farmacie Gr. T. Popa, Clinica de Anestezie i Terapie Intensiv, Iai,
Romnia
Esofagectomia pentru cancerul esofagian este una dintre cele mai invazive intervenii chirurgicale. Scopul lucrrii de fa este de a evalua rspunsul inflamator n
esofagectomia toracoscopic comparativ cu chirurgia clasic (toracotomia) i dac acest rspuns poate anticipa apariia complicaiilor pleuropulmonare grave. A
fost efectuat un studiu prospectiv pe un numr de 27 de pacieni operai pentru neoplasm esofagian n perioada ianuarie 2014 decembrie 2015. Au fost efectuate
12 intervenii toracoscopice (44.44%) i 15 prin abord clasic cu toracotomie (55.56%). Markerii inflamatori studiai au fost CRP, presepsina i procalcitonina.
Determinrile s-au efectuat preoperator i postoperator la 6, 12 i 24 de ore. Au existat diferene semnificative n dinamica markerilor inflamatori ntre cele 2
loturi, att CRP ct i presepsina i procalcitonina fiind cu valori mai mari n lotul operat clasic comparativ cu lotul operat toracoscopic. De asemenea, se pare c
pot exista corelaii ntre nivelul markerilor inflamatori i apariia complicaiilor pleuropulmonare. n concluzie, esofagectomia minim invaziv mbuntete
rspunsul inflamator la trauma chirurgical contribuind la o scdere a morbiditii postoperatorii si a duratei de spitalizare.

Esophagectomy for esophageal cancer is one of the most invasive surgeries. The purpose of this paper is to evaluate the inflammatory response in thoracoscopic
esophagectomy compared with classic surgery (thoracotomy) and whether this response may predict serious pleuralpulmonary complications. A prospective
study was conducted on a total of 27 patients operated for esophageal cancer from January 2014 until December 2015. During this period were performed 12
thoracoscopic (44.44%) esophagectomies and 15 by Classic thoracotomy approach (55.56%). Inflammatory markers studied were CRP, and procalcitonin,
presepsine. Measurements were performed preoperatively and postoperatively at 6, 12 and 24 hours. There were significant differences in the dynamics of
inflammatory markers between the two groups. All markers: Procalcitonin, CRP and Presepsine have higher values in thoracotomy group than in thoracoscopic
group. It also appears that there may be correlations between the levels of inflammatory markers and pleuropulmonary complications. In conclusion,
thoracoscopic esophagectomy reduces inflammatory response contributing to a reduction in postoperative morbidity and duration of hospitalization.

Chirurgia paliativ n neoplasmul gastric


Palliative Surgery in Gastric Cancer
Oana Ilona David, A. R. Stoian, V. A. Porojan, Violeta Elena Radu, I. S. Coman, V. T. Grigorean
Spitalul Clinic de Urgen Prof. Dr. Bagdasar-Arseni, Secia de Chirurgie General, Bucureti, Romnia
Introducere: Din totalul neoplasmelor gastrice diagnosticate n ultimii ani, studiile relev o frecven crescut a tumorilor gastrice depite chirurgical la
momentul prezentrii. Rolul chiururgiei paliative este intens dezbtut. Material i metod: Am realizat un studiu observaional, retrospectiv, unicentric, cuprinznd
pacienii diagnosticai cu tumori gastrice n Spitalul Bagdasar-Arseni pe o perioada de 5 ani. S-au studiat cu precdere pacienii cu tumori depite chirurgical:
tumori nerezecabile, tumori cu determinri secundare hepatice, peritoneale, limfatice. Pacienii au suferit laparotomii exploratorii urmate fie de derivaii digestive,
rezecii (pariale sau totale). n analiza statistic, s-au studiat preponderent factorii de prognostic precum vrsta, numrul, localizarea determinarilor secundare.
Rezultate: Rata globala de supravieuire a fost mai mare n cazul rezeciilor gastrice (7.2 vs 5.6 luni; P<0.001). n cazul pacienilor cu vrsta depind 60 de ani,
s-a observat o cretere a supravieuirii cu pn la 5 luni n cazul efecturii rezeciei gastrice. Totui, grupul pacienilor cu vrsta peste 60 de ani a fost caracterizat
de o morbiditate i o rat de mortalitate perioperatorie crescut (68 vs 32 %). Studiul parametrilor nu a evideniat o supravieuire mai mare n cazul efecturii
rezeciei gastrice efectuat la pacienii cu determinri secundare multiple. S-a observat un beneficiu semnificativ al efecturii rezeciei gastrice la pacienii cu
vrst sub 60 de ani, cu o singur localizare a determinrilor secundare. Concluzii: Vrsta, numrul, localizarea determinrilor secundare trebuie luate n
considerare n chirurgia paliativa n neoplasmul gastric, aceasta avnd beneficii clare n cazul pacienilor sub 60 de ani, cu o singur localizare a determinrilor
secundare. Cuvinte cheie: paliaie, neoplasm gastric, rezecii gastrice

Introduction: Recent studies show that patients with gastric cancer often present with incurable disease. The role of palliative surgery in gastric cancer is still in
debate. Means and method: We carried out an observational, retrospective, single center study enrolling patients diagnosed with gastric cancer in
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Bagdasar-Arseni Emergency Hospital over the last 5 years. We studied mostly patients with incurable disease: irresectable tumor, hepatic metastasis, peritoneal
metastasis. Patient suffered surgical interventions explorative laparotomy followed either by total or partial resection or gastroenterostomy. In our analysis,
particular attention was paid to the prognostic factors such as age, number and site of the metastasis. Results: Global survival rate was higher if resection was
performed (7.2 versus 5.6 months; p<0.001). In case of patients aged over 60 years, survival was higher up to 5 months if resection was carried out. Yet, in these
patients we encountered a higher morbidity and perioperative mortality rate (68 versus 32%). We did not find a higher survival rate in patients with multiple
metastatic sites suffering palliative gastric resection. However, in patients aged under 60 years with one metastatic site the benefits of a surgical intervention
were significant. Conclusions: Age, as well as the number and location of metastatic sites should be taken into account when considering palliative resection for
gastric cancer. This particular type of surgical intervention may be beneficial for patients under 60 years provided that the tumor has a single metastatic site. Key
words: palliation, gastric cancer, gastric resection

Anastomoza cervical (sau intratoracic) n chirurgia cancerului de esofag inferior


Cervical Anastomosis (or Intrathoracic) in the Lower Esophagus Cancer Surgery
N. D. Mrgritescu, V. urlin, D. Cru, A. Goganau, L. Barbu, . Ptracu, Daniela Marinescu, I. Georgescu
Spitalul Clinic Judeean de Urgen, Clinica Chirurgie General I, Craiova, Romnia
Esofagectomia subtotal const n rezecia a 90% din segmentul intratoracic al esofagului cu anastomoz esogastric intratoracic, sau rezecia intregului esofag
toracic plus segmentul inferior cervical, urmat de esogastroanastomoz cervical. Am urmrit elemente pro i contra pentru cele dou tipuri de anastomoze
privind trei aspecte:
I. Elemente anatomice i funcionale
1. bont gastric mai scurt - pune tensiune pe linia de sutur cu colapsul microvascularizaiei.
2. compresiunea bontului gastric la apertura toracic superioar poate compromite vascularizaia la nivelul anastomozei.
3. riscul de stenoz - crescut la pacienii cu scderea perfuziei sub 70% dect valorile prereconstructie.
4. recidiva anastomotic - redus pe anastomoz cervical comparativ cu cea intratoracic.
II. Complicaii postoperatorii
5. fistul anastomotic i stenoz anastomotic - complicaii comune celor dou tipuri. Mortalitatea - mai mare dup cea intratoracic (mediastinit).
6. anastomoz intratoracic - mai rapid, risc mai sczut de fistul i de complicaii pulmonare (recomandare B)
7. anastomoz cervical - mortalitate mai redus (recomandare C)
8. anastomoz cervical - avantajoas sub aspectul funcional- arsuri, regurgitaii, esofagit (recomandare C).
9. stenozele anastomotice, necesitatea dilataiilor, pierderea n greutate, evacuarea gastric, refluxul gastroesofagian, supravieuirea la 5 ani - rezultatele nu sunt
echivoce.
III. Prognostic oncologic
10. Anastomoza cervical permite seciunea mai nalt fa de extensia proximal a tumorii, fr reducerea semnificativ a recurenei locale (recomandare B).
Studiile comparative ale celor dou anastomoze sunt pe loturi mici, slab standardizate privind abordul chirurgical i tehnica anastomotic.
n concluzie, este nevoie de studii randomizate mari pentru a furniza suficiente argumente n favoarea uneia dintre ele.

Subtotal esophagectomy resection consists in the removal of 90% of the intrathoracic esophagus with intrathoracic esogastric anastomosis or resection of the
entire esophagus plus the lower cervical segment followed by esogastro anastomosis. We watched the pros and cons of the two types of anastomoses on three
points:
I. Anatomical and functional elements
1. Shorter gastric stump - puts tension on the suture line with collapse of the microvascularisation.
2. Compression of the gastric stump at the upper thoracic aperture may compromise the vasculature to the anastomosis.
3. Stenosis - increased risk in patients with decreased perfusion under 70% compared to prereconstruction values.
4. Anastomosis relapse - reduced for cervical anastomosis compared with intrathoracic.
II. Postoperative complications
5. Anastomotic fistula and anastomotic stenosis - common complications of both types. Mortality - higher after the intrathoracic (mediastinitis).
6. Intrathoracic anastomosis - faster, lower risk of fistula and pulmonary complications (B recommendation)
7. Cervical anastomosis - lower mortality (Recommendation C)
8. Cervical anastomosis - advantageous in terms of functional - burns, regurgitation, esophagitis (C recommendation).
9. Anastomotic stenoses, need for dilations, weight loss, gastric emptying, gastric reflux, 5 year survival results are not equivocal.
III. Oncological prognostic
10. Cervical anastomosis enables higher section against the proximal extension of the tumour without significant reduction of local recurrence (B
recommendation).
Comparative studies of the two anastomoses are on small plots, poorly standardized regarding surgical approach and anastomotic technique.
In conclusion it requires large randomized trials to provide sufficient arguments in favour of one of them.

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Analiza mutaional n decizia terapeutic a tumorilor gist
Mutation Analysis in GIST Tumors Therapeutic Decision
D. Predescu (1), M. Gheorghe (1), Maria Dobre (2), Carmen Ardelean (3), Cristina Iosif (4), Simona Enache (4), Marius Boeriu (1), S. Constantinoiu (1)
(1) Universitatea de Medicin i Farmacie Carol Davila / Spitalul Clinic Sf. Maria, Clinica de Chirurgie General i Esofagian, Bucureti, Romnia
(2) Institutul Naional Victor Babe, Departamentul de Morfopatologie, Bucureti, Romnia
(3) Spitalul Monza, Departament Oncoteam, Bucureti, Romnia
(4) Spitalul Clinic Sf. Maria, Departamentul de Anatomie Patologic, Bucureti, Romnia
Tumorile stromale gastrointestinale (GIST) sunt cele mai frecvente tumori mezenchimale primare ale tractului gastro-intestinal. Localizri atipice (epiploic,
mezenteric, retroperitoneal, etc) pot fi ntlnite. Caracteristica imunohistochimic a GIST este supraexpresia CD-117 (c-KIT) i CD34 sau receptorul al factorului
de cretere derivat plachetar (PDGFRA).
Monoterapia rezecional se adreseaz unor cazuri selecionate. Confirmarea unor rezultate favorabile prin tratament direcionat ctre inte moleculare specifice
de tip Imatinib mesilat fac necesar terapia de tip multimodal. Chiar i n aceste condiii, rspunsul diferit al pacienilor cu GIST n functie de diverse criterii
(localizarea tumoral, ratele de mitoz i mai ales profilul molecular), determin nevoia unei ajustri a tratamentului multimodal.
n perioada 2004-2015, n Clinic au fost operai 30 pacieni cu GIST: 19 cu localizare gastric, 7 intestinal, 2 sigmoidian i 2 cazuri de extraGIST (1 pancreatic, 1
burs omental). Toi pacienii au beneficiat de rezecii chirurgicale mai mult sau mai puin extinse. Principiul chirurgiei este rezecia R0. Nu am folosit terapia
neoadjuvant pentru down-staging tumoral. La 18 pacieni am administrat tratament adjuvant specific. Efracia tumoral sau rezecia R1 a tumorii primare au avut
un impact negativ asupra supravieuirii. Toate cazurile au fost confirmate HP i imunohistochimic, cu ncadrarea n grupe de risc (Fletcher, Miettinen sau
Joensuu). Din lotul operat, 13 pacieni au beneficiat de studierea prin secveniere a mutaiilor oncogenelor cu corelarea clinico-patologic i terapeutic (studiu
Persother4). Statusul mutaional poate fi considerat ca factor predictiv i de prognostic pentru pacienii cu GIST tratai cu Imatinib dup chirurgie radical. Toi
pacienii au fost evaluai periodic postoperator.
Chirurgia rmne principalul tratament la pacienii cu GIST localizat rezecabil. Folosirea Imatinib mesilat (ori derivai) aduce o mbuntire semnificativ a
supravieuirii la pacienii cu genotip specific. Utilizarea criteriilor histologice de stratificare a riscului de progresie a bolii, precum i asocierea studiul genotipului
individual al fiecarei tumori, poate optimiza opiunea terapeutic adjuvant la aceti pacieni.

Gastrointestinal stromal tumors (GIST) are the most common primary mesenchymal tumors of the gastrointestinal tract. Atypical locations (epiploon, mesenteric,
retroperitoneal, etc.) can be found. The immunohistochemical characteristic of GIST is CD 117 (c-kit) and CD34 overexpression or receptor of platelet-derived
growth factor (PDGFR).
Resection as monotherapy addresses only in selected cases. Confirmation of positive results with treatment directed at specific molecular targets, like Imatinib
mesylate, made mandatory multimodal therapy. Even under these conditions, the different response of patients with GIST according to various criteria (tumor
location, mitotic rates and especially molecular profile), determine the need for adjustments of the multimodal treatment.
During 2004-2015, in our clinic were operated 30 patients with GIST: 19 with gastric localization, 7 intestinal, 2 sigmoidian and 2 extraGIST (1 pancreatic, 1
omental sac). Symptoms were nonspecific: abdominal pain, anemia, fatigue, palpable tumor, upper GI bleeding or intestinal obstruction. Pre-surgery imaging
used: barium meal, abdominal ultrasound, CT, PET-CT. All cases were confirmed with HP and immunohistochemistry, and divided into risk groups (Fletcher,
Miettinen or Joensuu). For 13 patients we managed to perform study by sequencing of oncogenes mutations (Persother4 Study). In all patients we performed
surgical resection more or less extensive. The goal of surgery is R0 resection. We did not use neoadjuvant therapy for tumor down-staging. 18 patients have
received adjuvant specific therapy. Tumoral rupture or R1, R2 resection of the primary tumor have a negative impact on survival. All patients were periodically
evaluated postoperatively.
Using Imatinib mesylate or derivatives demonstrates significant improvement in survival for patients with specific genotype. Surgery remains the main treatment
for patients with localized GIST. Using histological criteria for risk stratification of disease progression and individual study of each tumor genotype can optimize
adjuvant treatment option in these patients.

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Limfadenectomia D2 - atunci i acum


D2 Lymphadenectomy - Then and Now
G. Dimofte, S. T. Makkai-Popa, V. Porumb, Natalia Velenciuc, C. Roat, S. Lunc
Institutul Regional de Oncologie, Clinica II Chirurgie, Iai, Romnia
Obiectivul studiului: n ciuda progreselor recente referitoare la studiul biologiei moleculare a cancerului gastric i a implementrii programelor de screening, orice
diagnostic diferit de cel de cancer gastric precoce ridic nc probleme din punct de vedere al terapiei necesare pentru obinerea unei supravieuiri de lung
durat. Scopul studiului de fa este de a compara supravieuirea global a unui grup de control din momentul introducerii limfadenectomiei D2 cu un grup de
studiu actual.
Material i metode: Am comparat un grup de control de 135 de pacieni cu un numr de 47 de pacieni care au suferit gastrectomie cu limfadenectomie D1 sau D2.
Rezultate: n grupul de control am gsit un numr de 22 (30,56%) de pacieni la care s-a practicat limfadenectomie D2, comparat cu 40 (85,1%) de astfel de
pacieni n grupul de studiu. Supravieuirea medie n lotul de studiu a fost de 33,12 24,58 luni, cu o supravieuire de 20% la 5 ani, fa de lotul de control unde
supravieuirea la 2 ani a fost de 11%, respectiv 0% la 5 ani. Am folosit apoi ANOVA pentru a compara supravieuirea n cele dou grupuri de studiu i am gsit o
diferen de supravieuire global semnificativ statistic (p < 0,001).
Concluzii: Se observ o diferen de supravieuire clar ntre cele dou grupuri care poate fi explicat prin curba de nvare, dar i prin utilizarea
limfadenectomiei D2 modificate.

Objective: Despite recent progress in terms of the study of the molecular pathways involved in gastric cancer and the improvement in screening, a diagnosis
other than early gastric cancer is still a challenge from a point of view of the treatment required to obtain a long-term survival. We aim to compare overall survival
between patients that underwent D2 lymphadenectomy when the method was newly introduced and now.
Material and Method: A historical control group of 135 patients was compared with a study group of 47 patients undergoing gastrectomy with D1 or D2
lymphadenectomy.
Results: In the control group a number of only 22 (30,56%) patients had had a D2 lymphadenectomy, while in the study group 40 (85,1%) patients had had D2
lymphadenectomies. The average overall survival in our study group was 33,12 24,58 months, with a 20% overall survival at 5 years. In the control group we
found that only 11% of the patients were still alive after 2 years and the 5 year overall survival was 0%. ANOVA was used to statistically compare the survival
differences between the two groups and a significant statistical difference was found (p < 0,001).
Conclusions: A clear difference in terms of overall survival is visible between the two groups which could be explained by the learning curve and by the modified
D2 lymphadenectomy.

Limfadenectomia D2 n tratamentul cu viz radical al cancerului gastric


D2 Lymphadenectomy in Radical Treatment of Gastric Cancer Patients
B. Filip, Mihaela Mdlina Gavrilescu, Mihaela Buna-Arvinte, I. Huanu, Maria-Gabriela Aniei, D. V. Scripcariu, I. Radu, V. Scripcariu
Institutul Regional de Oncologie / Universitatea de Medicin i Farmacie Gr. T. Popa, Clinica I Chirurgie Oncologic, Iai, Romnia
Introducere: Limfadenectomia reprezint una din etapele principale de tratament n tumorile digestive. Extensia limfadenectomiei n tratamentul cu viz radical
al cancerului gastric rmne controversat.
Material i metode: Am efectuat un studiu retrospectiv care a inclus toi pacienii operai pentru cancer gastric n perioada iunie 2012 - decembrie 2015 n cadrul
Clinicii I Chirurgie Oncologic IRO Iai. Au fost analizate caracteristicile clinico-biologice ale pacienilor, tipul de intervenie chirurgical, extensia
limfadenectomiei i complicaiile postoperatorii legate de aceasta.
Rezultate: n perioada de studiu au fost inclui n studiu 144 pacieni la care s-au practicat 82 gastrectomii subtotale(GST) i 62 gastrectomii totale(GT).
Limfadenectomia D2 a fost efectuat la 103 pacieni (71.03%), 59 de GT (95%) i varianta modificat pentru 44 de GST (53%). Morbiditatea global postoperatorie
a fost de 26,1%, 33.87% din cei cu GT (21 pacieni) i 19.5% la cei cu GST (16 pacieni). Pacienii la care s-a practicat limfadenectomie D2 au prezentat o
morbiditate global de 30.1%, complicaie fistular n 19.4%(20 p), durata spitalizare medie 9,4 zile cu un numr mediu de ganglioni de 31.85 fa de 14,63% (6 p),
spitalizare medie 8,3 zile i un numr de ganglioni mediu 22.3 pentru limfadenectomia D1.
Concluzii: Tratamentul standard cu viz radical n cancerul gastric trebuie s includ o limfadenectomie loco-regional tip D2 asociat gastrectomiei totale sau
subtotale, n condiii de siguran pentru pacient fr a crete rata complicaiilor postoperatorii i oferind cea mai bun real stadializare i cel mai bun
prognostic pe termen lung.

Aim: Lymphadenectomy remains the cornerstone in surgical treatment of gastrointestinal malignancies. The extent of lymphadenectomy in gastric cancer
patients remains controversial.
Methods: We performed a retrospective study which included all the patients diagnosed with gastric cancer in which radical surgery was performed, between
June 2012 and December 2015 in the 1st Surgical Unit of Regional Institute of Oncology Iasi. We analyzed the patient and tumor characteristics, the type of
surgery and the postoperative outcomes based on the extent of lymphadenectomy.
Results: There were 144 patients diagnosed with gastric cancer in which were performed 82 subtotal gastrectomies (STG) and 62 total gastrectomies (TG). D-2
lymphadenectomy was performed in 103 patients (71.03%), 59 TG (95%) and 44 STG (53%). Overall morbidity was 26,1%, 33.87% for the TG (21 patients) and
19.5% for STG (16 patients). D2 lymphadenectomy patients presented an overall morbidity of 30.1%, fistula occurred in 19.4% (20 pts), overall hospital stay 9,4
24

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days with a mean lymph nodes number of de 31.85 compared with 14,63% (6 pts), mean hospital stay 8,3 days and a mean lymph nodes number of 17,43 for the
D1 lymphadenectomy.
Conclusion: Standard radical treatment for gastric cancer must include beside total or subtotal gastrectomy a radical regional lymphadenectomy. This can be
performed in a well fit patient without the risk of a high morbidity rate; the main advantage is the accurate staging of the patient and the longest survival.

Esofagectomia minim invaziv: poziia procubit versus decubit lateral


Minimally Invasive Esophagectomy: Procubit versus Lateral Decubitus Position
N. Dnil (1), M. Costache (1), Mihaela Andronic (1), V. Scripcariu (2), Mihaela Blaj (3), A. Ciumanghel (3)
(1) Spitalul Clinic Judeean de Urgene Sf. Spiridon / Universitatea de Medicin i Farmacie Gr. T. Popa, Clinica I Chirurgie, Iai, Romnia
(2) Institutul Regional de Oncologie / Universitatea de Medicin i Farmacie Gr. T. Popa, Clinica I Chirurgie Oncologic, Iai, Romnia
(3) Spitalul Clinic Judeean de Urgene Sf. Spiridon / Universitatea de Medicin i Farmacie Gr. T. Popa, Clinica Anestezie i Terapie Intensiv, Iai, Romnia
Utilizarea esofagectomiei minim invazive n tratamentul cancerului esofagian a crescut n ultimii ani cu beneficii nete dovedite cel puin pe termen scurt. Scopul
lucrrii de fa este de a compara rezultatele obinute dup esofagectomia minim invaziv n poziie de procubit (PC) fa de poziia de decubit lateral (DL) stng.
A fost efectuat un studiu prospectiv pe un lot de 12 pacieni cu esofagectomie minim invaziv: 7 pacieni n grupul PC i 5 pacieni n grupul DL. Nu au existat
decese n nici unul din grupe. Pierderile de snge n timpul esofagectomiei toracoscopice (timp toracic) au fost semnificativ mai mici n grupul PC (11953 mL) fa
de DL (345174mL). Incidena complicaiilor respiratorii a fost mai mic n grupul PC dect n grupul DL. De asemenea, rspunsul inflamator sistemic cuantificat
prin CRP a fost semnificativ mai mare n grupul DL dect n grupul PC. Alte avantaje ale poziiei de procubit sunt: cmp vizual superior cu o poziie ergonomic a
chirurgului precum i faptul c se folosesc numai 3 trocare fa de 4 trocare n poziia de decubit. n concluzie utilizarea PC la pacienii cu neoplasm esofagian n
timpul esofagectomiei este sigur i fezabil. Utilizarea PC poate fi considerat o procedur mai puin invaziv dect DL.

Treatment of esophageal cancer using minimally invasive esophagectomy has increased as indication in recent years with proven net benefits at least in the short
term. The purpose of this paper is to compare the results after minimally invasive esophagectomy realized in procubit position (PC) vs. left lateral decubitus
position (LD). A prospective study was conducted on a lot of 12 patients with minimally invasive esophagectomy: 7 patients in the PC and 5 patients in the LD.
There were no deaths in either group. Blood losses during thoracoscopic esophagectomy (for thoracic step) were significantly lower in the PC group (119 53 mL)
to LD group (345 174mL). The incidence of respiratory complications was lower in PC group than in the group DL. Also systemic inflammatory response
measured by CRP was significantly higher in the LD group than PC. Other advantages of procubit position are: superior visual field with an ergonomic position of
the surgeon, the access using only three ports compared with four trocars in lateral decubitus position. In conclusion, the use of PC in patients with esophageal
cancer during esophagectomy is safe and feasible. The esophagectomy in PC position can be considered a less invasive procedure than LD.

Endoprotezare gastric pentru adenocarcinom gastric cu disfagie total


Gastric Endo-Prosthesing in Adenocarcinoma with Total Dysphagia
D. Sabu (1), D. G. Bratu (1), H. Noor Mohammady Far (2), Vanina Marcu Iordnescu (2), C. G. Smarandache (3), A. D. Sabu (1)
(1) Universitatea Lucian Blaga, Spitalul Clinic Judeean de Urgen, Clinica Chirurgie II, Sibiu, Romnia
(2) Spitalul Clinic Judeean de Urgen, Clinica Chirurgie II, Sibiu, Romnia
(3) Universitatea de Medicin i Farmacie Carol Davila / Spitalul Universitar de Urgen, Chirurgie, Bucureti, Romnia
Introducere: Neoplasmul gastric reprezint a doua cauz de deces prin cancer din lume. Incidena este de 23% la brbai i 12% la femei. Tabloul clinic este unul
srac cu simptomatologie vag nespecific. Adenocarcinomul gastric reprezint 90% dintre tumorile gastrice. Avnd n vedere apariia tardiv a simptomatologiei,
de cele mai multe ori avem de-a face cu un neoplasm gastric avansat, fr indicaie de radicalitate.
Material i metod: Prezentm cazul unui pacient n vrst de 62 ani, cu adenocarcinom gastric cu caracter agresiv, prezentnd metastaze peritoneale,
ganglionare i hepatice, anemie moderat i hipoproteinemie. Tumora situat la nivelul corpului i antrului gastric. Pacientul a fost investigat att prin date
bio-umorale ct i imagistic (examen bariu-pasaj, CT abdomino-pelvin i endoscopie digestiv superioar). Explorrile s-au repetat postoperator pentru
verificarea eficienei protezei gastrice. Dup o pregtire corespunzatoare, s-a intervenit chirurgical practicndu-se laparoscopie exploratorie, adezioliz,
endoprotezare gastric prin foraj transtumoral prin traciune, fixarea captului distal al protezei (tub Pezzer) la nivelul duodenului, drenaj peritoneal i parietorafie.
Rezultate: Postoperator evoluia pacientului a fost favorabil, cu reluarea imediat a alimentaiei att pentru lichide ct i pentru semisolide. Acesta a beneficiat
de o spitalizare de 9 zile, dintre care 2 zile fiind preoperator.
Concluzii: Endoprotezarea gastric prin foraj transtumoral prin traciune permite reluarea alimentaiei prin redobndirea traiectului fiziologic al tubului digestiv,
pacientul alimentndu-se normal. Aceast intervenie prezint o ncadrare social rapid, fr a invalida individul precum faringostoma, gastrostoma sau
jejunostoma de alimentaie.

Introduction: Gastric cancer is the second cause of cancer death in the world. The incidence is 23% in men and 12% in women. The clinical picture is poor with
vague non-specific symptoms. Gastric Adenocarcinoma represents 90% of gastric tumors. Given the belated appearance of symptoms, most often we deal with
advanced gastric cancer with no indication of radicalism.
Material and method: We present a 62-year old patient with Aggressive gastric Adenocarcinoma with peritoneal metastasis, lymph nodes metastasis and liver
metastasis, moderate anemia and hypoproteinemia. Tumor located in the gastric body and antrum. The patient was investigated by blood and data imaging
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(barium-exam passage, abdominal-pelvic CT and upper gastrointestinal endoscopy). The explorations were repeated postoperative to verify the effectiveness of
gastric prosthesis. After proper preparation, we performed exploratory laparoscopy, transtumoral gastric endo-prosthesing by drilling, fixation of the distal end of
the prosthesis (tube Pezzer) to duodenum, peritoneal drainage and parietoraphy. Results: Postoperatively the patient's evolution was favorable with immediate
resumption of feeding, both liquid and semisolid. He has benefited from a 9-day hospitalization, of which two days were preoperatively.
Conclusions: Transtumoral gastric endo-prosthesing by drilling allows resumption of alimentation through the physiological digestive tract, the patient being
normally supplied. This intervention shows a rapid social integration, without invalidating the individual as faringostoma, gastrostomy or jejunostomy for
alimentation.

Limfadenectomia D2 n cancerul gastric - experiena personal


D2 Lymphadectomy in Gastric Cancer - Personal Experience
Cristina Dan, R. C. Popescu
Spitalul Clinic Judeean de Urgen Sf. Apostol Andrei, Secia de Chirurgie General, Constana, Romnia
Obiectivul studiului: Cancerul gastric constituie o problem major de sntate public, prin frecven, agresivitate i prin rata sczut de curabilitate n stadiul
simptomatic. La ora actual, limfodisecia D2 dup model japonez este considerat un standard terapeutic n cancerul gastric.
Material i metode: Prezentm experiena personal constnd n 73 de pacieni operai pe parcursul ultimilor 5 ani, la care s-a realizat limfodisecie D2 asociat
diferitelor tipuri de gastrectomie n funcie de localizarea tumoral. S-au recoltat n medie un numr de 36 de ganglioni, care au fost analizai histopatologic,
numrul de ganglioni invadai avnd importan n stabilirea tratamentului oncologic i a prognosticului. Vrsta pacienilor a fost cuprins ntre 43-74 ani.
Rezultate: Pacienii au fost urmrii clinic pe o perioad de 24-48 luni, la 28 de pacieni nenregistrndu-se recidive locale.
Concluzii: Limfodisecia ideal n cazul cancerului gastric trebuie s stadializeze extensia bolii i s fie un element de prognostic; n plus ar trebui s
mbunteasc supravieuirea prin nlturarea selectiv i complet a tuturor ganglionilor cu posibile metastaze cu morbiditate i mortalitate minime.

Objective: Gastric cancer continues to be a major public health problem by frequency, aggressiveness and low rate of cure in symptomatic stage. At the moment,
D2 lymph dissection in gastric cancer after the Japanese model is considered a standard therapy.
Material and method: We present our personal experience consisting of 73 patients operated during the last five years, in whom we performed D2
lymfodissection associated to different types of gastrectomy, depending on the tumoral localization. There were harvested on average a total of 36
lymphonodules, which were histopathological, analyzed, the number of positive lymph nodes being important for establishing oncological treatment and
prognosis. Patient age ranged between 43-74years.
Results: Patients were clinically observed for a period of 24-48 months, in 28 patients local recurrences were not registered.
Conclusions: Ideal lymphodissection in gastric cancer should stage the extent of disease and it is a prognostic factor; in addition it should improve survival by
removing of all the lymph nodes with minimal morbidity and mortality.

Tehnici moderne de radioterapie pentru tumorile de esofag: dou prezentri de caz


Modern Radiotherapy for Oesophageal Cancer: Two Case Reports
Iuliana-Ramona Giurgiu, C. Barbu, G. Rcu, Cristina Duran, Ruxandra Mitulescu
Clinica de Oncologie i Radioterapie Amethyst, Radioterapie, Otopeni, Romnia
Introducere: Incidena tumorilor esofagiene crete cu vrsta, carcinomul scuamos fiind cel mai frecvent tip histologic. Stadiul i localizarea tumorii sunt mai
importante dect histologia n ghidarea deciziei de tratament.
Material i metode: n aceast lucrare este prezentat planul de radioterapie pentru doi pacieni diagnosticai cu tumor de esofag, tratai n Clinica Amethyst
Bucureti. n primul caz, tumora este localizat n esofagul inferior iar radioterapia a fost administrat n scop preoperator. Cel de-al doilea caz a fost diagnosticat
cu carcinom scuamocelular de esofag superior local avansat i s-a administrat radiochimioterapie cu intenie definitiv. S-a utilizat tehnica de radioterapie cu
intensitate modulat, versiunea VMAT.
Rezultate: n ambele cazuri, radioterapia a putut fi administrat n siguran pn la atingerea dozei optime, cu efecte adverse minime la nivelul organelor
sntoase din vecintate. n primul caz s-a obinut rspuns patologic complet iar n cel de-al doilea, rspuns complet clinic i pe computer tomografia de control
efectuat la 2 luni de la terminarea tratamentului.
Concluzii: Chirurgia este principalul act terapeutic cu scop curativ dar doar 40% din pacieni supravieuiesc 2 ani. Radiochimioterapia preoperatorie conduce la un
beneficiu de supravieuire de 13% la 2 ani. Pentru pacienii inoperabili se utilizeaz radiochimioterapia concomitent n scop curativ cu conservarea funciei de
organ i asigurarea unei caliti a vieii acceptabil.

Background: Oesophageal cancer incidence increases with age, squamous cell carcinoma being the most common histological type. The stage and location of
the tumor are more important than histology in guiding therapeutic decision making.
Material and methods: Radiotherapy technique for 2 patients diagnosed with oesophageal tumor is presented in this paper. They have been treated at the
Bucharest Amethyst Clinique. First case had the tumor in the inferior oesophagus and he received preoperative radiotherapy. The second patient was
diagnosed with locally advanced squamous cell carcinoma of the superior oesophagus and he was treated with definitive chemoradiation. We used the VMAT
radiotherapy technique.
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Results: Both cases got an optimal dose of radiotherapy with minimal adverse effects on organs at risk. In the first patient we obtained complete pathological
response. In the second case we reached complete response on clinical symptomatology and on computed tomography.
Conclusions: Surgery is the principal curative therapy but only 40% of patients survive for 2 years. Preoperative chemoradiation leads to a survival benefit of 13%
at 2 years. Curative concomitant chemoradiation is used in case of inoperable tumors with the advantage of organ preservation and an acceptable quality of life.

Tratamentul chirurgical al cancerului gastric proximal


Surgical Treatment of Proximal Gastric Cancer
L. Antoci (1), S. Revencu (2), N. Ghidirim (3), Ana Donscaia (1), V. Godoroja (1), M. Cernat (1), Nadejda Corobcean (3), Ana Parasca (3), Irina Rurac (3),
Nelea Ududovici (3)
(1) Institutul Oncologic, Departamentul Gastropulmonologie, Chiinu, Republica Moldova
(2) Universitatea de Stat de Medicin i Farmacie Nicolae Testemianu, Clinica de Chirurgie, Chiinu, Republica Moldova
(3) Universitatea de Stat de Medicin i Farmacie Nicolae Testemianu, Catedra de Oncologie, Hematologie i Radioterapie, Chiinu, Republica Moldova
Introducere: n ultimele decenii se atest o cretere a morbiditii prin cancer gastric proximal, care deseori implic jonciunea eso-gastric (JEG), este depistat n
stadii tardive i tratamentul chirurgical rmne pn n prezent o problem a chirurgiei tractului digestiv.
Scopul studiului: Aprecierea conduitei terapeutice n tumorile cu implicarea JEG
Materiale i metode: Studiul a fost efectuat n Institutului Oncologic din Republica Moldova. Pe parcursul 2010-2014, au fost efectuate 618 operaii radicale pe
motiv de cancer gastric, dintre care 80 pentru cancer gastric proximal cu implicarea JEG, cu vrsta bolnavilor cuprins ntre 37 i 78 de ani 25 - femei i 55 brbai. Au fost efectuate 62 gastrectomii: n 37 de cazuri (46,25%) - prin acces abdominal, dintre care 13 (35,14%) operaii au avut caracter combinat i n 25
(31,25%) - prin toraco-freno-laparotomie, dintre care 13 (52%) - combinat. Rezecii gastrice polare superioare au fost efectuate n 18 cazuri: 9 (11,25%) - prin acces
abdominal, dintre care 5 (55,56%) - combinate i 9 (11,25%) - prin toraco-freno-laparotomie, toate purtnd caracter combinat. n toate cazurile, operaiile au fost
extinse cu rezecia unui segment de esofag, de regul, cu limfodisecii D2, iar cele prin acces toraco-freno-laparotomic - cu limfodisecie paraesofagian i
mediastinal inferioar. Cele mai frecvente complicaii postoperatorii au fost pancreatita acut postoperatorie n 21,3% (n=17) i pleurezia exudativ n 20% (n=16),
rezolvate conservativ. Dehiscene de anastomoz, fistule i letalitate postoperatorie nu au fost nregistrate.
Concluzii: Pentru a elabora o tactic curativ corect, n tumorile cu implicarea JEG, cu efectuarea operaiei R0 i limfodiseciei regionale adecvate, pacientul
trebuie investigat complex. Decizia abordului chirurgical depinde de aprecierea nivelului afectrii esofagului.

Introduction: In the last decades there is an increase in morbidity of proximal gastric cancer, which often involves the esogastric junction (EGJ), is detected in late
stages and the surgical treatment to date remains an unsolved problem of gastrointestinal (GI) surgery.
Aim: To assess the therapeutic management of tumors involving EGJ.
Material and methods: The study was conducted in the Oncological Institute of Moldova. During 2010-2014 were carried out 618 radical operations for gastric
cancer, out of which 80 for proximal gastric cancer with the involvement of EGJ. The age of patients was between 37 and 78 years old, male:female ratio 1:2,2.
Results: 62 gastrectomies were performed: 37 (46.25%) - by abdominal approach, of which 13 (35.14%) included operations with the removal of adjacent organs
(AO). In 25 (31.25%) of the cases the approach was by thoraco-phreno-laparotomy (TPL), of which 13 (52%) - with AO. Upper polar gastric resections were
performed in 18 cases: 9 (11,25%) - through abdominal approach, of which 5 (55.56%) - with AO and 9 - through TPL, all with AO. In all cases the operations
included resection of the esophagus and in the majority of cases - D2 lymphadenectomy. The operations with TPL approach received paraesophagial and inferior
mediastinal lymphadenectomy. The most common postoperative complications were postoperative acute pancreatitis in 21.3% cases (n=17) and exudative pleural
effusion in 20% cases (n=16), treated conservatively. Anastomotic dehiscence, fistulas and postoperative lethality were not registered.
Conclusions: In order to develop a proper curative management of tumors involving EGJ with R0 resections and appropriate regional lymphadenectomy, the
patient should be complexly investigated. Decision on surgical approach depends on assessing the level of damage of the esophagus.

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Endoprotezare esofagian prin foraj transtumoral prin traciune


Esophageal Endo-Prosthesing by Transtumoral Drilling
D. Sabu (1), D. G. Bratu (1), H. Noor Mohammady Far (2), Vanina Marcu Iordnescu (2), C. G. Smarandache (3), A. D. Sabu (1)
(1) Universitatea Lucian Blaga, Spitalul Clinic Judeean de Urgen, Chirurgie II, Sibiu, Romnia
(2) Spitalul Clinic Judeean de Urgen, Chirurgie II, Sibiu, Romnia
(3) Universitatea de Medicin i Farmacie Carol Davila / Spitalul Universitar de Urgen, Chirurgie, Bucureti, Romnia
Introducere: Neoplasmul esofagian reprezint a aptea cauz de deces prin cancer n lume. Mai mult de jumtate dintre pacienii diagnosticai cu cancer
esofagian au nevoie de ngrijiri paliative, care presupun rezolvarea stenozei esofagiene pentru refacerea toleranei digestive i reluarea alimentaiei,
mbuntind astfel calitatea vieii pacienilor.
Materiale i metode: Prezentm cazul unui pacient n vrst de 52 de ani, cunoscut cu gastrectomie subtotal pentru ulcer duodenal, diagnosticat n decembrie
2015 cu carcinom scuamos esofagian nekeratinizat 1/3 proximal cu invazia traheei i a corzii vocale drepte, pentru care i s-a administrat cur incomplet de
chimioterapie datorit apariiei disfagiei totale. Pacientul s-a prezentat pe lng simptomatologia menionat anterior i cu disfonie, scdere ponderal (15 kg n
ultimele 3 luni) i astenie marcat. Pacientul a fost investigat endoscopic, s-au recoltat biopsii, ns fr a se putea avansa prin zona tumoral. n acest caz s-a
efectuat laparoscopie exploratorie, laparogastroscopie, endoprotezare esofagian prin foraj transtumoral prin traciune, gastrorafie, drenaj.
Rezultate: Evoluia postoperatorie a fost favorabil cu reluarea imediat a alimentaiei. Drenajul se suprim la o zi postoperator. Durata medie de spitalizare este
de 3 zile ns, datorit investigaiilor postoperatorii, aceasta se poate prelungi.
Concluzie: Acest tip de procedeu miniinvaziv este deosebit de util n reluarea alimentaiei pacienilor care prezint stenoz esofagian cauzat de cancerul
esofagian i nu numai. Pacientul a reluat la scurt timp tratametul oncologic. Avnd n vedere atacul minim aspura organismului datorit miniinvazivitii, se
potrivete pacienilor cu o patologie neoplazic, cu un sistem imunitar deficitar i cu rezerve proteino-energetice reduse.

Introduction: Esophageal cancer is the seventh cause of cancer death in the world. Dysphagia is the most common symptom found in this neoplasia, having a big
impact on patient nutrition. More than half of the patients diagnosed with esophageal cancer need palliative care, which include solving esophageal stenosis for
rebuilding digestive tolerance and resumption of alimentation, thus improving quality of life.
Materials and methods: We present the case of a patient aged 52, with subtotal gastrectomy for duodenal ulcer, diagnosed in December 2015 with esophageal
squamous cell carcinoma 1/3 proximal with invasion of trachea and vocal cord righteous, who was given incomplete chemotherapy cure due to the occurrence of
total dysphagia. The patient presented in addition to the aforementioned symptoms and hoarseness, weight loss (15 kg in 3 months) and marked weakness. The
patient was investigated endoscopically, biopsies were taken, but without being able to pass the tumor. In this case we performed exploratory laparoscopy,
laparogastroscopy, esophageal endo-prosthesing by transtumoral drilling, gastrorafy, drainage.
Results: The postoperative evolution was favorable with immediate resumption of food. Drainage was removed one day after surgery. Average length of
hospitalization is 3 days but due to postoperative investigations, it may be extended.
Conclusion: This type of minimally invasive procedure is particularly useful to resume alimentation for patients with esophageal stenosis caused by esophageal
cancer and beyond. Given the minimal attack on the body due to minimal invasive procedures, this surgical method fits the patients with weak immune systems
and with low protein and energy reserves.

Tendine actuale ale spectrului patologiei chirurgicale: comparaie 2013-2015 vs. 2003-2005 vs. 1993-1995
Current Trends in the Range of Surgical Pathology: Comparison 2013-2015 vs. 2003-2005 vs. 1993-1995
A. Nicolau (1), Raluca Vasile (2)
(1) Spitalul Clinic de Urgen Floreasca, Clinica de Chirurgie, Bucureti, Romnia
(2) Spitalul Clinic de Urgen Floreasca, Clinia de Chirurgie, Bucureti, Romnia
Pe 6 decembrie 1993, unul dintre noi a efectuat prima colecistectomie laparoscopic (CL), deschiznd calea chirurgiei miniminvazive i a terapiei prin acces
minim. Lucrarea noastr compar ponderea afeciunilor i a interveniilor chirurgicale (IC) efectuate n perioada 2013-2015, cu cele din 2003-2005, respectiv
1993-1995. Numrul mediu anual al IC a fost de 6596, comparativ cu 7056, respectiv 6026, dintre care laparoscopice 1512 (22,92%), 1377 (19,51%), 127 (2,10%).
Se constat o scdere substanial a IC pentru ulcer gastroduodenal, 68 n medie anual, comparativ cu 195, respectiv 588 i a apendicectomiilor, 442, comparativ
cu 1211, respectiv 1490. A crescut incidena CL la 1253, comparativ cu 1237, respectiv 104. A sczut numrul de pancreatite acute operate la 23, comparativ cu 42,
respectiv 74 i a ocluziilor intestinale, 83 comparativ cu 94, respectiv 145. Se constat o cretere alarmant a patologiei maligne, o medie anual de 970 IC,
comparativ cu 626, respectiv 385. Cea mai mare expansiune au avut-o tumorile maligne colorectale, 420, comparativ cu 299, respectiv 173. Numrul de
taumatisme operate a evoluat negativ, 129 n medie pe an n 2013-2015, fa de 337 n 2003-2005, respectiv 394 n 1993-1995. Considerm c aceste modificri
trebuie s se reflecte n pregtirea rezidenilor n mod special.

On December 6th, 1993 a member of our team performed the first laparoscopic cholecystectomy (LC), pioneering the Minimally Invasive Surgery. Our paper
compares the prevalence of surgical interventions (SI) performed in 2013-2015 against those in 2003-2005 and 1993-1995 respectively. The yearly average
number of SI was 6,596, compared to 7056 and 6026 out of which the following were laparoscopies: 1,512 (22.92%), 1,377 (19,51%) and 127 (2,10%). We note a
substantial decrease of SI for gastro- duodenal ulcers, 68 average/year compared to 195 and 588, and for appendectomies, 442 compared to 1,211 and 1,490. LCs
have increased to 1,253 compared to 1,237 and 104. The number of operations for acute pancreatitis and bowel obstruction decreased to 23 compared to 42 and
28

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74, and to 83 compared to 94 and 145. An alarming rise in malignant pathologies is noted, to 970 SIs compared to 626 and 385. The most substantial increase is
seen in colorectal malignant tumor: 420 compared to 299 and 173. The number of traumas has decreased to 129 compared to 337 and 394. We believe these
changes must be reflected especially in the resident training programme.

Afectarea intestinal n tulburrile acute ale circulaiei mezenterice. Experiena ultimilor 5 ani
Intestinal Impairment in Acute Mesenteric Ischemia. Five Years Experience
D. Ene, C. Turcule, T. F. Georgescu, E. Ciuc, A. Vldscu, M. Beuran
Spitalul Clinic de Urgen Floreasca, Clinica de Chirurgie I, Bucureti, Romnia
Ischemia mezenteric acut este o urgen absolut, care necesit management rapid i eficient pentru a limita ntr-o msur ct mai mare efectul asupra
viabilitii i integritii intestinale.
Etiopatogenic, exist 4 cauze de infarct mezenteric acut:
1. Embolismul arterial 40-50%
2. Tromboza arterial 25%
3. Tromboza venoas 10%
4. Nonocluziv 20%
Scopul lucrrii de fa este de a identifica gradul afectrii intestinale i impactul prognostic n funcie de etiologie i raportate la factorii de risc cu prevalen cea
mai mare la grupul studiat.
Dintre factorii de risc care predispun la apariia acestor condiii, recunoatem: aritmiile cardiace, cardiomiopatiile, anevrismul ventricular, ateroscleroz, istoricul
de evenimente embolice, hipotensiunea arterial, strile maligne, interveniile chirurgicale recente, policitemia.
n cadrul lucrrii de fa, au fost studiai 53 de pacieni internai n secia Chirurgie I a Spitalului de Urgen Bucureti, avndu-se n vedere evoluia postadmisie
prin prisma factorilor de risc cu importana cea mai mare (fibrilaia atrial, infarctul miocardic n antecedente, insuficien cardiac, ischemia mezenteric n
antecedente i prezena sau absena terapiei anticoagulante).
Din analiza noastr, a reieit c prognosticul vital este mai bun n ce privete etiologia embolic fa de cea trombotic i de cea nonocluziv. Pe de alt parte,
etiologia venoas predispune pacientul ctre o evoluie mai rapid ctre necroz intestinal, n ciuda faptului ca simptomatologia nu este at de puternic ca cea
din etiologia arterial.

Acute mesenteric ischemia represents an absolute emergency that needs a rapid and efficient management for a limited effect over intestine viability and
integrity.
Etiopathogenetically, there are 4 determinants of acute mesenteric infarction:
1. Arterial embolism 40-50%
2. Arterial thrombosis 25%
3. Venous thrombosis 10%
4. Nonocclusive 20%
Our purpose was to identify the degree of intestinal impairment and the patient prognosis depending on the etiology and reported to the most prevalent risk
factors found in our group.
Among all risk factors, the most important are: cardiac arrhythmias, cardiomyopathies, ventricular aneurism, atherosclerosis, a history of embolic events,
malignancy, polycythemia and recent surgery.
In our study, were recorded 53 patients admitted in the 1st Department of General Surgery of Bucharest Emergency Hospital, been taken in consideration
postadmission evolution through the most important risk factors (atrial fibrillation, prior myocardial infarction, cardiac failure, prior mesenteric ischemia and the
presence or absence of anticoagulant therapy).
Our analysis showed that vital prognosis is better for the embolic etiology compared to the thrombotic or nonocclusive ones. On the other hand, venous
impairment causes a far more aggressive intestinal necrosis, despite that its symptomatology is not as loud as the arterial impairment.

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Fasceita necrotizant - circumstan septic major - experiena SCUBA n ultimii 3 ani


Necrotizing Fasciitis - Major Septic Occurrence - Experience of Bagdasar-Arseni Emergency Hospital Surgery Clinic
Over the Last 3 Years
V. A. Porojan, Oana Ilona David, I. S. Coman, Violeta Elena Radu, C. D. Badiu, M. Paraschiv, A. R. Stoian, V. T. Grigorean
Spitalul Clinic de Urgen Prof. Dr. Bagdasar-Arseni, Secia de Chirurgie General, Bucureti, Romnia
Introducere: Fasceita necrotizant reprezint un tip rar, dar foarte grav de infecie a esuturilor moi, caracterizat de o extensie rapid a inflamaiei i a necrozei n
esturile muscular, adipos i tegumenar.
Material i metod: Lotul include 16 pacieni diagnosticai cu fasceit necrotizant (cu localizri variate) n Clinica de Chirurgie General a Spitalului
Bagdasar-Arseni. Sunt analizate urmtoarele variabile: vrsta, sexul, comorbiditi (diabet zaharat, obezitate, neoplazii, imunosupresie, insuficien renal i
cardiac), localizarea fasceitei, timpul de la debutul simptomatologiei pn la prezentare, prezena ocului septic la momentul prezentrii, tratamentul i evoluia
postintervenie chirurgical obiectivat prin studiul perioadei de spitalizare, al supravieuirii i monitorizarea parametrilor clinici i biologici pre i postintervenie
chirurgical.
Rezultate: n lotul pacienilor studiai, se observ o preponderen a sexului masculin (11 pacieni din totalul de 16). Vrsta medie a fost de 65.87 (cu limite
cuprinse ntre 30-89 ani). Majoritatea prezentau co-morbiditi importante precum diabet zaharat, obezitate, insuficien cardiac sau renal de cele mai multe
ori asociate. n toate cazurile s-a intervenit chirurgical de urgen, practicndu-se debridri extinse i necrectomie, urmate de reintervenii zilnice cu excizia
progresiv a zonelor de necroz. Mortalitatea global a fost de 62,5% (10/16), de cele mai multe ori decesul survenind n primele 5 zile de la internare din cauza
ocului septic.
Concluzii: Rata crescut a mortalitii generate de fasceita necrotizant, n special n rndul pacienilor vrstnici, cu multiple comorbiditi, este direct dependent
de starea general de la momentul prezentrii, prezena ocului septic fiind principalul factor de prognostic nefavorabil.
Cuvinte cheie: fasceita necrotizant, oc septic, necrectomie

Introduction: Necrotizing fasciitis is a rare infection involving soft tissue, characterized by rapid extension of inflammation and necrosis within muscular tissue,
adipose tissue and skin.
Means and methods: We studied 16 patients diagnosed with necrotizing fasciitis (affecting various body parts) in Bagdasar-Arseni Emergency Hospital, General
Surgery Clinic. Age, gender, comorbidities (such as diabetes, obesity, cancer, immunosuppression, renal or cardiac failure), localization of the infection, as well as
time between the symptoms debut until admission into the hospital were analyzed. Also, the impact of septic shock at admission into the hospital as well as
surgical treatment and postoperative evolution were studied by analyzing the hospitalization period, survival rate, clinical and biological parameters and their
evolution after treatment.
Results: Our patients were mostly males (11 males from a total of 16 patients). The medium age was 65.87 (with a minimum of 30 years old and a maximum of 89).
Most of our patients had serious comorbidities such as diabetes, obesity, renal or cardiac failure. All patients suffered surgical interventions implying extensive
debridement and necrectomy followed by daily re-interventions having as purpose the excision of the new formed areas of necrosis. Global mortality was 62.5%
(10 out of 16 patients), in most cases death occurring within the first 5 days of hospitalization, by septic shock.
Conclusions: High mortality in necrotizing fasciitis is secondary to a critical state at presentation, in old patients with multiple comorbidities, the presence of
septic shock being the main factor associated with poor prognosis.
Key words: necrotising fasciitis, septic shock, necrectomy

Sindromul de iritaie peritoneal n fosa iliac dreapt - surprize diagnostice, atitudine terapeutic
Right Lower Abdominal Quadrant Peritoneal Irritation Syndrome - Diagnostic Surprises, Therapeutic Attitude
G. Chiriac (1), D. Jiju (1), R. Ene (1), R. Georgescu (1), D. Grigore (1), A. Rou (1), Alina Chiriac (2)
(1) Spitalul Judeean de Urgen, Secia de Chirurgie General, Slatina, Romnia
(2) Spitalul Judeean de Urgen, Secia de Anestezie i Terapie Intensiv, Slatina, Romnia
Sindromul dureros acut de fos iliac dreapt, cu semne de iritaie peritoneal, constituie o problem diagnostic avnd implicaii terapeutice i prognostice
uneori n afara ateptrilor echipei chirurgicale sau ale pacientului/familiei acestuia; pentru chirurgii familiarizai cu urgena, entitatea nu pune probleme
deosebite dar nici nu-l situeaza pe chirurgul operator ntr-o poziie ntotdeauna confortabil. Lucrarea i propune s aduc n discuie o serie de patru cazuri
clinice (ultimele 12 luni); este vorba despre un pacient tnr cu o tumor inflamatorie cecal, o leziune apendicular de tip granulomatos la o pacient de 46 ani,
un neoplasm de cec perforat la o pacient de 70 ani, un abces pericecal tardiv postapendicectomie (9 ani) la un pacient de 52 ani. Stabilirea unui diagnostic
preoperator graviteaza ntre relativitatea anamnezei i limitele explorrii CT abdominale; n toate cazurile, diagnosticul a fost stabilit intraoperator (cu sau fr
laparoscopie diagnostic). Momentul interveniei nu a permis examene histopatologice sau citologice intraoperator. Ca urmare, intervenia chirurgical s-a
efectuat avnd permanent n vedere posibila/aparent evidenta malignitate; n toate cazurile descrise s-a efectuat hemicolectomie dreapt cu evoluie ulterioar
favorabil.

Acute right lower abdominal quadrant pain syndrome, with signs of peritoneal irritation, represents a diagnostic problem with therapeutic and prognostic
implications sometimes beyond the expectations of the surgical team or the patient / his relatives ; for the surgeons familiarized with the emergencies, this entity
does not raise special problems nor does it rank the surgeon in a position always comfortable. The paper aims to bring into question a series of four clinical cases
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(last 12 months); a young patient with a cecal inflammatory tumor, a granulomatous appendicular lesion in a 46-year old patient, a microperforated cecal
neoplasm in a 70-year old patient, a late pericecal post-appendectomy abscess (9 years) in one patient 52 years old. Preoperative diagnosis gravitates between
the ambiguous medical history and some limits of the CT abdominal exploration; in all cases the diagnosis was established intraoperative (with or without
diagnostic laparoscopy). The surgery time didnt allow intraoperative histopathological examinations or cytology. Surgery was performed bearing in mind the
possible/seemingly malignancy; in all cases. The right hemicolectomy was performed with good subsequent evolution.

Patologia iatrogen chirurgical


Iatrogenic Surgical Pathology
Valentina Pop-Began (1), V. T. Grigorean (1), D. Pop-Began (2), C. G. Popescu (3), . Duescu (3), C. Badiu (3)
(1) Spitalul Universitar de Urgen Elias, Chirurgie General, Bucureti, Romnia
(2) Universitatea de Medicin i Farmacie Carol Davila, Catedra de Sntate Public i Management Sanitar, Bucureti, Romnia
(3) Spitalul Clinic de Urgen Prof. Dr. Bagdasar-Arseni, Chirurgie General, Bucureti, Romnia
Obiectiv: Studiul patologiei iatrogene chirurgicale.
Material i metod: Din epoca elenistic i pn n epoca modern, Jurmntul Hipocratic a fost asumat de viitorii medici, care s-au obligat s-i dovedeasc
ataamentul fa de profesie, s-i ndeplineasc contiincios datoria. Nicio specialitate medical nu este imun la erori. Studiul include lucrri bazate pe
observaii personale, numeroase articole, volume cu caracter tiintific.
Rezultate: Anual, n lume, se efectueaz 234 milioane de operaii. Astfel, nelegem posibilitatea apariiei erorii medicale, motiv pentru care Organizaia Mondial
a Sntii a lansat Lista de verificare a procedurilor chirurgicale. Printre specialitile medicale cu cele mai multe erori medicale se afl ginecologia i chirurgia.
Astzi, patologia iatrogen trebuie cunoscut, ceea ce impune mprirea responsabilitii medico-legale, ctre toate elementele sistemului medical. Actele
medicale pot fi urmate de incidente i accidente. Conform diferitor statistici, n corpul pacienilor sunt uitate instrumente chirurgicale, diferite obiecte. Astzi, sunt
cunoscute numeroase asemenea erori, pe care presa le face cunoscute.
Concluzii: Astzi, se impune cunoaterea efectelor negative ale actelor medicale pentru ndeprtarea implicaiilor medico-legale.
Cuvinte cheie: chirurgie, iatrogenie, patologie.

Objective: The study of iatrogenic surgical pathology.


Methods: From the Hellenistic era and until the modern era, the Hippocratic "Oath" was assumed by future physicians who found themselves obliged to prove
their commitment to the profession, to conscientiously fulfill their duty. There is not a medical specialty immune to errors. The study includes works based on
personal observations, numerous articles, and scientific volumes.
Results: Every year, 234 million operations are carried out all over the world. Thus, we understand the potential for medical error occurrence, which is why the
World Health Organization launched the "Surgical Procedures Checklist". Surgery and gynecology are among the medical specialties with most medical errors.
Today, iatrogenic pathology must be known, which requires sharing forensic medical responsibility to all the elements of the medical system. Medical procedures
may be followed by incidents and accidents. According to different statistics, surgical instruments and various objects are forgotten in patients bodies. Nowadays,
this kind of errors are very well known, mostly through the media, which make them popular.
Conclusions: Today, we should be aware of the negative effects of medical acts in order to avoid forensic implications.
Key words: surgery, iatrogeny, pathology

Tratamentul chirurgical al lipoamelor valvei ileo-cecale


Surgical Treatment of Ileo-Cecal Valve Lipomas
B. Stancu, I. A. Mironiuc, O. Andercou, Daniela Pintea, . Chiorescu, F. Mihileanu, Ioana Constantinescu, G. Olteanu
Universitatea de Medicin i Farmacie Iuliu Haieganu, Disciplina Chirurgie II, Cluj-Napoca, Romnia
Introducere: Lipoamele sunt cele mai obinuite tumori benigne mezenchimale ntlnite la nivelul tractului gastrointestinal, sunt localizate la nivelul ileonului distal
i regiunii colorectale (n special colonel drept), rareori n stomac sau intestinul subire proximal. Lipoamele intestinale se deterioreaz rar, fiind complicate cu
ocluzii intestinale sau hemoragie, i nu recidiveaz dup tratament.
Materiale i metode: Prezentm 2 cazuri clinice cu o cauz rar de ocluzie intestinal la adult, cu dureri abdominale, unul dintre ele din cauza invaginaiei
ileo-colice cauzat de un lipom al valvei ileo-cecale.
Rezultate: Manifestrile clinice ale lipomului simptomatic includ durere abdominal, hemoragie sau subocluzie intestinal. Tomografia computerizat i
examinarea ecografic au fost efectuate i au identificat imagini tipice de forma unui crnat sau forma unei inte. ntr-un caz am efectuat excizia
laparoscopic a lipomului datorit localizrii subseroase a acestuia i n cellalt hemicolectomie dreapt i colecistectomie convenionale. Examinarea
histopathologic a confirmat lipoamele i evoluia pacienilor a fost favorabil, fr complicaii.
Concluzie: Invaginaia intestinal la adult datorit lipomatozei intestinale este o cauz rar de ocluzie intestinal, fiind o patologie provocatoare pentru chirurg.
Diagnosticul preoperator este adesea greit sau ntrziat din cauza simptomelor nespecifice.
Cuvinte cheie: lipom valv ileo-cecal, invaginaie, laparoscopie, hemicolectomie

Introduction: Lipomas, the most common benign mesenchymal tumours found in the gastrointestinal tract, are located in the distal ileum and colorectal region
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(mainly the right colon), rarely in the stomach or proximal small intestine. Intestinal lipomas seldom deteriorate, being complicated with intestinal obstruction or
haemorrhage, and do not relapse after cure.
Materials and Methods: We present 2 clinical cases with a rare cause of intestinal obstruction in adult, with abdominal pain, one of them due to ileo-colic
intussusception by a lipoma of the ileo-cecal valve.
Results: The clinical manifestations of symptomatic lipoma include abdominal pain, haemorrhage, or incomplete intestinal obstruction. Computed tomography
and ultrasonographic examination were performed and typical sausage-like or target-like images were found. In one case we performed a laparoscopic
lipoma excision due to the subserosal location and in the other one conventional right hemicolectomy and cholecystectomy were performed. The
histopathological examination confirmed the lipomas and the evolution of the patients was favourable and uneventful.
Conclusion: Adult bowel intussusception due to intestinal lipomatosis is a rare cause of intestinal obstruction and a challenging condition for the surgeon.
Preoperative diagnosis is often missed or delayed because of non-specific symptoms.
Keywords: ileo-cecal valve lipoma, intussusception, laparoscopy, hemicolectomy

Consideraii asupra stenozelor anastomotice benigne n chirurgia colorectal


Considerations for Benign Anastomotic Stenosis in Colorectal Surgery
P. A. Radu, M. N. Brtucu, N. D. Garofil, Cristina Iorga, C. Iorga, M. Zurzu, V. Paic, F. Popa, V. D. E. Strmbu
Spitalul Clinic de Nefrologie Dr. Carol Davila, Chirurgie General, Bucureti, Romnia
Strictura benign este o complicaie relativ comun n anastomozele colorectale dup rezecie anterioar joas. Ocazional, anastomoza se poate nchide complet.
Am analizat foile de observaie la pacienii cu intervenii chirurgicale pentru patologie colo-rectal ntre ianuarie 2012 i decembrie 2015. Principalele msuratori
au fost demografice, indicaia pentru intervenia chirurgical iniiala, BMI, comorbiditi, tratament anterior, nivelul anastomozei, istoricul de radioterapie i date
legate de reintervenii.
19 pacieni (15 brbai) s-a ncadrat pentru acest studiu. Nou pacieni au fost diagnosticai cu cancer, dintre care 7 au efectuat radioterapie. Interveniile
chirurgicale iniiale au fost: rezecie anterioar joas (n=9) rezecie anterioar nalt (n=9) i sigmoidectomie (n =1). 2 pacieni au dezvoltat fistule anastomotice,
tratate conservator. La majoritatea pacienilor (n=17) nu s-a cobort unghiul splenic i nu s-a ligaturat VMI la origine. n cazul a nou pacieni s-a putut realiza
mobilizarea unghiului splenic i ligatura superioar a vaselor mezenterice. apte pacieni (36%) au dezvoltat complicaii postoperatorii. Postoperator cu o medie
de urmrire de 22 luni s-au raportat 5 cazuri de stricturi anastomotice de diverse grade.
La pacienii ce au dezvoltat stricturi anastomotice n departamentul nostru, s-au constat urmtoarele aspect: unghiul splenic necobort i lipsa ligaturii la origine
a VMI. Mobilizarea unghiului splenic, ligatura la origine a pediculului, rezecia stricturii anastomotice i refacerea anastomozei pot fi realizate cu succes i cu
rezultate satisfctoare.

Benign stricture is a relatively common complication of colorectal anastomosis after low anterior resection. On occasion, the anastomosis may completely close.
Medical records were reviewed for patients who underwent surgery for colorectal pathology between January 2012 and December 2015. The main outcome
measures were demographics, indications for initial surgery, body mass index, comorbidities, previous treatment, level of anastomosis, history of radiotherapy,
and operative data for reoperative surgery.
19 patients (15 males) were eligible for the study. Nine patients had a diagnosis of cancer, 7 of whom received radiotherapy. The initial surgeries were low
anterior resection (n = 9), high anterior resection (n=9), and sigmoidectomy (n=1). 2 patients had anastomotic leak after initial surgery, treated conservative. The
majority of patients (n = 17) had an intact splenic flexure and inferior mesenteric vein. In 9 patients, full mobilization of splenic flexure and high ligation of
mesenteric vessels was performed. Seven patients developed postoperative complications. Over a mean follow-up of 20 months, there were 5 cases of
anastomotic stricture of different degrees.
An intact splenic flexure and mesenteric vessels were the most prevalent in patients who developed anastomotic strictures in our department. Full mobilization of
the splenic flexure, high ligation of the mesenteric vessels, anastomotic stricture resection, and re-anastomosis can be successfully performed with satisfactory
outcomes.

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Complicaiile colonoscopiei diagnostice - tratament conservator, endoscopic sau chirurgical?


Complications of Diagnostic Colonoscopy - Conservative, Endoscopic or Surgical Treatment?
C. Iorga (1), Anca Manta (1), P. A. Radu (1), Cristina Iorga (1), V. D. E. Strmbu (1), F. Popa (2)
(1) Spitalul Clinic de Nefrologie Dr. Carol Davila / Universitatea de Medicin i Farmacie Carol Davila, Secia de Chirurgie General, Bucureti, Romnia
(2) Spitalul Clinic de Nefrologie Dr. Carol Davila, Secia de Chirurgie General, Bucureti, Romnia
Introducere: Colonoscopia este una dintre cele mai valoroase metode de diagnostic i tratament n cazul patologiei colorectale, efectuat de rutin att de
chirurgi ct i de gastroenterologi. nregistreaz complicaii rare, dar amenintoare de via, ca perforaia i hemoragia. n cazul colonoscopiei diagnostice, se
nregistreaz ntre 0,02 i 3% din cazuri perforaii ce necesit tratament de urgen.
Material i metod: Studiul, retrospectiv, a fost efectuat n Clinica de Chirugie a Spitalului Dr. Carol Davila n perioada iunie 2012-februarie 2016 pe 967
colonoscopii diagnostice, efectuate cu sedare. 98% din cazuri au fost efectuate pn la nivelul ileonului terminal. S-au prelevat 228 biopsii.
Rezultate: Complicaiile nregistrate au fost hemoragii locale dup prelevarea de biopsii ce nu au necesitat tratament i 2 cazuri de perforaii sigmoidiene. ntr-un
caz a fost perforaie diverticular din cauza barotraumei i n cealalt caz perforaia a fost mecanic. Diagnosticul a fost pus la mai puin de 6 ore postprocedural,
iar tratamentul a fost chirurgical n ambele cazuri-colorafie, cu evoluie ulterioar favorabil. n cazul perforaiilor de mici dimensiuni, diagnosticate
intraprocedural, se poate opta pentru clipare endoscopic.
Concluzii: Colonoscopia, n ciuda complicaiilor poteniale rmne una dintre metodele principale de diagnostic i tratament a afeciunilor colorectale.

Introduction: Colonoscopy is one of the most valuable methods of diagnosis and treatment for colorectal pathology, usually performed by both surgeons and
gastroenterologists. The complications are rare, but life-threatening, as perforation and hemorrhage. In case of diagnostic colonoscopy, were recorded between
0.02 and 3% cases of perforation, requiring emergency treatment.
Material and method: The study, retrospective, was performed in Clinical Surgery Hospital "Carol Davila" in the period June 2012-February 2016; were performed
967 diagnostic colonoscopies with sedation. 98% of the cases were carried out up to the terminal ileum. 228 biopsies were taken.
Debates: Local bleeding complications were recorded after the taking of biopsies and did not require treatment and 2 cases of sigmoid perforation. In one case,
perforation was diverticular due to barotrauma and in the other case the cause was mechanical. It was diagnosed in less than 6 hours after the procedure, and
the treatment was surgical in both cases-colon suture with subsequent favorable development. If small perforations are diagnosed during the procedure, we can
perform endoscopic clipping.
Conclusions: Colonoscopy, despite potential complications remains one of the main methods of diagnosis and treatment of colorectal diseases.

Comparaie ntre chirurgia clasic i cea minim invaziv n tratamentul diverticulitei complicate
Comparison Between Open and Minimally Invasive Treatment of Complicated Diverticulitis
I. Tnase (1), S. Pun (1), B. Stoica (1), I. Negoi (2), R. Anghel (1), A. Chiotoroiu (1), M. Beuran (2)
(1) Spitalul Clinic de Urgen Floreasca, Chirurgie General II, Bucureti, Romnia
(2) Spitalul Clinic de Urgen Floreasca, Chirurgie General III, Bucureti, Romnia
Introduction: The surgical treatment of acute diverticulitis has changed dramatically in the last decade. Indications for extensive, resectional surgery are now
limited to patients with complicated Hinchey stage III or IV diverticulitis. As limited intervention like peritoneal lavage has become more frequent, so did the
indications for minimally invasive surgery.
Aim: This study was designed to analyze short-term postoperative results of open surgery compared with minimally invasive surgery for the patients that
underwent surgery for acute complicated diverticulitis from January 2013 to December 2015, in Bucharest Emergency Clinical Hospital.
Results: From the 221 patients admitted with acute diverticulitis in the studied period, a total of 56 patients underwent surgical treatment, from which 14
underwent minimally invasive treatment. The main limited intervention was represented by lavage and drainage (5 open surgery and 11 in the laparoscopic group)
followed by colonic suture in 7 cases (5 open surgery and 2 in the laparoscopic group). Resectional surgery (resection with primary anastomosis, Harmann
procedure or total colectomy) was done in 20 cases. Mean hospitalization period was longer in the patients that underwent minimally invasive surgery (12 days vs
16 days). No major postoperative complications were encountered in the minimally invasive group but the mean age of these patients was significantly lower than
in the open surgery group (54 years vs 68 years).
Conclusion: Limited laparoscopic interventions significantly decrease the length of stay, and postoperative recovery period and they are followed by fewer
complications, nevertheless open surgery remains a valuable resource for the elderly or patients with important comorbidities.
Keywords: diverticulitis, open surgery, laparoscopic surgery.

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Apendicectomia prin abord deschis sau laparoscopic, o comparaie ntre ieri i azi, o privire ctre mine
Open Versus Laparoscopic Appendectomy, a Look Between Yesterday and Today to Foresee Tomorrow
R. Mehic, Vasilica Marcu, S. Popa, Veronica Tlmaciu, Rita Anghel, I. Lic, M. Beuran
Spitalul Clinic de Urgen Floreasca, Chirurgie General, Bucureti, Romnia
Scop: S analizm evoluia laparoscopiei n abordarea apendicitei acute (AA) n ultimii 10 ani, s comparm datele din spitalul nostru cu alte spitale din strintate
i s gsim factorii care au dus la aceast evoluie.
Metod: Am analizat datele comparative dintre 2005 i 2015, urmrind frecvena AA comparativ cu alte diagnostice, participarea medicilor rezideni sau seniori
ca prim operator, raportul dintre abordul deschis sau laparoscopic i factorii care au dus la alegerea metodei. Pentru acest scop am folosit baza de date a
Spitalului de Urgen Bucureti i un chestionar adresat medicilor chirurgi, orientat pe motivele care i-au fcut s aleag tehnica operatorie.
Rezultate: Am gsit o diferen semnificativ n frecvena interveniilor pentru AA ntre 2015 (11%) i 2005 (24%). Abordul laparoscopic a fost peste 20% n 2015
comparativ cu mai puin de 1% n 2005, multe fcute de chirurgi tineri. Vrem s evideniem deasemenea alte avantaje ale abordului laparoscopic: o mai bun
explorare pentru acurateea diagnosticului sau pentru descoperirea poziiilor anormale ale apendicului sau cecului; o mai bun toalet a cavitii peritoneale;
posibilitatea rezolvrii n acelai timp a patologiilor asociate.
Concluzii: Abordul laparoscopic a crescut datorit accesibilitii metodei i instruirii chirurgilor tineri i rezidenilor. Pe lng avantajele clasice (cosmetic, infecii
de plag mai puine) evideniem un diagnostic mai corect i posibilitatea tratrii patologiilor asociate.

Aim: To analyze the evolution of laparoscopy in approaching acute appendicitis (AA) in the last 10 years, to compare the data from our hospital with other foreign
hospitals and find the factors that lead to this evolution.
Methods: We analyzed the comparative data between 2005 and 2015, looking for the frequency of AA comparing with others diagnosis, the involvement of
resident or senior as first surgeon, the ratio between open and laparoscopic approach and the factors who lead to choosing the method. For this aim we used the
database from the Emergency Hospital Bucharest and a questionnaire addressed to our surgeons, focused on the motives that make them to choose the
operative technique.
Results: We found a significant difference in frequency of operations for AA between 2015 (11%) and 2005 (24%). The laparoscopic approach was over 20% in
2015 compare with less than 1% in 2005, many made by young surgeons. We notice also some other advantages for laparoscopic approach: a better exploration
for accuracy of the diagnosis or to find other acute or chronic pathologies associated with AA; identification of abnormal position of appendix or cecum; a better
cleaning of abdominal cavity; the possibility to manage in the same time of other associated pathologies.
Conclusions: Laparoscopic approach of AA is increasing because of the accessibility of the method and teaching of young surgeons and residents. Besides the
classic advantages (cosmetic, low surgical infections) we emphasize a better diagnosis and the possibility to treat associated pathologies.

Rezultatele abordului minim invaziv n apendicita acut. Studiu comparativ laparoscopie vs. clasic
Results of Minimally Invasive Approach in Acute Appendicitis. A comparative Study Laparoscopy vs. Classic
C. Tara, A. Dobrescu, C. Lazr, D. A. Brebu, G. Noditi, G. Verde, C. Du, F. Lazr, S. Pantea
Spitalul Clinic Judeean de Urgen Pius Brnzeu, Clinica 2 Chirurgie, Timioara, Romnia
Scop: S prezentm vasta noastr experien n apendicectomia laparoscopic i s dezbatem limitele dintre apendicectomia minim invaziv i clasic.
Material i Metod: Au fost revizuite toate foile de observaie electronice, n perioada 2011-2015, dup criteriul apendicectomie clasic sau laparoscopic. Au fost
nregistrate sexul, vrsta, comorbiditile, indicele de mas corporal (IMC), stadiul bolii, complicaiile intraoperatorii i postoperatorii.
Rezultate: Au fost realizate 612 apendicectomii. Apendicectomie laparoscopic (AL) s-a efectuat n 431 de cazuri, apendicectomie clasic (AC) n 181 de cazuri.
Raportul femei/brbai a fost 1.25:1, principalul motiv pentru aceasta fiind c, la multe laparoscopii de diagnostic am preferat s efectum i apendicectomie cu
toate c motivul internrii a fost o patologie ginecologic. Comorbiditaile au fost prezente mai des n cazul AC 15% vs. 7% n AL. IMC a fost mai ridicat n cazul AL
28.7 kg/m2 comparativ cu AC 26.5 kg/m2. Stadiul bolii a fost mai avansat n grupul AC cu un procent mai mare de peritonit localizat i generalizat.
Complicaiile au fost ntlnite mai des in grupul AC.
Discuii: n primii ani a fost un procent mai mare de AC, dar acesta s-a schimbat dramatic n favoarea AL, ceea ce a dus la motive de ngrijorare n privina
pregtirii rezidenilor. Sexul feminin i persoanele obeze sunt indicate a fi operate laparoscopic. Cazurile mai dificile au fost operate clasic.
Concluzii: Cu toate c AL a devenit procedeul preferat, trebuie s ne antrenm i n AC, care i-a pstrat locul n arsenalul chirurgului.

Aim: To present our vast experience in laparoscopic appendectomy and to raise a few questions about the boundaries between minimally invasive
appendectomy and the open counterpart.
Methods: All the patients electronic charts were reviewed for the code of open or laparoscopic appendectomy between 2011-2015. The sex, age, comorbidities,
body mass index (BMI), stage of the disease, complications during and after procedure were recorded.
Results: There were 612 cases of appendectomy. Laparoscopic appendectomy (LA) was performed in 431 cases, open appendectomy (OA) in 181 cases.
Females/males ratio was 1.25:1, main reason for this was that in many cases of diagnostic laparoscopy we have chosen to perform appendectomy even if the
reason for admission was a gynecological condition. Comorbidities were presented more often in the OA 15% versus 7% in the LA group. BMI was higher in the LA
28.7 kg/m2 compared to OA 26.5 kg/m2. The stage of the disease was more advanced in the OA group with more localized and generalized peritonitis.
Complications were encountered more often in the OA group.
Discussion: There was still a high percentage of OA during the first years, but then this changed dramatically in favor of LA, which raised concerns about the
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training of the residents. Obese and female patients are more prone to be operated by LA. The more difficult cases were operated by OA. Conclusion: Although
LA has become the preferred method we still have to train in OA, which keeps its place in the surgeon armamentarium.

Adenoamele paratiroidiene. Evaluare critic n legtur cu 18 cazuri operate


Parathyroid adenomas. Critical Appraisal of Surgical Therapy in 18 Cases
M. R. Diaconescu (1), I. Costea (1), M. Glod (1), Smaranda Diaconescu (2)
(1) Universitatea de Medicin i Farmacie Gr. T. Popa, Clinica IV Chirurgie, Iai, Romnia
(2) Universitatea de Medicin i Farmacie Gr. T. Popa, Clinica V Pediatrie, Iai, Romnia
Introducere: Adenoamele paratiroidiene reprezint cea mai frecvent form anatomoclinic de hiperfuncie paratiroidian.
Material i metode: Dintr-o serie de 84 pacieni de hiperparatiroidism - 20 primar i 64 renal (CKD-MBD) - 18 cazuri au fost operate pentru adenoame solitare ale
glandei. Au fost analizate datele clinice de labo- orator i imagistice, procedurile utilizate i rezultatele obinute.
Rezultate: Am nregistrat 16 femei i 2 brbai cu vrste ntre 16 - 58 (medie 46) ani. Clinic au predominat manifestrile urolitiazice (n=9), (n=9), cele osoase (n=6)
i fenomenele pancreatice (n=2), un caz asimptomatic fiind descoperit incidental cu ocazia unei tiroidectomii.
Calcemia medie a fost de 11,5+-2,2 mg/dL, fosforul seric de 4,4+-0,5 mg/dL iar PTH dozat doar la 12 bolnavi a variat ntre 127-738 pg/L. Studiile localizatoare au
obiectivat formaiunea prin ultrasonografie (n=16) i prin scintigrafie cu sestamibi (n=5). S-au practicat 18 adeno-mectomii (2 minim invazive) n 7 cazuri asociate
cu exereze tiroidiene. Microscopia a confirmat diagnosticul de adenom cu celule principale i oxifile, ntr-un caz fiind vorba de un adenom atipic. n alt caz, la 4
ani dup adenomectomie, bolnavul a prezentat o recidiv malign (leziune nou sau diagnostic eronat ?). Evoluie postchirurgical excelent cu excepia recidivei
carcinomatoase care a decedat dupa 14 luni.
Concluzii: Adenoamele paratiroidiene, dei produc suferine sistemice clinic evidente, n majoritatea cazurilor nu sunt ns ntotdeauna uor de diagnosticat. Ele
beneficiaz substanial de tratamentul chirurgical considerat standardul de aur al acestor leziuni.

Background: Parathyroid adenomas represent the most common anatomoclinical variety of hyperparathyroidism.
Material and Methods: In a series of 84 cases of hyperparathyroidism i.e. 20 primary and 64 renal (CKD-MBD), 18 patients underwent surgery for solitary
adenomas of these glands. Clinical data, laboratory and imaging test results, surgical procedures and outcome were comprehensively analyzed.
Results: We registered 16 women and only two men, aged between 16-58 (mean age 46) years old. From the clinical point of view urolithiasis manifestations
prevailed in 9 cases, bone signs in 6 patients and pancreatic phenomena in only two. One case was asymptomatic being discovered accidentally during
thyroidectomy. The main serum calcium at the time of diagnosis was 11,5+-2,2 mg/dl and phosphorus was 4,4+-0,5 mg/dL. The mean parathyroid hormone (PTH)
level (measured only in 12 patients) ranged between 127-738 pg/L. Ultrasonography accurately identified lesions in 16 cases and Technetium-99m sestamibi
scintigraphy in only 5 cases. Eighteen adenomectomies were performed (two minimally invasive procedures). In 7 situations concomitant thyroid exeresis were
done. Pathology revealed single parathyroid adenoma consisting of main and oxyphyl cells in 17 cases. In one patient an atypical adenoma was identified and in
another case 4 years after removal of a benign adenoma the subject presented a clinical recurrence which proved to be a carcinoma (new lesion or erroneous
diagnosis?). Postsurgical clinical outcome was favorable in all situations excepting the case with carcinoma which died after 14 months.
Conclusion: Parathyroid adenoma produced evident systemic clinical features but not always easy to diagnose. They significantly benefit from surgical treatment
which may be considered the gold standard of these lesions.

Dificulti n identificarea i biopsia cancerelor mamare infraclinice


Difficulties in Preoperative Localisation and Surgical Biopsies of Non-Palpable Breast Cancers
C. Bordea, A. Blidaru, B. El Houcheimi, Iulia Matei, Adelina Toma
Institutul Oncologic Prof. Dr. Al. Trestioreanu, Chirurgie Oncologic II, Bucureti, Romnia
Screeningul mamografic i creterea rezoluiei mamografiei, precum i progresele ecografiei mamare i utilizarea RMN au determinat identificarea din ce n ce
mai frecvent a unor leziuni mamare suspecte de mici dimensiuni care nu au expresie clinic. Leziunile mamare infraclinice descoperite mamografic i/sau
ecografic ridic probleme privind atitudinea adecvat. Diagnosticul i tratamentul chirurgical al acestor leziuni impun localizarea preoperatorie.
Considerm excizia chirurgical ca metod optim de abordare a acestor leziuni. Excizia n totalitate a leziunii permite un examen histopatologic complet, asigur
un diagnostic corect i n acelai timp operator se poate efectua intervenia chirurgical curativ.
n cazul acestor leziuni dac nu se efectueaz localizarea preoperatorie, chirurgul este pus n situaia de a opera o imagine care nu are expresie clinic. Fr
localizare, excizia chirurgical este oarb, leziunea fiind greu de identificat chiar i intraoperator. Localizarea preoperatorie orienteaz actul chirurgical, asigur
c leziunea evideniat mamografic va fi extirpat i evit rezecii mamare largi inutile.
Cuvinte cheie: tumori mamare nepalpabile, localizare preoperatorie

Mammographic screening, enhanced mammography resolution as well as advances in breast ultrasound examination and MRI have resulted in the increasingly
more frequent identification of small suspect mammary lesions that do not have a clinical expression. Infraclinical mammary lesions discovered on
mammography/ultrasonography/MRI raise problems with respect to an appropriate approach. Diagnosis and treatment of such lesions require their pre-operative
localization.
We believe surgical excision to be a good method of approach in such lesions. Full excision of the lesion enables complete histological examination and
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immunohistochemistry, ensures right diagnosis and curative surgical intervention can be performed within the same operative time.
In the absence of pre-operative localization of such lesions, the surgeon is put in the situation of operating an image that has no clinical expression. Unless the
lesion is localized preoperatively, surgical excision is performed blindly, as the lesion is hard to identify.
Pre-operative localization provides guidance for surgery, ensures the mammographically identified lesion is removed and helps avoid large, unnecessary
mammary resections.
Key words: non-palpable mammary tumors, pre-operative tumor localization

Rspunsul complet la chimioterapia neoadjuvant n cancerul mamar. Experiena Clinicii I Chirurgie Oncologic
IRO Iai
The Complete Response to Chemotherapy in Breast Cancer. The Experience of Surgical Unit I of ROI Iai
A. Panu (1), I. Radu (1), N. Ioanid (2), R. Vieru-Mooc (2), A. Pantazescu (1), Mihaela Buna-Arvinte (1), Mihaela Mdlina Gavrilescu (1), Ana-Maria Muin (1),
adiye Ioana Scripcariu (3), V. Scripcariu (1)
(1) Institutul Regional de Oncologie, Clinica I Chirurgie Oncologic, Iai, Romnia
(2) Institutul Regional de Oncologie, Clinica I Chirurgie Oncologic, Departamentul Ginecologie Oncologic, Iai, Romnia
(3) Spitalul Clinic de Obstetrica si Ginecologie Cuza Vod, Clinica I Obstetric i Ginecologie, Iai, Romnia
The Complete Response to Chemotherapy in Breast Cancer. The Experience of Surgical Unit I of ROI Iai
Introducere: Cancerul mamar (CM) n stadii avansate: IIB, IIIA (To-3,N2), IIIB (T4,No-2) i IIIC (To-3,N3c), non-metastatic, are indicaii de chimioterapie
neoadjuvant (CHn). Am evaluat, n cazuistica clinicii, n special, cazurile cu rspuns complet la CHn.
Obiectivul studiului: Evaluarea particularitilor cazurilor de CM cu rspuns complet la CHn.
Material i Metod. n cadrul acestui studiu am folosit cazuistica Clinicii I Chirurgie Oncologic IRO Iai din perioada mai 2012 - februarie 2016.
Rezultate: Din cele 776 de cazuri de CM operate n clinica noastr, 217 (aprox. 28%) au beneficiat de CHn dintre care 12 paciente (aprox. 5,5%) au prezentat
rspuns complet ypT0N0 regresie tumoral i gaglionar complet. n toate cazurile s-a practicat mastectomie radical modificat tip Madden.
Particularitile eantionului: Vrst medie de 55 de ani (40-69 de ani). Stadiile de CM n care au fost diagnosticate: stadiul IIB 3 cazuri (25%), IIIA 5 cazuri
(41,6%), IIIB 3 cazuri (25%), IIIC 1 caz (8,3%). Tipul histologic carcinom invaziv NST n toate cazurile. Subtipuri histologice: tipul triplu negativ 7 cazuri
(58,3%), tipul HER2+ 3 cazuri (25%); tipul luminalB 2 cazuri (16,6%). n majoritatea cazurilor s-au folosit 4-8 cicluri de CHn bazat pe combinaia dintre
Ciclofosfamid i Adriamicin+Docetaxel+/-Trastuzumab n cazurile HER2+.
Concluzii: Lotul este mai tnr fa de media pe CM n general. Majoritatea cazurilor studiate au subtipul - triplu negativ (paradoxal cunoscut cu un pronostic
foarte nefavorabil). Rolul benefic al anticorpului monoclonal (Herceptin n 5 cazuri). Scopul CHn n CM este vindecarea prin transformarea unui cancer inoperabil
n unul abordabil chirurgical cu viz curativ.

Breast cancer (BC) in the advanced stages: IIB, IIIA, IIIB and IIIC, non-metastatic, has indications of neoadjuvant chemotherapy (NCH). We evaluated in particular
cases with complete response to NCH.
The objective of the study: Evaluation peculiarities of BC cases with complete response to NCH.
Material and method: In this study we used casuistic of Surgical Oncology ROI Iasi in the period May 2012 - February 2016.
Results: Out of the 776 cases of CM operated in our clinic, 217 (approx. 28%) received CHN - 12 patients (approx. 5.5%) had complete response - ypT0N0. In all
cases we practiced Madden modified radical mastectomy.
Sample peculiarities: Mean age 55 (40-69). Stages of CM with the following diagnoses: stage IIB - 3 cases (25%), IIIA - 5 cases (41.6%), IIIB - 3 cases (25%), IIIC - 1
case (8.3%). Histology - NST invasive carcinoma in all cases. Histologic subtypes: triple negative type - 7 cases (58.3%), type HER2 + - 3 cases (25%); luminalB
type - 2 cases (16.6%). In most cases they used NCH 4-8 cycles based on the combination of Adriamycin and Cyclophosphamide + Docetaxel +/- trastuzumab in
HER2 + cases.
Conclusions: The lot is younger than the average in BC in general. Most cases studied subtype - triple negative - (Paradoxically, known with a very unfavorable
prognosis). The beneficial role of monoclonal antibody (Herceptin in 5 cases). The purpose of NCH is converting an inoperable BC into one which could be healed
by surgery.

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Cancerul de sn
Breast Cancer
E. F. Georgescu, M. Ioana, M. Cucu, A. Goganau, M. Bica, . Ptracu
Spitalul Clinic Judeean de Urgen, Secia de Chirurgie General, Craiova, Romnia
Cancerul de sn este cea mai frecvent afeciune neoplazic la femeie, reprezentnd 23% din neoplasmele aprute la femei, la nivel global i 27% n rile n curs
de dezvoltare.
Cea mai frecvent form de cancer mamar este reprezentat de carcinomul ductal ce apare la nivelul celulelor ductelor, dar poate aprea i la nivelul lobilor
glandei mamare.
Aceast afeciune beneficiaz de cinci variante standard de tratament. Tratamentul chirurgical este cea mai folosit metod terapeutic, avnd, de asemenea,
mai multe variante: operaie de conservarea a snului (Breast-conserving surgery), mastectomie total, mastectomie radical modificat. Alte variante de
tratament sunt reprezentate de: radioterapie, chimioterapie, terapii hormonale i terapii intite, aceata din urm fiind o terapie ce folosete anticolrpi monoclonali
sau inhibitori de tirozin-kinaze sau ciclin-kinaze pentru a inti direct celulele tumorale fr a influena celulele normale.
Folosirea biomarkerilor este necesar pentru a ne asigura c pacienii cu cancer mamar beneficiaz de cel mai bun tratament. Exist biomarkeri consacrai, cum
ar fi receptorii estrogenici, receptorii pentru progesteron, pentru HER2 i Ki67, care joac un rol important pentru mprirea neoplasmelor mamare n
subcategorii i selectarea terapiei optime. Pentru pacienii ale cror celule tumorale exprim receptori hormonali se folosec terapii antihormonale cu
4-hydroxytamoxifen sau inhibitori aromatici, n timp ce anticorpii monoclonali HER2 au fost folosii pentru pacienii cu neoplasm mamar positivi la HER2.
Cu toate acestea, rata de mortalitate a pacienilor este nc mare, din cauza recidivelor. De aceea sunt invetigai noi markeri moleculari ce pot determina rata de
eec terapeutic, dar i markeri ce pot constitui noi inte terapeutice.

Breast cancer is the most common neoplastic disease in women representing 23% of malignancies occurrence in women, globally and 27% in developing
countries.
The most common form of breast cancer is ductal carcinoma which occurs in the duct cells, but can also appear on the lobes of the breast.
This disease has five different standardized types of treatment. Surgery is the most common therapeutic method also having several variants: breast conservation
surgery, total mastectomy, modified radical mastectomy. Other treatment options are: radiation, chemotherapy, hormone therapy and targeted therapies, the
latter being a therapy that uses monoclonal antibodies or inhibitors of tyrosine kinases or cyclin-kinases to directly target tumor cells without affecting normal
cells.
Using biomarkers is needed to ensure that breast cancer patients receive the best treatment. There are well known biomarkers such as estrogen receptors,
progesterone receptors, for HER2 and Ki67 that play an important role in breast neoplasms dividing and sub-optimal therapy selection. For patients whose tumor
cells express hormonal receptors are used anti-hormonal therapies with 4-hydroxytamoxifen or aromatic inhibitors, while HER2 monoclonal antibodies were used
for breast cancer patients with HER2 positive.
However the mortality rate of patients is still high due to relapses. This is why new molecular markers that may determine the therapeutic failure rate are
investigated, and also markers that can constitute new therapeutic targets.

Pledoarie pentru ecografia mamar fcut de chirurg


A Plea for Breast Echography Performed by the Surgeon
. Voiculescu (1), R. V. Scunau (1), E. Popa (1), S. Stnilescu (1), Elena Gabriela Voiculescu (2), Ileana Popa (3), T. Burco (1)
(1) Spitalul Clinic Colea, Secia de Chirurgie General, Bucureti, Romnia
(2) Clinica Elite, Secia de Obstetric-Ginecologie, Bucureti, Romnia
(3) Spitalul Clinic Colea, Secia de Anatomie Patologic, Bucureti, Romnia
Ecografia este o tehnic imagistic neiradiant i neinvaziv, foarte disponibil, relativ ieftin, care permite ghidajul n timp real al tehnicilor intervenionale i
care se preteaz att practicii de cabinet, ct i folosirii n sala de operaie. n acelai timp, ecografia este considerat de Colegiul American al Radiologilor ca al
doilea mijloc de diagnostic al patologiei mamare i fiind propus a seconda DE PRINCIPIU screeningul mamografic al cancerului de sn n SUA.
Dorim s prezentm succint modul n care ecografia relev anatomia mamar, direciile n care ea se poate face util chirurgului senolog i unele aspecte,
sperm, convingtoare ale utilizrii sale n cabinetul de consultaie sau sala de operaie. Att nelegerea patologiei mamare, ct i interpretarea semiologiei
ecografice ar avea de ctigat de pe urma acestei asocieri ntre chirurgul senolog i ecografie, iar avantajul disponibilitii tehnicii fr a necesita prezena n
orice moment a ecografistului-radiolog este evident.
Trecem n revist avantajele sale n localizarea topografic a leziunii, detalierea aspectelor privind raportul su cu structurile adiacente, vascularizaie, situaia
ganglionilor axilari, ghidajul biopsiei instrumentale, marcarea preoperatorie lezional, evaluarea diseciei, piesei operatorii nainte de a fi trimis pentru
examinare radiologic i histopatologic, evidenierea eventualelor colecii postoperatorii i a eventualelor recidive. Vom prezenta detalii tehnice de realizare i
aspecte imagistice elocvente asupra avantajelor ecografiei mamare fcute de chirurg.
Deocamdat ne propunem s sensibilizm corpul chirurgilor senologi privind orizontul pe care utilizarea ecografiei efectuate de ei nii l poate deschide.

Ultrasound is a non-invasive and non-irradiant imaging technique which is readily available, relatively cheap, which allows real time guidance of interventions and
that can be used in the consultation room, as well as the operating room. At the same time, ultrasound is considered by the American College of Radiologists as a
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valuable tool in diagnosing breast pathology and recommended as the second screening option of breast cancer in the USA.
We would like to present concise manner the way in which ultrasound imaging highlight the breast anatomy, the ways in which it could become useful for the
surgeon and some aspects that we hope are convincing enough to reveal its value in the consultation or operating room. Understanding the breast pathology, as
well as interpreting the imaging semiology would be enriched by using this connection between the breast surgeon and ultrasound. Furthermore, the advantage
of it being available without the presence of ultrasound technician/radiologist is obvious.
We would like to pinpoint its advantages in localizing the lesion, detailing aspects regarding its relation with adjacent structures, vascularization, axillary ganglia
status, instrumental guided biopsy, preoperative lesion marking, dissection evaluation of the intra-operative fragment before it will be sent for radiological and
histopathological examination, highlighting possible postoperative collections and relapses. We will also present technical features and eloquent imaging aspects
regarding the advantages of surgeon-performed breast ultrasound.
For now we only have in mind to reach out to our fellow breast surgeons and make them aware of the endless horizon that imaging performed by themselves can
offer.

Indicaiile actuale ale diferitelor tipuri de mastectomii n cancerul glandei mamare


Current Indications of Different Types of Mastectomies in Breast Cancer Treatment
A. Blidaru, C. Bordea, Elena Ichim, Mihaela Radu, Aniela Noditi, M. Pleca
Institutul Oncologic Prof. Dr. Al. Trestioreanu, Chirurgie Oncologic II, Bucureti, Romnia
Cancerul mamar a reprezentat dintotdeauna o problem important a oncologiei. n ultimul timp ns, datorit creterii accentuate a incidenei i prevalenei sale,
a devenit o mare problem de sntate public.
Lucrarea de fa i propune s analizeze indicaiile actuale ale diferitelor tipuri de mastectomii n tratamentul cancerului mamar.
Noile concepii privind biologia cancerului mamar au schimbat ns modalitile de abordare chirurgical. S-a demonstrat c amploarea terapiei loco-regionale nu
amelioreaza semnificativ supravieuirea. Astfel, mastectomia radical modificat a nlocuit treptat mastectomia radical. Mastectomia cu evidare
axilo-transpectoral i operaia Patey au fost cele mai des practicate intervenii n Institutul Oncologic Bucureti pna la sfritul anilor 80.
Urmtoarea etap a constituit-o nlocuirea operaiei Patey de ctre operaia Madden. Aceasta din urm a nregistrat o cretere continu, ajungnd la un procent
de 75 % din totalul interveniilor pentru cancer mamar n Romnia.
Din anul 1999, n Institutul Oncologic Bucureti practicm i diferite tehnici de reconstrucie mamar postmastectomie. Mastectomiile radicale modificate sunt
nlocuite n aceste cazuri de mastectomii ce pstreaz n aceeai siguran oncologic mai mult tegument (skin-sparring mastectomies), sau complexul
areolo-mamelonar (nipple-areola sparring mastectomies).

The 20th century witnessed a continuous series of changes in breast surgery.


In the last century, the Halsted radical mastectomy used to be the standard surgical procedure in breast cancer (over 90%).
Gradually, the Halsted procedure was replaced, towards the end of the seventies, by modified radical mastectomy techniques. Following that time interval, the
Madden type modified radical mastectomy began to be the most frequently used technique, so that it is still accounted for more than three quarters of all surgical
operations for breast cancer in Romania.
Since 1999, we perform post-mastectomy breast reconstruction. In these cases, the modified radical mastectomies were replaced with the same oncological
safety results by skin-sparring and nipple sparring mastectomies.
All these confirm that our diagnosis and therapeutic standards have been aligned with the European ones and stand proof to the major changes going on in
breast surgery.

38

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Eficiena REGEN-Sil n prevenia cicatricilor dup incizii n regiunea cervical anterolateral pentru abordul
tiroidei i a paratiroidelor
REGEN-Sil Efficiency in Scar Prevention after Anterior Lateral Cervical Incisions Used in Thyroid and Parathyroid
Approach
A. Grigorovici (1), Alina Clin (1), Mirela Cherciu (2), A. Popovici (1)
(1) Spitalul Clinic Judeean de Urgene Sf. Spiridon, Clinica IV Chirurgie, Iai, Romnia
(2) Spitalul Arcadia, Centrul de Dermatologie i Estetic Medical, Iai, Romnia
Introducere: Cicatricile hipertrofice sau cheloide rezultate din intervenii chirurgicale, arsuri i traumatisme pot fi asociate cu o afectare substanial fizic i
psihologic. Ghidurile n vigoare recomand pentru prevenia i tratamentul cicatricilor terapia cu produse pe baz de siliconi, considerat standardul de aur.
REGEN-Sil este o combinaie unic pentru c asociaz polidimetilsiloxanul cu polidimetilsiloxan crospolimerul i trimetilsiloxisilicatul, ceea ce l difereniaz de
restul produselor pe baz de siliconi de pe pia.
Material i metod: Studiul clinic prospectiv, comparativ, randomizat, deschis, are drept principal obiectiv: evaluarea eficienei dispozitivului medical REGEN-Sil
n prevenia cicatricilor dup incizii chirurgicale comparativ cu un produs topic semisolid pe baz de siliconi. 100 pacieni crora li s-au practicat incizii chirurgicale
n regiunea cervical anterolateral au fost inclui n studiu. Pacienii au fost tratai cu REGEN-Sil (50 pacieni) i cu produsul de comparaie (50 pacieni).
Evaluarea eficienei celor dou produse se realizeaz utiliznd scala Vancover, iniial, la o lun i dup trei luni de tratament. Uurina i durata de administrare,
rezultatele cosmetice ale tratamentului i evaluarea general a satisfaciei sunt apreciate utiliznd un chestionar de ctre medic i pacient la aceiai timpi.
Concluzii: Rezultatele pariale au pus n eviden beneficiul semnificativ al produsului REGEN-Sil versus rezultatele terapeutice obinute cu produsul de
comparaie. Satisfacia pacienilor i a medicului au artat, de asemenea superioritatea REGEN-Sil. Aceste constatri preliminare demonstreaz c REGEN-Sil
este eficient i sigur pentru prevenia cicatricilor hipertrofice i cheloide.
Cuvinte cheie: cicatrice postoperatorie, hipetrofic, cheloid, Regen-sil

Introduction: Hypertrophic and keloid scars resulting from surgical incisions, burn and traumatic wounds can be associated with a substantial physic and
psychological overcome. Todays guides recommend for the prevention and the treatment of scars silicone based products judged as the gold standard.
REGEN-Sil is a unique combination, it is associating polymethylsiloxane with polydimethylsiloxane crosspolymer and trimethylsoloxysilicate which distinguish it
from the rest of market products based on silicone.
Materials and Method: Clinical prospective study, by comparison, random and open trial with the main objective the evaluation of the REGEN-Sil medical
efficiency in scar prevention after surgical incisions set side by side with a semi-solid product based on silicone. 100 patients with cervical anterolateral incisions
have been included in the study. The patients have been treated with REGEN-Sil (50 patients) and a comparison product (50 patients). The evaluation of the
efficiency of the two products is assessed based on the Vancouver scale first after one month and later after three months. The easiness and the period of
administration, the cosmetic results and final general evaluation of the satisfaction are determined using a questionnaire both for the physician and the patient at
the same stage.
Conclusion: The partial results highlight the heavy benefit of REGEN-Sil product versus therapeutic results obtained with the comparison product. Patient and
physician satisfaction have also shown the superiority of REGEN-Sil. These preliminary findings prove that REGEN-Sil is efficient and safe in hypertrophic and
keloid scars.
Keywords: post-operative scar, hypertrophic, keloid, REGEN-Sil

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Tratamentul chirurgical n cancerul mamar


Surgical Treatment of Breast Cancer
C. D. Vidrighin (1), T. . Tenea Cojan (2), I. Pun (2), M. Florescu (2), G. Mogo (2), D. G. Mogo (2), I. Georgescu (3)
(1) Spitalul Municipal, Secia Chirurgie, Caracal, Romnia
(2) Spitalul Clinic Ci Ferate, Clinica Chirurgie, Craiova, Romnia
(3) Spitalul Clinic Judeean de Urgen, Clinica I Chirurgie, Craiova, Romnia
Introducere: Cancerul mamar este neoplazia cu frecvena cea mai mare la sexul feminin reprezentnd cca 25% din toate cancerele diagnosticate anual, fiind a
doua cauz de deces dup cancerul pulmonar, la femei.
Scopul prezentrii este urmrirea rezultatelor pe termen lung a pacientelor cu cancer mamar din dou clinici chirurgicale.
Material i metod: Analiza retrospectiv a 1529 cazuri (1511 femei - 98,82% i 18 brbai - 1,18%) cu cancer mamar operate n perioada 1995-2012, la Clinica
Chirurgie Spitalul Clinic CF Craiova i Clinica Chirurgie I Spitalul Clinic Judeean de Urgen Craiova.
Rezultate: S-au nregistrat 502 cazuri (32,84%) de intervenii chirurgicale conservatoare, 856 cazuri (55,98%) de mastectomii radicale i 171 cazuri (11,18%) de
mastectomii de toalet.
Am ntlnit urmtoarele complicaii: recidiv local 45 cazuri (2,94%), 26 cazuri dup chirurgia conservatoare (5,18%), 19 dup mamectomia total (2,22%),
recidiv regional (ganglionara) 11 cazuri (0,72%), recidiv sistemic 87 cazuri (5,69%): pulmonar 29 cazuri (33,33%), hepatic 20 cazuri (22,99%), cerebral 8
cazuri (9,2%), osoas 12 cazuri (13,79%), multipl 18 cazuri (20,69%), falsele recidive 17 cazuri (1,11%), edem postoperator al snului 33 cazuri (6,57%), dezunirea
suturilor 23 cazuri (1,5%), 11 cazuri cu necroz tegumentar (47,83%), 12 cazuri datorit suturii n tensiune (52,17%), defect tegumentar ppld 15 cazuri (0,98%),
cicatrici retractile 24 cazuri (1,57%), hematoame 24 cazuri (1,57%), seroame 42 cazuri (2,75%), cellulite 24 cazuri (1,57%), colecii purulente 9 cazuri (0,59%),
limfocele 14 cazuri (0,92%), bra gros 17 cazuri (1,11%).
Concluzii: Analiza rezultatelor precoce i la distan indic rezultate similare ale celor dou tipuri de intervenii chirurgicale, conservatoare i radical, cu un
procent mai ridicat al recidivelor locale dup chirurgia conservatoare.

Introduction: Breast cancer is the most common malignancy of the female representing about 25% of all cancers diagnosed annually and is the second cause of
death after pulmonary cancer, in women.
The purpose of the presentation is pursuing long-term outcomes of patients with breast cancer two surgical clinics.
Methods: Retrospective analysis of 1529 cases (1511 women - 98.82% and 18 men - 1.18%) with breast cancer between 1995 and 2012 operated in the CF Craiova
Hospital Surgical Clinic and First Surgical Clinic Emergency County Hospital Craiova.
Results: There were 502 cases (32.84%) of conservative surgery, 856 cases (55.98%) of radical mastectomy and 171 cases (11.18%) of mastectomies toilet.
I met these complications: local recurrence 45 cases (2.94%), 26 cases after conservative surgery (5.18%), 19 cases after radical mastectomy (2.22%), regional
recurrence (lymph) 11 cases (0.72%), systemic recurrence 87 cases (5.69%): pulmonary 29 cases (33.33%), hepatic 20 cases (22.99%), brain 8 cases (9.2%), bone
12 cases (13.79%), multiple metastases 18 cases (20.69%), false relapses 17 cases (1.11%), postoperative edema of the breast 33 cases (6.57%), disunity suture
23 cases (1.5%): 11 cases of skin necrosis (47.83%) and 12 cases due to the suture tension (52.17%), skin defect PPLD 15 cases (0.98%), scar retractile 24 cases
(1.57%), hematoma 24 cases (1.57%), seroma 42 cases (2.75%), cellulite 24 cases (1.57%), purulent collections 9 cases (0.59%), lymphocele 14 cases (0.92%), arms
thick 17 cases (1.11%).
Conclusions: The analysis of early and long term results indicate similar results of the two types of surgery, conservative and radical mastectomy, with a higher
percentage of local recurrence after conservative surgery.

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Riscuri neuro-vasculare n chirurgia paratiroidian


Neuro-Vascular Risks in Parathyroid Surgery
M. N. Brtucu (1), P. A. Radu (1), N. D. Garofil (1), V. Paic (1), M. Zurzu (1), Corina Popa (1), F. Popa (2), V. D. E. Strmbu (1)
(1) Spitalul Clinic de Nefrologie Dr. Carol Davila, Chirurgie, Bucureti, Romnia
(2) Spitalul Clinic de Urgen Sfntul Pantelimon, Chirurgie, Bucureti, Romnia
n hiperparatiroidismul secundar nefropatiei cronice tratamentul chirurgical este singurul curativ. Actualmente sunt utilizate 3 tehnici diferite: paratiroidectomie
total, paratiroidectomie subtotal i paratiroidectomie total cu autotransplant imediat. Indiferent de tehnica aleas, datorit multiplelor variante de poziie ale
nervilor recureni, ramurilor vasculare tiroidiene i pediculilor paratiroidieni, chirurgul trebuie s ia n calcul pe oricare dintre ele pentru a evita lezarea acestora n
cursul paratiroidectomiei. Lezarea unilateral a nervului laringeu recurent determin disfonie pe cnd leziunile bilaterale conduc la dispnee inspiratorie acut i
necesia traheostomie de urgen. Am analizat 250 de pacieni cu HPS i insuficien renal cronic, internai n clinic n perioada octombrie 2011-iunie 2015,
toi fiind supuli interveniei chirurgicale. S-au realizat 229 (91,6%) paratiroidectomii totale, 14 (5,6%) paratiroidectomii subtotale iar 7 (2,8%) intervenii chirurgicale
au fost considerate incomplete (mai puin de 4 glande paratiroide evideniate intraoperator).
Complicatii: Infarct miocardic 2 cazuri (0,8%), accident vascular cerebral 1 caz (0,4%), complicaii locale hemoragice 4 bolnavi (1,6%), disfonie 3 cazuri (1,2%). La
cei 4 pacieni (1,6%) care au dezvoltat complicatii hemoragice locale s-a reintervenit chirurgical, evoluia lor post-operatorie fiind favorabil. Mortalitatea general
a fost de 0.8% (2 pacieni - IMA i AVC) iar morbiditatea specific postoperatorie 2.8% reprezentat de 4 complicaii locale hemoragice i 3 cazuri cu disfonie
tranzitorie. Paratiroidectomia este grevat de un numr redus de complicaii postoperatorii. Complicaiile hemoragice (excluznd leziunile carotidiene sau
jugulare), chiar dac nu sunt semnificative cantitativ, impun ns o sanciune chirurgical n urgen datorit riscului de asfixie prin hematom compresiv la nivelul
lojei cervicale. Leziunile recureniale bilaterale impun traheostomie de urgen.

For secondary hyperparathyroidism of chronic nephropathy, surgery represents the only curative treatment. Currently there are used three different techniques:
total parathyroidectomy, subtotal parathyroidectomy and total parathyroidectomy with immediate autotransplant. Regardless of the technique, because of
multiple variants of position of recurrent nerve, thyroid vascular branches and parathyroid pedicles, the surgeon must keep in mind this multiple variants, to avoid
their damage during parathyroidectomy. Recurrent laryngeal nerve unilateral damage will determine hoarseness, meanwhile bilateral damage leads to acute
inspiratory dyspnea and it requires emergency tracheostomy. We analyzed 250 patients with secondary hyperparathyroidism and chronic renal disease,
hospitalized in our clinic from October 2011 to June 2015, all patients received surgical treatment.There have been 229 (91.6%) total parathyroidectomy, 14 (5.6%)
subtotal parathyroidectomy and 7 (2.8%) cases were incomplete (intraoperative, were found less than 4 glands).
Complications: 2 cases of acute myocardial infarction (0.8%), 1 case of stroke (0.4%), 4 cases of local bleeding complications (1.6%), 3 cases of dysphonia (1.2%).
For the 4 patients (1.6%) who developed bleeding complications, we opted for surgical treatment and postoperative status was favorable. Overall mortality was
0.8% (2 patients with AMI and stroke) and postoperative specific morbidity was 2.8%, represented by 4 local bleeding complications and 3 cases of transient
hoarseness. The parathyroidectomy is encumbered by a reduced number of postoperative complications. Bleeding complications (excluding carotid/jugular
injuries), even if not quantitatively significant, impose a surgical emergency sanction because of the risk of asphyxia made by a hematoma compression in the
cervical lodge. Bilateral recurrent nerve damage requires emergency tracheostomy.

Particulariti ale cancerului de sn la brbat


Particularities of Breast Cancer in Men
E. Trcoveanu (1), A. M. Vasilescu (1), C. Lupacu (1), N. Vlad (1), Ionela Negoi (2)
(1) Universitatea de Medicin i Farmacie Gr. T. Popa/ Spitalul Clinic Judeean de Urgene Sf. Spiridon, Clinica I Chirurgie, Iai, Romnia
(2) Spitalul Clinic Judeean de Urgene Sf. Spiridon, Clinica I Chirurgie, Iai, Romnia
Cancerul mamar la brbai este rar (1% din toate cancerele de sn) i prezint o serie de particulariti.
Material i metod: Am efectuat un studiu retrospectiv analiznd pacienii internai i tratai n Clinica I Chirurgie Spitalul Clinic de Urgen Sf. Spiridon Iai n
perioada 1 ianuarie 2008 - 31 decembrie 2015, cu tumori maligne ale snului. Au fost inclui n studiu bolnavii diagnosticai anatomopatologic cu cancer de sn.
S-au urmrit datele clinice, paraclinice i de urmrire postoperatorie ale bolnavilor. Dei numrul relativ mic de cazuri nu a permis o interpretare statistic am
urmrit s scoatem n eviden particularitile acestui cancer rar la brbai.
Rezultat: n perioada 2008 - 2015 n clinica noastr au fost tratate 319 cancere mamare, din care doar 11 la brbai, deci 3,4%, cifr superioar datelor din
literatur. Vrsta medie a brbailor cu cancer de sn a fost de 67 ani cu zece ani mai mare ca a femeilor cu aceast boal. Ca factori favorizani n lotul studiat,
notm: fumatul, consumul de alcool la 10 bolnavi, obezitatea prezent la 9 din 11 bolnavi, grupa de snge AII, Rh+ la 8 bolnavi, adenomul periuretral la 7 bolnavi,
diabet zaharat la 6 bolnavi. Antecedentele familiale neoplazice au fost nregistrate la 3 bolnavi, din care unul cu sindrom Lynch tip II, purttor al mutaiei BRCA2.
La 3 bolnavi cancerul de sn a fost a 2-a sau a 3-a neoplazie dup cancer de piele, dup cancer de uroteliu i sarcom pri moi i un caz de neoplasm de colon
stng aprut la 4 ani dup un cancer de sn operat, chimio i radiotratat (sindrom Lynch).
Concluzii: Brbaii fac o form particular de cancer mamar. Spre deosebire de femei, la brbai aceast neoplazie se descoper la o vrst mai naintat, cu o
rat mai mare de interesare limfonodular i de pozitivitate a receptorilor hormonali. Tratamentul trebuie personalizat i efectuat n echip multidisciplinar.

Breast cancer in men is rare (1% of all breast cancers) and shows some particularities.
Methods: We performed a retrospective study analyzing patients admitted and treated in First Surgical Clinic, Emergency Hospital St. Spiridon Iasi from 1
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January 2008 to 31 December 2015 with malignant breast tumors. Patients included in the study were diagnosed with breast cancer after pathological
examination. We followed the clinical data, laboratory and postoperative follow-up of patients. Although relatively small number of cases did not permit a
statistical interpretation, I sought to highlight the particularities of this rare cancer in men.
Results: Between 2008 and 2015 in our clinic were treated 319 breast cancers, of which only 11 men, so 3.4%, higher rate to literature data. The mean age of men
with breast cancer was 67 years, ten years older than women with same disease. The favoring factors in the study group were: smoking, alcohol consumption in
10 patients, obesity present in 9 patients, blood type IIA, Rh+ in 8 patients, periurethral adenoma in 7 patients, diabetes in 6 patients. Neoplastic family history
was recorded in 3 patients, one of Lynch syndrome type II, with BRCA2 mutation. In three cases the breast cancer was the 2nd or 3rd neoplasia after skin cancer
after cancer urothelium and sarcoma soft tissue and in one case with colon cancer left, 4 years after breast cancer surgery, with chemotherapy and radiotherapy
(Lynch syndrome).
Conclusions: Men have a particular form of breast cancer. Unlike women, this neoplasia is found in men at an older age, with a higher rate of lymphatic invasion
and hormone receptor positivity. Treatment should be personalized and conducted by a multidisciplinary team.

Modaliti de abord chirurgical n patologia tiroidian aria mediastinal


Surgical Approach in Thyroid Pathology within Mediastinal Area
A. Grigorovici (1), C. Velicescu (1), Alina Clin (1), A. Popovici (1), Cristina Cristea (2), Voichia Mogo (2), Delia Ciobanu (3), Cristina Preda (2)
(1) Spitalul Clinic Judeean de Urgene Sf. Spiridon, Clinica IV Chirurgie, Iai, Romnia
(2) Spitalul Clinic Judeean de Urgene Sf. Spiridon, Clinica de Endocrinologie, Iai, Romnia
(3) Spitalul Clinic Judeean de Urgene Sf. Spiridon, Serviciul de Anatomie Patologic, Iai, Romnia
Introducere: Afeciunile tiroidiene cu dezvoltare mediastinal sunt relativ rare (5%). Modalitatea de abord este de regul cervical i foarte rar combinat cu alte
proceduri.
Material i metod: n Clinica IV Chirurgie n perioada 2009 - 2015 au fost operai 3218 pacieni cu afeciuni tiroidiene. Dintre acetia, 160 de pacieni au avut i
extensii mediastinale (0,24%). Pentru aceti pacieni s-au practicat 6 rezecii claviculare medii i 2 sternotomii, restul au fost abordate strict pe cale cervical.
Concluzie: Cervicotomia este procedeul de elecie n afeciuni tiroidiene cu extensie mediastinal inclusiv evidrile ganglionare ale sectorului VII.
Cuvintele cheie: gu cervico-mediastinal, cervicotomie, sternotomie, rezecie clavicular

Introduction: The thyroid pathology with mediastinal evolution is relatively rare (5%). The surgical approach is usually cervical and rarely combined with others
procedures.
Materials and Method: In the 4th Surgery Department between 2009 and 2015, 3218 patients have been operated from thyroid affections. Among them, 160 had
mediastinal extension (0,24%). For these patients 6 middle clavicle resections and 2 sternotomy have been performed, the rest have been approached only
cervicaly.
Conclusion: The cervicotomy is the primary procedure used in mediastinal thyroid goitre including lymph node removal excisions of the level VII.
Keywords: cervical thoracic goitre, cervicotomy, sternotomy, clavicle resection

Tratamentul chirurgical al gigantomastiei - prezentare de caz


Surgical Treatment of Gigantomastia - Case Report
Terezia Boruah
Spitalul Orenesc, Compartimentul Chirurgie, Cugir, Romnia
Gigantomastia definete hipertrofia mamar excesiv care necesit ndeprtarea chirurgical a mai mult de 1500 g de esut mamar/sn. Gigantomastia este
asociat frecvent cu dureri ale coloanei cervico-dorsale i cu intertrigo submamar. Pacientele cu gigantomastie prezint afectri severe ale imaginii corporale
proprii, precum i probleme de intergrare social. Utilizarea metodelor conservative de manageriere a gigantomastiei (purtarea de sutiene adaptate, exerciiul
fizic, scderea ponderal), nu a dat rezultate. Tratamentul chirurgical al gigantomastiei reprezint o provocare pentru chirurg. Multiple tehnici chirurgicale de
reducie mamar sunt utilizate astzi, toate centrate pe rezultatele funcionale i estetice. Prezentm cazul unei paciente de 49 ani, internat pe secia Chirurgie
a Spitalului Orenesc Cugir cu tabloul clinic al unei gigantomastii bilaterale, fiecare sn fiind apreciat volumetric la peste 13000 cm cubi (relaii ecografice i
mamografice normale). Pacienta acuza dureri la nivelul coloanei cervico-dorsale, examenul radiologic al coloanei obiectivnd prezena cifozei. La aceast
pacient s-a efectuat, n anestezie general, reducie mamar bilateral, utiliznd tehnica pstrrii pediculului mamar inferior (tehnica T-ului inversat). S-a
efectuat drenajul subcutan bilateral, exteriorizat la nivelul anului submamar. Reducia mamar a constat n ndepartarea a aproximativ 4500 g esut mamar/sn.
Evoluia postoperatorie a pacientei a fost favorabil exceptnd persistena unei hipoestezii mamelonare. La o lun postoperator rezultatul estetic i funcional a
fost bun (ameliorarea net a simptomatologiei algice, schimbarea percepiei propriei imagini corporale). Dei reducia mamar pentru gigantomastie este
efectuat preponderent de chirurgii plasticieni, efectuarea ei de ctre chirurgii generaliti nu crete statistic riscul apariiei complicaiilor, n condiiile unui
training specific n chirurgia mamar i a unui planning preoperator adecvat.
Cuvinte cheie: gigantomastie, reducie mamar, rezultate estetice i funcionale

Gigantomastia represents excessive breast hypertrophy, requiring reduction of more than 1500 g of breast tissue per breast. Gigantomastia is frequently
associated with pain at the level of cervico-thoracic spine, as well as inframammary intertrigo. Patients having gigantomastia present problems with body image
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perception and social adjustment problems. Conservative measures for treatment of gigantomastia (wearing properly fitted brassiere, physical exercise and
weigh loss) failed to improve the symptoms and patients satisfaction indices. Surgical treatment of gigantomatia represents a challenge for the surgeon. Many
surgical techniques of breast reduction are used today, all of them being focused on the functional and aesthetic outcome. Here we present the case of a 49-year
old lady, admitted in the Surgery Department of Municipality Hospital of Cugir, having the clinical setting of bilateral gigantomastia, each breast having a volume
appreciated to be more than 13000 l (with normal ultrasound and mammographic details).The patient was accusing pain at the level of cervico-thoracis spine,
with the X-ray exam of the spine revealing the presence of kyphosis. This patient underwent, under general anesthesia, bilateral breast reduction, using the
inferior pedicle preservation technique (inverted T-technique). Subcutaneous drainage tubes were placed at the level of inframammary fold. Breast reduction
consisted of reduction of more than 4500 g of breast tissue/breast. Postoperative course of the patient was uneventful, except for the persistence of a
perimamelonar hypoesthesia. One month after the surgery, the functional and aesthetic result was considered to be good (relief of pain, change in the body
image perception). Although breast reduction for gigantomastia is mainly performed by plastic surgeons, this procedure being performed by general surgeons
does not statistically increase the risk of postoperative complications, if the general surgeons are specifically trained in breast surgery and they adequately plan
the breast reduction.
Key words: gigantomastia, breast reduction, aesthetic and functional results

Gua retrosternal - experiena Clinicii 2 Chirurgie, Timioara


Retrosternal Goiter - Experience of Surgical Clinic 2, Timioara
F. Vrcu (1), C. Tara (1), D. A. Brebu (1), Adina Raluca Coman (2), M. Ppuric (3), Marioara Cornianu (4), C. Barbu (2), F. Lazr (1)
(1) Universitatea de Medicin i Farmacie Victor Babe, Clinica 2 Chirurgie, Timioara, Romnia
(2) Spitalul Clinic Judeean de Urgen Pius Brnzeu, Clinica 2 Chirurgie, Timioara, Romnia
(3) Spitalul Clinic Judeean de Urgen Pius Brnzeu, Clinica de Anestezie i Terapie Intensiv, Timioara, Romnia
(4) Universitatea de Medicin i Farmacie Victor Babe, Departamentul Anatomie Patologic, Timioara, Romnia
Introducere: Tiroidectomia este tratamentul de elecie pentru gua retrosternal (GRS), plonjat total intratoracic sau parial. Prezentm un studiu retrospectiv pe
36 cazuri de GRS.
Metode: Acesta este un studiu retrospectiv fcut ntre anii 2010-2014 la pacienii cu GRS operai n Clinica 2 Chirurgie a Spitalului Clinic Judeean de Urgen
Pius Brinzeu Timioara. Toi pacienii au fost supui tiroidectomiei totale sau subtotale, iar n 9 cazuri echipa operatorie a cuprins chirurgi generaliti i chirurg
toracic.
Rezultate: Studiul a inclus 36 pacieni, dintre care 22 femei i 14 brbai. Dintre acetia 21 au fost mai n vrst de 60 ani. Doar 3 gui au fost maligne: 2
carcinoame medulare i unul limfom non-Hodgkin. La dou cazuri a fost nevoie de tratament preoperator pentru ca pacienii s fie adui n starea de eutiroidie. n
acest studiu, 90% din gui au fost excizate folosind doar cervicotomia; ntr-un singur caz a fost necesar sternotomia, ntr-unul toracotomia, iar la un caz a fost
necesar o sterno-toracotomie. n toate cele 3 cazuri care au necesitat mai mult dect o cervicotomie, au fost gsite gui plonjante de gradul III. Au fost
complicaii la 5 cazuri: hemoragie la 2 cazuri (unul dintre ele necesitnd reintervenia) i 3 cazuri cu paralizie recurenial.
Concluzii: GRS poate fi manageriat prin cervicotomie n marea majoritate a cazurilor, doar GRS mari, de gradul III cu vascularizaie tiroidian de origine toracic,
necesit sternotomie sau toracotomie. Complicaiile aprute mai frecvent in de dimensiunea guii, perioad mare de evoluie i de modificarea local a
raporturilor anatomice.

Introduction: Thyroidectomy is the treatment of choice for retrosternal goiter (RSG), whether expansion of intrathoracic goiter is total or partial. We present a
retrospective study of 36 cases of RSG.
Methods: This is a retrospective study between 2010 and 2014, on the patients with RSG operated in Surgical Clinic No.2 of County Emergency Hospital Timisoara.
All the patients had total or subtotal thyroidectomy, in 9 cases the operatory team was composed of general surgeons and thoracic surgeon.
Results: There were 36 patients, including 22 females and 14 men. Twenty one patients were older than 60 years of age. Only 3 goiters were malignant: two
medullar carcinoma and one non-Hodgkin lymphoma with B cell. Two cases needed preoperatory treatment in order to achieve normal thyroid hormones values.
In this study, 90 % of the goiters were removed only with the use of cervical approach; in one case sternotomy was used, in another thoracotomy, and a
combined approach in another case. In all three cases which required more than a cervical access large RSG grade III were found. There were complications in
five cases: hemorrhage in 2 cases (one requiring re-operation) and recurrent laryngeal nerve palsy in 3 cases.
Conclusion: RSG can be managed by cervical approach in the vast majority of cases, only large RSG grade 3 with thoracic origin of the thyroid vascularization
require systematic sternotomy or thoracotomy. Complications are more frequent due to the size of the goiter, the long period of evolution and the modified local
anatomical landmarks and reports.

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n cutarea unui rspuns - adrenalectomia laparoscopic pentru metastaze n glanda suprarenal


In Search of an Answer - Laparoscopic Adrenalectomy for Suprarenalian Metastases
O. Ginghin (1), R. Iosifescu (2), R. Iorgulescu (2), V. Popa (3), A. Stoica (2), Andrada Spnu (2), Clarisa Brlog (2), R. Munteanu (2), M. Liescu (2), N. Iordache (2)
(1) Spitalul Clinic de Urgen Pentru Copii Sf. Ioan, Secia de Chirurgie Oncologic, Bucureti, Romnia
(2) Spitalul Clinic de Urgen Pentru Copii Sf. Ioan, Secia de Chirurgie General, Bucureti, Romnia
(3) Spitalul Clinic de Urgen Pentru Copii Sf. Ioan, Secia de Chirurgie Toracic, Bucureti, Romnia
Astzi, cnd conceptul liver first i gsete un loc bine stabilit n chirurgia metastazelor hepatice din cancerul colorectal, ne-am intrebat dac putem vorbi despre
un loc definit al metastazelor suprarenaliene in cancerul pulmonar.
Material metod: n perioada ianuarie 2010 - decembrie 2015 n clinica de Chirurgie General a Spitalului Clinic de Urgen Pentru Copii Sf. Ioan au fost
efectuate 101 suprarenalectomii pe cale laparoscopic. Din acestea 11 au fost pentru metastaze din cancerul pulmonar.
Rezultate: Am analizat evoluia pacienilor dup intervenia chirurgical, precum i impactul ordinii tratamentului complex oncologic - chimioterapie, intervenie
pentru tumora primara i operaia pentru suprarenal.
Concluzii: Dei numarul mic de pacieni nu permite tragerea unor concluzii, suprarenalectomia efectuat naintea interveniei pentru tumora primar nu modific
evoluia oncologic a pacientului.

Today, when liver first is a wide spread concept in hepatic surgery for colorectal liver metastasis, we raised the question if we can find a well-defined place for
adrenal metastases in lung cancer.
Material and method: Between January 2010 and December 2015 in the General Surgery department of "Sf. Ioan" Hospital we performed 101 adrenalectomy via
laparoscopy. From these 11 were performed for lung cancer metastases.
Results: We analysed the evolution of patients after adrenalectomy, but also the impact of the therapeutic sequence in the complex oncologic treatment chemotherapy, surgery for the primary tumor and adrenalectomy.
Conclusions: Even if the small number of cases does not allow us to draw a conclusion, adrenalectomy can be safely performed before the intervention for the
primary tumor wit safe oncological pathway for the patient.

Tumori abdomino-pelvine
Abdomino-Pelvic Tumors
M. Tnase, P. I. Oprea, T. Artenie, V. tefnescu, Mdlina Prun, C. Drgan, A. C. Dima, F. Macau, Silvia Stng
Spitalul Universitar de Urgen Militar Central, Chirurgie I, Bucureti, Romnia
ntr-un serviciu de Chirurgie de Urgen, tumorile abdomino-pelvine reprezint o patologie relativ frecvent ntlnit, de etiologie variat i care de cele mai multe
ori pune la ncercare experiena i ndemnarea chirurgului.
Lucrarea reprezint un studiu retrospectiv al experienei de peste 40 de cazuri n ultimii 5 ani ai serviciului Chirurgie I al Spitalului Universitar de Urgen Militar
Central.
Dac n cazul urgenelor, terapia chirurgical a vizat n primul rnd rezolvarea complicaiilor tumorale (ocluzie, hemoragie, peritonita etc.) n cazul interveniilor
programate viza de radicalitate oncologic a fost pe primul plan.
Cuvinte cheie: tumori abdomino-pelvine, echipa multidisciplinar

In an emergency surgery service, the abdominal pelvic tumors represent a relatively frequent pathology encountered, of varied etiology and they most often
challenge the skills and the experience of the surgeon.
The work represents a retrospective study of over 40 cases from the latest five years in the general surgery service of the Emergency Surgery Service Central
Military University Hospital.
If in the case of an emergency the surgical therapy has as main priority the solving of tumor complications (obstruction, hemorrhage, peritonitis etc.), in the case
of scheduled interventions the first priority was the oncological radicality.
At the end, the conclusions emphasize the necessity of involving a multidisciplinary team in the management of such complex cases.
Keywords: Tumors abdomen - pelvis, multidisciplinary team

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Algoritmi de diagnostic i tratament n bolile vasculare periferice - experiena Spitalului Orenesc Cugir
Algorithms of Diagnostic and Treatment of Vascular Peripheric Diseases - Experience of Municipality Hospital of
Cugir
Terezia Boruah
Spitalul Orenesc, Compartimentul Chirurgie, Cugir, Romnia
Patologia vascular periferic (arterial, venoas, diabetic, mixt) prezint o inciden crescut n rndul populaiei generale. Alternativele de diagnostic i
tratament ale bolilor vasculare periferice sunt multiple i nestandardizate, astfel nct rezultatele obinute sunt cel puin inomogene. Secia Chirurgie a Spitalului
Orenesc Cugir a dezvoltat, ncepnd cu anul 2013 o baz de date cuprinznd bolnavii cu patologie vascular periferic diagnosticai i tratai n spital, n ideea
standardizrii unor protocoale de diagnostic i tratament a acestor afectiuni. Prezentm cazuistica Spitalului Orenesc Cugir (iunie 2013-februarie 2016), cu
privire la diagnosticul i tratamentul bolilor vasculare periferice. n studiu au fost inclui un numr de 630 pacieni (240-arteriopatie cronic obliterant a
membrelor inferioare, 320-boal venoas, 70-boal vascular periferic de etiologie mixt). Aplicarea protocoalelor standardizate de diagnostic i tratament a
bolilor vasculare periferice a permis identificarea unor msuri de reducere a impactului factorilor de risc, precum i o mbuntire a prognosticului pe termen
lung a acestor pacieni.
Cuvinte cheie: patologie vascular periferic, protocoale de diagnostic i tratament

Vascular peripheric pathology (arterial, venous, diabetic, intricated) has a high incidence among general population. Diagnostic and treatment alternatives are
multiple and not standardized and the results are not homogenous. Surgery Department of Municipality Hospital of Cugir, developed, starting with 2013 a data
base where the patients having vascular peripheric disease were included. We present the experience of our hospital (2013-2016), regarding the diagnostic and
treatment of vascular peripheric disease. In our study, 630 patients were included (240 patients having obliterating chronic artheriopathy, 320 patients having
venous disease, 70 patients having intricate etiology). Applying standardized protocols of diagnostic and treatment of vascular peripheric disease allowed
identification of measures of reducing the impact of risk factors and improving the long term prognosis of the patients.
Key words: vascular peripheric disease, diagnostic and treatment protocols

Tratamentul laparoscopic n tumorile renale


Laparoscopic Nephroureterectomy for Renal Tumors
C. Lupacu (1), M. L. Zabara (1), Delia Rusu-Andriei (1), Felicia Crumpei (2), C. Bradea (3), Oana Apopei (4), Corina Ursulescu-Lupacu (2), Alexandra Vornicu (1),
Ana-Maria Trofin (1)
(1) Spitalul Clinic Judeean de Urgene Sf. Spiridon, Clinica II Chirurgie, Iai, Romnia
(2) Spitalul Clinic Judeean de Urgene Sf. Spiridon, Clinica de Radiologie, Iai, Romnia
(3) Spitalul Clinic Judeean de Urgene Sf. Spiridon, Clinica I Chirurgie, Iai, Romnia
(4) Spitalul Clinic Judeean de Urgene Sf. Spiridon, Clinica de Anestezie i Terapie Intensiv, Iai, Romnia
Introducere: Excizia chirurgical rmne tratamentul de elecie n cancerul renal localizat i carcinomul cu celule de tranziie a tractului urinar superior.
Tratamentul chirurgical se poate realiza prin diferite metode de abord, incluznd nefroureterectomiile radicale prin abord clasic i proceduri laparoscopice.
Material i metode: n cadrul Clinicii II Chirurgie a Spitalului Sfntul Spiridon Iai, au fost identificai cincisprezece pacieni cu tumori renale n perioada 1
ianuarie 2013 i 31 decembrie 2015 i patru dintre acestia au beneficiat de proceduri laparoscopice.
Rezultate: Dimensiunea medie a tumorii a fost de 4,5 cm, iar durata interveniei chirurgicale a fost cuprins ntre 80 i 120 de minute. Pierderea estimat de
snge a fost mai mic de 200 ml. Conversie la o intervenie chirurgical clasic nu a fost necesar. Evoluia postoperatorie a fost simpl, pacienii avnd o
spitalizare postoperatorie de 4 pn la 6 zile. Examenul histologic confirm carcinomul renal n trei cazuri i ntr-un caz a fost decelat originea tumorii n tractul
urotelial superior.
Concluzi: Nefroureterectomia radical laparoscopic are beneficii superioare nefrectomiilor clasice asociind o morbiditate inferioar i ar putea fi tratamentul de
elecie n tumorile renale T1 i T2.

Aim: Surgical excision remains the core to the management of localised renal cancer and upper tract transitional cell carcinomas. There are a number of surgical
approaches to manage this condition including open radical nephroureterectomy and laparoscopic procedures.
Methods: In Second Surgical Clinic of Saint Spiridon Hospital, fifteen patients with renal tumors were identified between January 1, 2013 and December 31, 2015
and four of them underwent laparoscopic procedure.
Results: Mean tumor size were 4.5 cm and the operative time were between 80 and 120 minutes. The blood loss was less than 200 mL. Conversion to open
surgery wasnt necessary. The postoperative course was simple, patients being discharge in 4 to 6 days. The histological exam confirm the renal carcinoma in
three cases and one case established the origin of the tumor in the upper urothelial tract.
Conclusions: Radical laparoscopic nephrouretectomy has benefits over open RN in terms of morbidity and could be the standard of care for T1 and T2 tumors.

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Physicians Session Oral Communications

Pelvisul gol - complicaii i tratament


The Void Pelvis - Complications and Treatment
V. Muntean (1), R. Simescu (2), G. E. Petre (2), D. Slceriu (2), C. Cheregi (2)
(1) Spitalul Clinic Ci Ferate / Universitatea de Medicin i Farmacie Iuliu Haieganu, Clinica Chirurgie IV, Departamentul Chirurgie, Cluj-Napoca, Romnia
(2) Spitalul Clinic Ci Ferate / Universitatea de Medicin i Farmacie Iuliu Haieganu, Clinica Chirurgie IV, Cluj-Napoca, Romnia
Obiective: Spaiile rezultate n urma rezeciei organelor pelvine sunt cauza unor complicaii postoperatorii redutabile: abcese pelvine, ocluzii, fistule intestinale i
urinare i hernii perineale. n studiul prezent am urmrit complicaiile legate direct de spaiul pelvin aprut n urma rezeciilor multiorgan i a soluiilor terapeutice
n aceste situaii.
Material i metode: ntr-un studiu prospectiv observaional de cohort am urmrit indicaiile, tratamentul i evoluia postoperatorie la 122 pacieni cu exenteraii
pelvine operai ntr-o perioad de 10 ani (2005-2016).
Rezultate: Din cei 122 pacieni, la 48 rezeciile au fost sub ridictorii anali (la 12 cu rezecii perineale largi i 8 cu sacrectomie) i la 74 deasupra ridictorilor.
Spaiul intrapelvin rezultat a fost umplut cu marele epiploon preparat pe vasele gastroepiploice stngi la 106 pacieni (la 16 marele epiploon absent sau
inutilizabil). La ali 45 pacieni planeul pelvin i perineul au fost refcute cu lambouri miocutanate de drept abdominal (37 pacieni, 22 cu vaginoplastie), gluteu
mare (6) i perineal posterior Singapore (2 pacieni).
Rezultate: Complicaiile postoperatorii datorate direct spaiului gol intrapelvin s-au nregistrat la 21 pacieni: 12 abcese pelvine, 5 ocluzii intestinale, 8 fistule
intestinale i 5 fistule urinare. La 13 pacieni s-a impus reintervenia chirurgical, n 8 cazuri tratamentul conservativ a fost suficient i doi pacieni au decedat.
Doar 5 din cei 21 pacieni cu complicaii postoperatorii; aveau plastie pelvin cu mare epiploon sau lambouri miocutanate.
Concluzii: Umplerea pelvisului cu esuturi viabile, marele epiploon sau lambourile miocutanate reprezint o strategie valoroas de prevenire a complicaiilor
postoperatorii dup exenteraiile pelvine.

Study objectives: Vacant spaces resulting after resection of pelvic organs are the source of major postoperative complications: abscesses, intestinal occlusions,
urinary and intestinal fistulas, hernias of the perineum. Our study analyzed complications of the pelvic void that resulted after multiorgan resections and also tries
to identify therapy options in these situations.
Patients and methods: Through a prospective observational cohort study we analyzed the indications, treatment options and postoperative outcome of 122
patients with pelvectomies, operated on during 2005-2016.
Results: Out of the 122 eligible patients, in 48 resection limit was under the levator ani muscles (extensive perineal resections in 12 and sacrectomy in 8) and in 74
above. The resulting vacant pelvic space was filled with the great omentum pedunculated on the left gastro-epiploic vessels in 106 patients (in 16 patients the
great omentum was absent/unusable). In 45 patients the pelvic floor and perineum were reconstructed with myocutaneous flaps using the rectus abdominus
muscle (37 patients, 22 for vaginoplasty), gluteus maximus (6 patients) and posterior perineal Singapore flaps (2 patients).
Results: 21 patients developed complications directly related to the vacant pelvic space: 12 pelvic abscesses, 5 intestinal occlusions, 8 intestinal fistulas and 5
urinary fistulas. 13 patients required reoperations, 8 cases a non-operative treatment and 2 patients died. Only 5 of the 21 patients with postoperative
complications had a great omentum or myocutaneous reconstructions of the pelvis.
Conclusions: Filling the vacant pelvic space with viable tissue, great omentum or myocutaneous flaps is a valuable strategy of preventing postoperative
complications after pelvectomies.

Tratamentul multimodal al tumorilor neuroendocrine cu localizare extradigestiv


Multimodality Treatment for Extradigestive Neuroendocrine Tumors
Mihaela Mdlina Gavrilescu, I. Radu, I. Huanu, B. Filip, Mihaela Buna-Arvinte, Ana Maria Muin, N. Ioanid, Maria Gabriela Aniei, D. V. Scripcariu, V. Scripcariu
Institutul Regional de Oncologie / Universitatea de Medicin i Farmacie Gr. T. Popa, Clinica I Chirurgie Oncologic, Iai, Romnia
Introducere: Tumorile neuroendocrine cuprind un numr de tumori cu un comportament heterogen care variaz de la tumori cu grad de malignitate sczut pn
la malignitate crescut. Carcinoamele neuroendocrine de sn sau de col uterin sunt rare, nsumnd mai puin de 1%, respectiv 2%.
Material i metode: Studiu retrospectiv care include paciente tratate n cadrul Clinicii I Chirurgie Oncologic pentru neoplasm mamar, col uterin i corp uterin n
perioada 1 mai 2012-31 decembrie 2015. Au fost evaluate caracteristicile clinice i biologice, tipul de tratament efectuat i rezultatele postoperatorii.
Rezultate: Prima pacient n vrst de 36 de ani a fost diagnosticat cu tumor de col uterin motiv pentru care a beneficiat de radio-chimioterapie urmat de
histerectomie radical cu limfadenectomie pelvin (ypT2bN1). La 1 an postoperator, pacienta se prezint pentru evaluarea chirurgical a unei formaiuni tumorale
mamare drepte. Rezultatul histopatologic stabilete diagnosticul de metastaz de carcinom neuroendocrin cu celula mic. A doua pacient n vrst de 68 de ani
la care s-a practicat histerectomie total cu anexectomie bilateral este diagnosticat cu carcinom neuroendocrin cu celul mare i carcinom papilar seros de
endometru. n ceea ce privete localizarea la nivel mamar, 8 paciente au fost diagnosticate cu carcinom neuroendocrin. Vrsta a fost cuprins ntre 56 i 84 de
ani. Dou paciente au beneficiat de chimioterapie neoadjuvant. Toate cazurile au fost imunoreactive pentru cel puin 2 markeri neuroendocrini (cromogranina i
sinaptofizina).
Discuii: Carcinomul neuroendocrin cu localizare extradigestiv este rar i are un prognostic nefavorabil. n completarea evalurii histopatologice, este obligatoriu
efectuarea unei testri imunohistochimice pentru stabilirea diagnosticului de carcinom neuroendocrin.

Introduction: Neuroendocrine tumors (NETs) comprise a heterogeneous group of neoplasms that vary from low-grade malignancy tumors to tumors with high
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malignancy. Neuroendocrine carcinomas of the breast or of the cervix are rare lesions, representing about 1%, respectively 2% of all tumors.
Material and methods: Retrospective study in which there were included patients diagnosed with breast, uterine cervical cancer and endometrial cancer and
treated in Ist Surgical Unit, Iai, Regional Cancer Institute, between 1 May 2012 to 31 December 2015.
Results: First patient, 36 years old, was treated with chemo-radiotherapy, followed by radical hysterectomy with pelvic lymphadenectomy (ypT2bN1). After one
year, the patient presented with lump in the right breast (a mastectomy was performed). Histological and immunohistochemistry established the presence of a
metastasis of small cell neuroendocrine carcinoma. The second patient, 68 years old, was diagnosed with large cell neuroendocrine carcinoma and papillary
serous endometrial carcinoma after performing a total abdominal hysterectomy with bilateral salpingo-oophorectomy. Regarding breast tumors, 8 patients were
diagnosed with neuroendocrine carcinoma. The minimum age was 56 years, maximum 84 years. Two patients received neoadjuvant chemotherapy. All cases
were immunoreactive for at least two neuroendocrine markers (chromogranin and synaptophysin).
Discussion: Neuroendocrine carcinoma with extradigestive localization is rare and has poor prognosis. In addition to histopathology, panel of
immunohistochemistry is mandatory in the diagnosis of neuroendocrine carcinoma.

Chirurgia robotic n sistemul medical din Romnia


Robotic Surgery in the Romanian Health System
I. Slavu (1), L. Alecu (2)
(1) Spitalul Clinic de Urgen Floreasca, Chirurgie General, Bucureti, Romnia
(2) Spitalul Clinic de Urgen Prof. Dr. Agrippa Ionescu, Chirurgie General, Bucureti, Romnia
Rezumat: Chirurgia robotic a aprut n sistemul de sntate romnesc n anul 2008 cu achiziionarea primelor dou sisteme robotice. Un sistem a aparinut
Centrului de Chirurgie General si Transplant Hepatic Dan Setlacec Fundeni, iar al doilea Spitalului de Urgen Floreasca, Bucureti. Finanarea a fost asigurat
de ctre Ministerul Sntii printr-un program special aprobat la nivel naional. Doar n primul an au fost realizate peste 150 de intervenii chirurgicale cu acest
sistem de ctre Centrul de Chirurgie General i Transplant Hepatic Dan Setlacec Fundeni. Un obiectiv cheie al programului a fost acela de a identifica
interveniile cost-eficiente care se situau la aproximativ 9000 RON/intervenie. Ulterior, s-au pus n funciune nc apte sisteme robotice, dintre care trei n
urologie i patru n chirurgie general. Avnd n vedere costul ridicat al consumabilelor i ntreinerea post-garanie, operarea acestor sisteme robotizate ar putea
fi realizat doar prin intermediul sistemului naional de sntate, sau cu ajutorul sectorului privat medical. Funcionarea programului a permis realizarea unui
numr limitat de cazuri anual iar ncepnd cu 2014 a fost sistat finanarea acestuia. Pe parcursul acestei perioade o experien semnificativ a fost ctigat
folosind chirurgia robotic n chirurgie general, urologie i ginecologie.

Abstract: Robotic surgery appeared in the Romanian health system in 2008 with the purchase of the first two surgical robots. One of them belonged to the Center
of General Surgery and Liver Transplantation Dan Setlacec Fundeni and the second to Floreasca Emergency Hospital. Funding was made by a Ministry of
Health special program. Since the first year of operation with the robotic system, Fundeni performed about 150 interventions. A key objective of the program was
to identify the interventions that are cost efficient situated at around 9000 RON each surgical intervention. Subsequently, there were put into operation another 7
robotic systems, of which three are in urology and four in general surgery. Given the high cost of consumables and post-warranty maintenance, operation of
these robotic systems could only be done through the national health system, or private sector. The operation of the program allowed for an annual limited
number of cases, and since 2014 the program funding was ceased. During this period, a significant experience was gained using robotic surgery in general
surgery, urology and gynecology as well.

Melanomul malign plantar - diagnostic i atitudine terapeutic


Malignant Melanoma of the Soles - Diagnostic and Therapeutical Attitude
Terezia Boruah
Spitalul Orenesc, Compartimentul Chirurgie, Cugir, Romnia
Melanomul malign este o form rar dar potenial letal de cancer, care poate s se dezvolte la nivelul plantei. Datele din literatur arat c, datorit
recunoaterii tardive sau a erorilor de diagnostic, melanomul plantar are un prognostic mult mai prost dect orice alt form de melanom cutanat. Prezentm
cazul unei paciente de 72 ani, trimis n serviciul ambulatoriu de chirurgie al Spitalului Orenesc Cugir, de ctre medicul de familie, cu diagnosticul de clavus
plantar stng. Examenul obiectiv al plantei a relevat prezena unei leziuni cutanate cu diametru de aproximativ 1.5 cm, cu aspect de clavus plantar, cu o zon de
hiperpigmentare central. S-a practicat excizia leziunii n anestezie local i s-a trimis proba pentru examen histopatologic. Examenul histopatologic (inclusiv
coloraiile imunohistochimice) a diagnosticat un melanom malign plantar. S-a efectuat recupa leziunii n limite de siguran oncologic i s-a evidentiat un
melanom malign plantar nodular, nivel Clak IV, indice Breslow de 3.5 mm (stadializare pTNM: pT3aNxMx). n urma consultului oncologic, s-a efectuat scintigrafie
ganglionar i marcaj cutanat, precum i biopsie ganglionar inghinal, care nu au evideniat metastaze ganglionare (M0). n acest context comisia de expertiz
ocologic nu a considerat necesar tratamentul chimioterapic, pacienta urmnd s fie monitorizat strict clinic i imagistic. Melanomul malign plantar reprezint o
condiie patologic rar i frecvent subdiagnosticat. Elaborarea i diseminarea unor ghiduri practice de recunoatere precoce a acestor leziuni, poate facilita
accesul rapid al acestor pacieni la tratament de specialitate, mbuntind evident prognosticul lor pe termen lung.
Cuvinte cheie: melanom malign plantar, tratament de specialitate, prognostic

Malignant melanoma is a rare, but potentially lethal form of cancer which may arise on the soles. Evidence suggests that due to misdiagnosis and later
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recognition, foot melanoma has a poorer prognosis than cutaneous melanoma elsewhere. We present the case of a 72 year old female patient, sent by the
general practitioner in the surgical out-patient department of Municipality Hospital Cugir having the diagnostic of plantar hyperkeratosis. Clinical examination of
the soles revealed a cutaneous lesion on the lateral side of the left sole, approximately 1.5 cm, with a central hyperpigmented area. The lesion was removed
under local anesthesia, and the specimen was sent for histopathological examination. The histopathological examination (including immunohistochemical
staining) diagnosed malignant melanoma of the sole. Re-excision of the lesion with oncological safety margins was performed and the histopathological
examination revealed a nodular malignant melanoma of the sole, level Clark IV, Breslow index of 3.5 mm (p TNM: pT3NxMx). Following the oncology consultation,
we performed ganglionar scintigraphy and cutaneous marking followed by inguinal ganglionar biopsy, which did not revealed ganglion metastasis (M0).In this
context, the oncology panel of experts did not indicate any chemotherapeutical regimen. The patient was enrolled in a strict clinical and imaging follow-up
program. Malignant melanoma of the soles is a rare and underdiagnosed condition. Development and dissemination of practical guides of early detection of
these lesions may facilitate earlier access of the patients to specialized treatment, in this way improving the long term prognosis.
Key words: malignant melanoma of the soles, specialized treatment, prognosis

Terapia prin vacuum - piciorul diabetic


Vacuum Therapy - Diabetic Foot
B. M. Ciuntu, C. Vasilu, . O. Georgescu
Spitalul Clinic Judeean de Urgene Sf. Spiridon, Chirurgie II, Iai, Romnia
Introducere: Tratamentul plgilor cronice sau supurate secundar unor intervenii chirurgicale complicate sau datorate altor stri patologice (diabet, ulcer varicos
etc.) solicit largi resurse materiale i umane. Conditia iniiala n tratamentul oricrei plgi supurate este debridarea chirurgical, aceasta convertind o plag
cronic n una acut capabil s parcurg etapele normale ale vindecrii.
Material i metod: Utilizarea unei pompe electronice de vacuum (VAC -Hartman) n vederea aplicrii presiunii negative la nivelul plgilor, utiliznd setrile
indicate (presiune negativ, durata meninerii n utilizare a unui kit) n concordan cu evoluia clinic a pacienilor. Schimbri ale dimensiunilor plgii, ncrctura
bacterian a acestora, precum i durata tratamentului au fost monitorizate pe tot parcursul evoluiei clinice a 11 bolnavi.
Rezultate: Vindecarea a fost obinut n toate cazurile, n 9 cazuri a fost necesar sutur secundar i n 2 cazuri au fost utilizate grefe de piele. n toate cazurile a
fost observat o reducere n dimnesiuni a plgii.
Concluzii: Dup ndeplinirea condiiilor iniiale n tratarea oricrei plgi, tratamentele adjuvante precum cel n vacuum i gsesc rolul potrivit.
n cazul pacienilor cu picior diabetic la care a fost necesar intervenia chirurgical, utilizarea terapiei cu presiune negativ a adus un beneficiu net n
conservarea membrului afectat, cu gesturi de exerez minim. Redusa dar benefica noastr experien ne ndreptete s continum folosirea tehnicii NPTW i
cu alte indicaii legate de chirurgia abdominal i nu n ultimul rnd n tratamentul paliativ al plgilor unde este considerat a fi o ateptare etic.

Introduction: Treatment of chronic wounds secondary to suppurative complicated surgery or due to other pathological conditions (diabetes, varicose ulcers, etc.)
requires larger human and material resources. The first treatment condition of any suppurated wounds is surgical debridement, this converting a chronic wound
into an acute one, capable of healing through normal stages.
Methods: Using an electronic pump vacuum (VAC -Hartman) in order to apply negative pressure to the wound using specified settings (negative pressure, the
duration of use of a kit) consistent with the clinical course of patients. Changes in the size of the wound, their bacterial loads and duration of treatment were
monitored throughout the clinical course of 11 patients.
Results: The cure was achieved in all cases, in 9 cases secondary suture was necessary in 2 cases skin grafts were used. In all cases it was observed a reduction
in wound dimensions.
Conclusions: After fulfilling baseline in treating any wounds, adjunctive treatments, such as vacuum, find the right role. We can say that the treatment of chronic
suppurative wounds with negative pressure atmosphere is an adjunctive technique with very good results.
In patients with diabetic foot that was required surgery, the use of negative pressure therapy yielded a net in the affected limb preservation with minimal excision
gestures. Reduced but beneficial experience allows us to continue our use of technology NPTW and other indications related to abdominal surgery and not least
in the palliative treatment of wounds where it is considered to be an "ethical calling".

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Rezeciile multiviscerale n cancerul epitelial ovarian avansat - perspective i limite ale chirurgiei citoreductive
Multiple Visceral Resections in Advanced Epithelial Ovarian Cancer - Perspectives and Limits of Cytoreductive
Surgery
V. M. Prunoiu, G. D. Subirelu, A. M. Marinca, C. Cirimbei, Snziana Octavia Ionescu, E. Brtucu, N. D. Straja
Institutul Oncologic Prof. Dr. Al. Trestioreanu, Chirurgie General i Oncologic I, Bucureti, Romnia
Chirurgia este o component eseniala a tratamentului cancerului epitelial ovarian avansat (COA). Scopul este o citoreducie maximal, astfel nct tumorile
reziduale s fie mai mici de 1 cm (citoreducie optimal), dac nu este posibil R0. Beneficiile chirurgiei citoreductive sunt evacuarea maselor tumorale, modificri
n kinetica celular cu creterea senzitivitii la chimioterapia postoperatorie i astfel rezultatele sunt mai favorabile.
Material i metod: Este un studiu retrospectiv (2005-2014), efectuat pe paciente operate n Clinica Chirurgie General i Oncologic I a Institutului Oncologic
Bucureti, n care am monitorizat 265 paciente cu cancer epitelial ovarian stadiile III i IV, cu vrste cuprinse ntre 27 i 79 ani. La 127 (47,9%) dintre acestea am
practicat, pe lng histerectomie total, anexectomie bilateral, omentectomie i rezecii multiviscerale: enterectomii, colectomii segmentare, apendicectomii
(altele dect pentru carcinoame mucoide), cistectomii pariale, metastazectomii i radioablaie (RFA) metastaze hepatice, splenectomie, gastrectomie parial,
RFA metastaze limfoggl. pelvini i interaorto-cavi, rezecii de perete abdominal.
Rezultate: Supravieuirea pacientelor a fost cuprins ntre 6 i 48 luni. Chirurgia citoreductiv, n asociere cu chimioterapia, au permis creterea calitii vieii i a
supravieuirii, cu o median de 31 luni pentru citoreducia optimal i 40 luni pentru pacientele cu R0, i de 13 luni pentru pacientele cu citoreducie suboptimal.
Concluzii: Creterea supravieuirii pacientelor i a calitii vieii acestora justific chirurgia citoreductiv extensiva n COA.

Surgery is an essential component of advanced epithelial ovarian cancer treatment (AOC). The purpose is a maximal cytoreduction so that the residual neoplastic
mass would be smaller than 1 cm (optimal cytoreduction), if R0 is not possible. The benefits of cytoreductive surgery are removal of tumor masses, changes in cell
kinetics with increased sensitivity to postoperative chemotherapy and so the results are more favorable.
Methods: This is a retrospective study (2005-2014) performed on patients operated in the Ist General Surgery and Oncology Clinic of the Bucharest Oncology
Institute, study in which we monitored 265 patients with epithelial ovarian cancer stages III and IV, with ages between 27 and 79 years. In 127 (47.9%) patients we
have also practiced besides hysterectomy, bilateral adnexectomy, omentectomy and multiple visceral resections: enterectomy, segmental colectomy,
appendectomy (other than for mucoid carcinomas), partial cystectomy, metastasectomy and radiofrequency ablation (RFA) of liver metastases, splenectomy,
partial gastrectomy, RFA of limfoggl. metastases - pelvic and inter-aortico-caval, abdominal wall resection.
Results: Patient survival varied between 6 and 48 months. Cytoreductive surgery in association with chemotherapy has enabled increased quality of life and
survival, with a median of 31 months for optimal cytoreduction and 40 months for patients with R0, and 13 months for patients with suboptimal cytoreduction.
Conclusions: Extensive cytoreductive surgery in AOC is justified by the increase in patient survival and quality of life.

Valoarea bandeletelor cu 4 i 6 brae n cura incontinenei urinare


The Value of Perineal Hammock with 4 and 6 Arms in Urinary Incontinence Cure
T. D. Potec (1), A. E. Iacobescu (1), Anca Gabriela Potec (2), Irina Nicoleta Penciuc (1)
(1) Spitalul Clinic Colentina, Secia de Chirurgie General, Bucureti, Romnia
(2) Universitatea de Medicin i Farmacie Carol Davila, Catedra de Anatomie Patologic, Bucureti, Romnia
Majoritatea pacientelor cu incontinen urinar au asociat ruptura de perineu anterioar cu cea posterioar. n studiul prezentat am ncercat s evalum care
este tratamentul optim al incontinenei urinare.
Metod: n baza inteniei de rezolvare chirurgical a incontinenei urinare au fost selectate un numr de 24 cazuri. Acestea au fost mprite n trei loturi n funcie
de diagnostic: lotul I - paciente cu incontinen urinar fr ruptur de perineu (5); lotul II - paciente cu incontinen urinar i cistocel (7); lotul III - paciente cu
incontinen urinar i cistorectocel (12). Lotul I a beneficiat de tratament chirurgical cu bandeleta cu 2 brae (retropubian); n cazul lotului II - 4 paciente bandeleta cu 4 brae (retropubian), o pacient - cistopexie transvaginal. n cazul lotului III - 2 paciente - cistorectopexie transvaginal i 10 paciente - bandelet
cu 6 brae.
Rezultate: S-a constatat c n cazul lotului I incontinena urinar se rezolv prin montarea bandeletei cu 2 brae, n cazul lotului II pacientele ce au beneficiat de
bandelet cu 4 brae s-au reintegrat n activitile socio-profesionale rapid, iar n cazul lotului III pacientele cu cistorectopexie transvaginal au avut recidive.
Concluzii: Bandeleta cu 2 brae rezolv cazurile de incontinen urinar fr ruptur de perineu. Bandeletele cu 4 i 6 brae rezolv i incontinena urinar i
ruptura de perineu.

Most patients have urinary incontinence associated with rupture of the posterior perineum prior. In the present study we tried to assess which is the optimal
treatment of urinary incontinence.
Method: In the intent of resolving urinary incontinence by surgery, there were selected a total of 24 cases. They were divided into three groups depending on the
diagnosis: group I - patients with urinary incontinence without perineal tear (5); group II - patients with urinary incontinence and cystocele (7); group III - patients
with urinary incontinence and cistorectocel (12). Group I received surgical treatment with the perineal hammock with two arms (retropubic); in sample II - 4
patients - perineal hammock with 4 arms (retropubic), a patient - transvaginal cistopexie. Group III - two patients - transvaginal cistorectopexy, 10 patients perineal hammock 6 armed.
Results: We found that in lot I urinary incontinence resolved by mounting perineal hammock with two arms, in group II patients who benefited from the perineal
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hammock with 4 arms were reintegrated into the activities of socio-professional fast, and in group III patients with transvaginal cistorectopexie had relapses.
Conclusion: 2 arms perineal hammock resolve cases of urinary incontinence without perineal tear. Perineal hammock 4 and 6 arms solves urinary incontinence
and perineal tear urinary incontinence.

Abordul terapeutic multidisciplinar n cancerele sincrone de ovar i col uterin


The Multidisciplinary Therapeutic Approach to Synchronous Ovarian and Cervical Cancers
C. Cirimbei (1), V. Rotaru (1), A. M. Marinca (1), G. D. Subirelu (1), Simona Cirimbei (1), Oana Pavalache (1), N. D. Straja (1), Carmen Panti (2), Sorela Rdoi (2),
Costina Diaconu (2)
(1) Institutul Oncologic Prof. Dr. Al. Trestioreanu, Clinica de Chirurgie General i Oncologic I, Bucureti, Romnia
(2) Institutul Oncologic Prof. Dr. Al. Trestioreanu, Clinica de Anestezie i Terapie Intensiv, Bucureti, Romnia
Incidena cancerelor sincrone genitale la populaia feminin este estimat la aproximativ 0,63%, majoritatea (peste 40%) fiind reprezentat de asocierea
cancerului ovarian cu cancerul de endometru. Extrem de rar este asocierea cancerului de ovar cu cancerul cervical, estimrile incidenei situndu-se la
aproximativ 0, 025% dintre aceste tipuri de neoplazii ale tractului genital feminin.
Obiective: Ne-am propus evaluarea retrospective a asocierii de cancere genitale, prin prisma experienei ultimilor 7 ani, focusnd particularitile algoritmului
terapeutic, bazat pe stadiul evolutiv al celor 2 leziuni concomitente, formele histologice, precum i elemente de tehnic operatorie, indicaii i complicaiile
perioperatorii.
Metod: n perioada septembrie 2008-mai 2016 am monitorizat un lot de 320 paciente cu neoplasm ovarian, dintre care 6 paciente, aveau asociat un cancer de
col uterin, protocolul terapeutic fiind constituit din 3 piloni chirurgie, radioterapie i chimioterapie, cu secvenialitate variabil. Monitorizarea s-a realizat prin
control clinic i CT, la interval de 3 luni.
Rezultate: Chirurgia a reprezentat n toate cazurile prima secven terapeutic, cu viz radical (n 2 cazuri) sau citoreductiv/diagnostic (n 4cazuri), urmnd ca
traiectoria terapeutic s fie decis de stadiul extensiei leziunilor cervicale i ovariene, corelat cu tipul de intervenie practicat initial. n 3 cazuri s-a impus
intervenia radical postchimioradioterapie, iar la distan alte 3cazuri au beneficiat de second-look de restadializare i citoreductie.
Concluzii: Experiena arat c stabilirea unui protocol strict n aceast asociere lezional este dificil, practic schemele terapetice trebuie adecvate fiecarui caz n
parte, personalizate, raportate la extensia lezional, responsivitatea la tratamentele adjuvante radio-chimioterapice, tipul de intervenie practicat, decizii luate n
echipe multidisciplinare.

The incidence of synchronous genital cancers in the female population is estimated to 0.63%; the association between ovarian and endometrial cancer
constitutes the majority (over 40%). The association between ovarian and cervical cancer is exceedingly rare, its incidence being estimated at roughly 0.025% of
this type of female genital cancers.
Objectives: Our main objective is to perform a retrospective evaluation of the association between these two cancers, based on the experience we have acquired
in the past 7 years. We plan on focusing our attention on the specifics of the therapeutic algorithm, taking into account the staging of both lesions at diagnosis,
their histological types and emphasizing the operating techniques used, along with their indications and alleged complications.
Method: We have been monitoring, between September 2008 and May 2016, a population of 320 patients with ovarian cancer. Out of the 320, 6 of them
associated a synchronous cervical neoplasm. Treatment, in each case, was based on the three pillars of cancer care: surgery, radiotherapy and chemotherapy, in
variable amounts and time frames. The monitoring process consisted in a clinical exam and a CT scan every three months.
Results: In all cases, surgery was the first step taken; in 2 cases a radical approach was applied, and in 4 cases a partial approach was chosen, aiming at lowering
the tumor burden and/or making a diagnosis. Following the initial step, considering staging and local extension, in correlation with the initial type of approach,
the future course of action would be decided. Thus, for 3 patients a radical/complete intervention was necessary after combined chemo-radiotherapy, and in time
3 cases were re-checked for lowering tumor burden or for restaging.
Conclusions: Our experience has taught us that trying to establish a strict, inflexible protocol for dealing with these combined entities is difficult; the best solution
is to adapt the course of action and establish a tailored algorithm of care, according to local extension, response to adjuvant chemo-radiotherapy and type of
initial surgery performed. These decisions should be made in teams that reunite surgeons, anaesthesiologists, radiotherapists and oncologists in order to obtain
the best results with minimum damage.

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Citoreducia secundar n cancerul epitelial ovarian recurent


Secondary Cytoreduction in Recurrent Epithelial Ovarian Cancer
G. D. Subirelu, A. M. Marinca, V. M. Prunoiu, C. Cirimbei, Snziana Octavia Ionescu, E. Brtucu, N. D. Straja
Institutul Oncologic Prof. Dr. Al. Trestioreanu, Clinica de Chirurgie General i Oncologic I, Bucureti, Romnia
Scopul acestui studiu este de a investiga beneficiile citoreduciei secundare (CS) n recidivele din cancerul epitelial ovarian (RCEO) i o ncercare de a determina
criterii de selecie a pacientelor cu RCEO pentru CS.
Material i metod: Este un studiu retrospectiv efectuat pe un lot de 172 paciente cu RCEO, operate n Clinica Chirurgie General i Oncologic I din Institutul
Oncologic Bucureti, ntre anii 2005 2014, vrsta pacientelor fiind cuprins ntre 29-79 ani. Fiecare caz a fost examinat cu privire la tipul histopatologic, grad de
difereniere, stadiu, citoreducie optimal (tumori reziduale mai mici de 1 cm) sau R0, schem de chimioterapie administrat, secven terapeutic, interval liber
de evoluie a bolii.
Rezultate: Studiul nostru relev rezultate superioare la pacientele cu RCEO sensibil la sruri de platin (cu un interval liber de evoluia bolii 6 luni). Dintre cele
172 paciente operate, la 52 de paciente s-au gasit leziuni localizate. La un numr mic de paciente s-a obinut rspuns clinic complet dup chimioterapie de a 2-a
linie, ansa de rspuns clinic complet fiind direct corelat cu intervalul liber de evoluie a bolii.
Concluzii: La pacientele cu RCEO, chirurgia citoreductiv secundar pare s mbunteasca durata celei de-a doua remisiuni.

The aim of this study is an investigation of the benefits of secondary cytoreduction (SC) in relapsed epithelial ovarian cancer (REOC) and a study to determine
selection criteria for SC in patients with REOC.
Materials and methods: We made a retrospective study on 172 patients operated in the Ist Clinic of General and Oncology Surgery of the Oncology Institute of
Bucharest, between 2005-2014, with ages between 29 and 79 years. We examined each case with reference to the histopathologic type, degree of
differentiation, stage, optimal cytoreduction (residual tumors smaller than 1 cm) or R0, the chemotherapy, therapeutic sequence, evolving disease-free interval.
Results: Our study reveals superior results in patients with REOC sensitive to Platinum salts (with a free interval of evolving of the disease 6 months). Out of the
172 operated patients we found lesions in 52 patients. In a small number of patients we achieved a clinical complete response after chemotherapy 2nd line, the
chance of clinical complete response correlated directly with the free interval of the disease evolution.
Conclusions: In patients with REOC, the cytoreductive surgery seems to improve the period of the secondary remission.

Exenteraia pelvin total pentru recidive de neoplasme de col uterin operate - o serie de 35 cazuri
Total Pelvic Exenteration for Centro-Pelvic Recurrences after Surgically Treated Cervical Cancer - A Series of 35
Cases
Irina Blescu (1), N. Bacalbaa (2)
(1) Spitalul Ponderas, Secia de Chirurgie General, Bucureti, Romnia
(2) Universitatea de Medicin i Farmacie Carol Davila, Secia de Obstetric i Ginecologie, Bucureti, Romnia
Obiectiv: De a demonstra beneficiul exenteraiilor pelvine n tratarea recidivelor centropelvine dup neoplasme de col uterin operat.
Material i metod: n perioada 2010 2013, 35 pacieni diagnosticai cu recidive centropelvine dup neoplasme de col uterin au fost supui interveniilor
chirurgicale de tipul exenteraiei pelvine cu rol curativ.
Rezultate: Recidivele centropelvine au fost diagnosticate dup o perioad medie de urmrire de 2,2 ani. n toate cazurile incluse n studiul de fa exenteraiile
pelvine totale au fost efectuate cu intenie de radicalitate. Continuitatea tractului digestiv a fost restabilit prin anastomose colo-anale n ae din cele 35 de
cazuri n care exenteraia pelvin a fost una supralevatorie n timp ce n celelalte 29 cazuri colonul sigmoid a fost exteriorizat n colostoma terminal. n ceea ce
privete reconstruciile urinare, acestea au fost effectuate n patru cazuri, principalele segmente utilizate pentru crearea neo-vezicii urinare fiind ileocolonul drept
respectiv colonul sigmoid. n unul din cele patru cazuri a aprut fistula urinar care a necesitat desfiinarea rezervorului urinar i exteriorizarea ureterelor n
ureterostomie cutanat dreapt. La un follow-up de 3 ani supravieuirea a fost de 62,8%.
Concluzii: Exenteraia pelvina total poate fi efectuat n condiii de siguran n cazul pacienilor cu recidive centropelvine dup neoplasm de col uterin operat i
poate crete supravieuirea la distan.

Objective: To demonstrate the benefit of pelvic exenterations in treating centropelvic recurrences after surgically treated cervical cancer.
Material and Methods: Between 2010 - 2013 35 patients diagnosed with centropelvic recurrences after surgically treated cervical cancer underwent pelvic
exenteration with curative intent.
Results: Centropelvic recurrences were diagnosed at a mean follow-up of 2.2 years. In all cases included in the present study total pelvic exenterations were
performed with curative intent. Digestive tract continuity was restored by colo-anal anastomose in six of the 35 cases in which a supralevator pelvic exenteration
was performed while in the other 29 cases the sigmoid colon was externalized in terminal colostomy. Regarding urinary reconstructions, they were effectuated in
four cases, the main segments used to create neo-bladder being the right ileocolon and sigmoid colon. In one of the four cases a urinary fistula occurred and
necessitated reoperation for exteriorization of the two ureters in terminal right ureterostomy. At three years follow-up the overall survival was 62.8%.
Conclusions: Total pelvic exenteration can be safely performed in patients with centro-pelvic recurrences after surgically treated cervical cancer and can increase
survival.

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51

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Physicians Session Oral Communications
Managementul cancerului ovarian local avansat
Management of Locally Advanced Ovarian Cancer
Mihaela Buna-Arvinte (1), I. Huanu (1), B. Filip (1), A. Pantazescu (1), Maria Gabriela Aniei (1), N. Ioanid (2), Mihaela Mdlina Gavrilescu (1),
adiye Ioana Scripcariu (3), A. Panu (1), V. Scripcariu (1)
(1) Institutul Regional de Oncologie, Clinica I Chirurgie Oncologic, Iai, Romnia
(2) Institutul Regional de Oncologie, Clinica I Chirurgie Oncologic, Compartimentul Ginecologie, Iai, Romnia
(3) Maternitatea Cuza Vod, Clinica I Obstetric i Ginecologie, Iai, Romnia
Introducere: Cancerul ovarian este cea de-a 6 cea mai frecvent neoplazie, diagnosticat la femei. Alturi de diagnosticul precoce i stadializarea corect
preoperatorie, chirurgia citoreductiv reprezint unul dintre cei mai importani factori de prognostic, n ceea ce privete supravieuirea global i intervalul liber
de boal. Scopul acestui studiu este de a evalua rezultatele postoperatorii pentru pacientele diagnosticate cu cancer ovarian epitelial local avansat, la care s-a
practicat tratament chirurgical de prima intenie (PDS) sau citoreducie tumoral dup chimioterapie neoadjuvant (CS).
Metode: Am efectuat un studiu retrospectiv n care am inclus toate pacientele cu cancer ovarian epitelial local avansat, la care s-a practicat tratament chirurgical
de prim intenie (PDS) sau citoreducie tumoral dup chimioterapie neoadjuvant (CS). Au fost analizate caracteristicile clinico-patologice i s-a efectuat o
analiz comparativ n ceea ce priveste morbiditatea i mortalitatea postoperatorie.
Rezultate: Au fost incluse 223 de paciente, ntr-o perioad de 44 de luni, diagnosticate cu cancer ovarian, n 125 cazuri s-a practicat tratament chirurgical per
primam i n 98 cazuri s-a optat pentru chimioterapie neoadjuvant, urmat de second look i citoreducie tumoral. n 70 % din cazuri, s-a practicat citoreducie
optim, cu un reziduu tumoral de sub 1 cm. La 53 de paciente s-a efectuat rezecie multiorganic. n grupul cu rezecii multiorganice, morbiditatea postoperatorie
sever (Dindo Clavien gradul III - IV), a fost apreciat n 15 cazuri.
Concluzii: Citoreducia tumoral, se caracterizeaz printr-o rat a morbiditii postoperatorii crescut, ns acestea pot fi evitate printr-o selecie atent a
pacientelor, respectiv o ngrijire postoperatorie adecvat, devenind astfel o opiune fezabil pentru pacientele diagnosticate cu neoplasm ovarian, pentru a
mbunti statistic rata supravieuirii globale, respectiv pentru mbuntirea calitii vieii.

Introduction: Ovarian cancer is the sixth most common cancer among women. In addition to diagnosis and staging, primary surgery is performed to achieve
optimal cytoreduction as the amount of residual tumor is one of the most important prognostic factors for survival of women with epithelial ovarian cancer. The
aim of this study was to evaluate the outcome for patients with epithelial ovarian cancer treated with primary debulking surgery (PDS) or cytoreductive surgery
after neoadjuvant chemotherapy (CS).
Methods: We performed a retrospective study on all patients in which surgical approach for ovarian cancer was upfront surgery or cytoreductive surgery after
neoadjuvant chemotherapy. Clinicopathological characteristics were described and a comparative analysis for postoperative morbidity and mortality was
performed.
Results: There were included 223 patients in a 44-month period, who were diagnosed with ovarian cancer, out of which 125 patients went for upfront surgery and
in 98 cases neoadjuvant chemotherapy was performed followed by citoreductive surgery. In 70% cases, optimal cytoreduction was achieved. In 53 patients
multiorgan resection was performed. In the multiorgan resection group overall severe complications (Dindo Clavien Grade III-IV) occurred in 15 cases.
Conclusions: Cytoreductive surgery involves a high risk of morbidity, but postoperative complications could be resolved in most cases with correct patient
selection and adequate postoperative care. Completeness of cytoreduction was proved to be crucial for long-term outcome.

Histerectomia radical robotic versus laparoscopic n cancerul cervical: un studiu comparativ cu cazuri pereche
Robotic versus Laparoscopic Radical Hysterectomy in Cervical Cancer Patients: A Matched-Case Comparative Study
S. Pantea, C. Du, D. A. Brebu, C. Tara, C. Lazr, A. Dobrescu, F. Lazr
Spitalul Clinic Judeean de Urgen Pius Brnzeu, Clinica 2 Chirurgie, Timioara, Romnia
Scop: Acest studiu are ca scop compararea rezultatelor iniiale postoperatorii i a ratei de complicaii la pacienii cu cancer cervical n faz incipient, ce au fost
supui histerecomiei radicale pe cale robotic (HRR) i histerectomiei radicale pe cale laparoscopic (HRL).
Material i Metod: Pacienii diagnosticai cu neoplasm cervical invaziv (stadiul I-IIA FIOG) crora li s-a efectuat HRR (n=11) n Clinica 2 Chirurgie, Timioara n
perioada septembie 2015martie 2016 au fost comparai cu pacieni selectai crora li s-a efectuat HRL n perioada 2011-2015. Cele 2 grupuri au fost similare din
punct de vedere al vrstei, IMC, stadiul bolii, subtipul histologic, dimensiunea tumorii i invazia ganglionar. Datele despre informaiile pacienilor i urmrirea
postoperatorie au fost colectate retrospectiv.
Rezultate: Timpul operator a fost crescut (242 vs 196 minute) n cazul HRR comparativ cu HRL, dar fr semnificaie statistic. Cantitatea medie de snge pierdut
intraoperator a fost semnificativ redus n cazul HRR (200 vs 350 ml; p=0.036). ntre complicaiile intraoperatorii i postoperatorii nu au fost diferene
semnificative ntre cele 2 grupuri (4.3% pentru HRR vs 1.45% pentru HRL; p=0.439). Numrul mediu de ganglioni prelevai nu a diferit semnificativ ntre cele 2
grupuri (16 n HRR vs 18 n HRL; p=0.563).
Concluzii: Cu toate c timpul operator a fost mai lung n cazul HRR datorit lipsei de experien n chirurgia robotic, am demonstrat c rezultatele postoperatorii
i rata complicaiilor HRR sunt comparabile cu HRL. n plus, aptitudinile chirurgicale pentru HRL sunt transmise cu usurin i n siguran la HRR n cazul unui
chirurg experimentat.

Aim: This study aimed to compare initial surgical outcomes and complication rates of patients with early-stage cervical cancer who underwent robotic radical
hysterectomy (RRH) and conventional laparoscopic radical hysterectomy (LRH).
52

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Methods: Patients diagnosed with invasive cervical cancer (IFOG stage I-IIA) who underwent RRH (n=11) at the 2nd Surgical Clinic, Timioara from September 2015
to March 2016 were compared with matched patients who underwent LRH (n=29) during 2011-2015. The 2 surgical groups were matched for variables of age,
body mass index, International Federation of Gynecology and Obstetrics stage, histological subtype, tumor size, and node positivity. All patient information,
surgical and postoperative follow-up data were retrospectively collected.
Results: Operating time was longer (242 vs 196 minutes) in the RRH group compared with the LRH group, but without statistical significance. The mean estimated
blood loss was significantly reduced in the RRH group (200 vs 350 mL; p=0.036). Intraoperative and postoperative complications were not significantly different
between the 2 groups (4.3% for RRH vs 1.45% for LRH; p=0.439). The median lymph nodes retrieval was not significantly different between the 2 groups (16 for
RRH vs. 18 for LRH; p=0,563).
Conclusions: Although the operating time was longer in the RRH cases because of lesser experience on robotic platform, we showed that surgical outcomes and
complication rate of RRH were comparable to those of LRH. In addition, surgical skills for LRH are easily and safely translated to RRH in the case of experienced
laparoscopic surgeons.

Tratamentul multimodal n cancerele epiteliale ovariene avansate


Multimodal Treatment in Advanced Epithelial Ovarian Cancer
A. M. Marinca, G. D. Subirelu, V. M. Prunoiu, Snziana Octavia Ionescu, L. Simion, E. Brtucu, N. D. Straja
Institutul Oncologic Prof. Dr. Al. Trestioreanu, Chirurgie General i Oncologic I, Bucureti, Romnia
Cancerul ovarian este al noulea cel mai comun cancer la femei i a cincea cauz de deces prin cancer. Aproximativ 90% dintre tumorile maligne primitive
ovariene sunt epiteliale ca origine (carcinoame), iar 70% dintre pacientele cu cancere epiteliale ovariene se prezint n stadii avansate, ceea ce ridic probleme
terapeutice majore. Obiectivul prezentului studiu este de a evalua rezultatele tratamentului multimodal - ai crui pivoi sunt chirurgia i chimioterapia, n cancerul
epitelial ovarian avansat (COA).
Material i metod: Este un studiu retrospectiv efectuat pe un lot de 389 paciente cu COA, operate n Clinica Chirurgie General i Oncologic I din Institutul
Oncologic Bucureti, ntre anii 2005-2014, vrsta pacientelor fiind cuprins ntre 27-79 ani.
Rezultate: Fiecare caz a fost examinat cu privire la tipul histopatologic, grad de difereniere, stadiu, amploarea interveniei chirurgicale i complicaiile acesteia,
schema de chimioterapie administrat i secvena terapeutic, vindecare sau interval liber de boal, calitatea vieii, recidive i tratamentul acestora. Sunt
evaluate influenele tipului histopatolgic, ale gradului tumorii i ale stadiului, ale interveniei chirurgicale efectuate i ale eventualului volum de tumor rezidual,
schemei de chimioterapie administrat i secvenei terapeutice asupra ratei de vindecare, intervalului liber de boal i ratei de recidiv.
Concluzii: COA este o afeciune n care vindecarea este rareori obinut, dar un interval ct mai lung liber de boal i o calitate rezonabil a vieii, sunt obiective
care justific tratatmentul.

Ovarian cancer is the ninth most common cancer in women and the fifth leading cause of cancer death. Approximately 90% of ovarian tumors are malignant
primitive epithelial in origin (carcinomas), and 70% of patients with ovarian epithelial cancer are in advanced stages, which raises a major therapeutic challenge.
The objective of this study is to evaluate the results of multimodal treatment - whose pivots are surgery and chemotherapy in advanced epithelial ovarian cancer
(AOC).
Methods: This is a retrospective study on a group of 389 patients with AOC operated in the Ist Clinic of General and Oncology Surgery of the Oncology Institute of
Bucharest, between 2005-2014, the age of the patients was between 27 and 79 years.
Results: Each case was examined with reference to the histopathologic type, degree of differentiation, stage, extent of surgery and its complications, the
chemotherapy and the sequence of treatment, the disease-free interval, quality of life, recurrences and their treatment. We evaluated the influence of the
histopathologic type, the tumor grading and the stage, of the surgery performed and eventual volume of residual tumor, chemotherapy schedule administered
and sequence of therapy to the rate of cure, the disease-free interval and the rate of relapse.
Conclusions: AOC is a condition in which the cure is rarely achieved, but a longer disease-free interval and a reasonable quality of life are goals that justify the
treatment.

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53

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Avantajele anastomozelor mecanice n chirurgia rectului


The Advantages of the Stapled Anastomosis in Rectal Surgery
M. H. Stanca
Institutul Regional de Gastroenterologie i Hepatologie Prof. Dr. Octavian Fodor, Clinica Chirurgie 3, Cluj-Napoca, Romnia
n ultimele decade chirurgia rectal pentru cancer s-a concentrat pe dezvoltarea tehnicilor care s asigure o ct mai mare acuratee din punct de vedere
oncologic i, n acelai timp, s ofere n perioada postrezecie o calitate a vieii ct mai aproape de normal. Amputaia de rect, considerat standardul de aur
pentru tumorile de rect mijlociu i inferior, a lsat locul rezeciilor anterioare joase i ultrajoase cu excizia total a mezorectului i prezervarea sfincterului anal,
urmate de anastomoze colorectale sau coloanale. Utilizarea anastomozelor mecanice au permis coborrea nivelului anastomozei, fr a fi sacrificat radicalitatea
oncologic. Cu toate c nu s-a demonstrat a fi superioare din punct de vedere al complicaiilor, acestea reduc timpul operator, permit efectuarea n totalitate a
tehnicii pe abord laparoscopic i, folosind tehnici adiionale, pot scuti pacientul de o stomie de protecie. Cazuistica Departamentului Chirugie din cadrul IRGH O.
Fodor Cluj-Napoca pe perioada ianuarie 2013 - februarie 2016 cuprinde 173 de cazuri de rezecii anterioare de rect cu anastomoz, din care dispozitivele
mecanice de sutur s-au utilizat la 95 de cazuri (54,90%). Fistula anastomotic a aprut la 7 cazuri cu sutur manual (8,97%), sutura mecanic fiind responsabil
pentru numai 3 cazuri (3,15%) Scopul prezentrii este acela de a sublinia avantajele suturii mecanice n anastomozele dup rezeciile rectale.

In the last decades surgery for rectal cancer focused on improvements of techniques to assure the best accuracy from the oncological point of view and, in the
same time, to offer a better quality of life in the post-resection period. Rectal amputation, considered the gold standard for mid and low rectum tumors let room
for the low and ultralow rectal resections with total mesorectal excision and preservation of the anal sphincter, followed by colo-rectal and colo-anal anastomosis.
Lowering of the level of the anastomose was facilitated by the use of the staping devices, without the sacrifice of the oncological radicality. Altought the
mechanical anastomosis dont seems to assure a real protection against the risk of anastomotic fistulas, stapling devices are reducing the operative time, are
permiting an exclusive laparoscopic approach and, using additional techique, could avoid a protection stomy. During the period of January 2013 February 2016,
in the surgery Department of IRGH O. Fodor Cluj-Napoca 173 restaurative anterior rectal resection were performed, from whom in 95 (54.90%) cases stapling
devices were used. Anastomotic fistula occurred in 7 cases of manual suture (8,97%), mechanical suture being responsible for 3 cases (3,15%). The aim of this
presentation is to highlight the advantages of mechanical suture in anastomosis after rectal resections.

Exenteraiile pelvine n chirurgia cancerelor rectale


Pelvic Exenterations in Rectal Cancer Surgery
D. Munteanu
Institutul Regional de Gastroenterologie i Hepatologie Prof. Dr. Octavian Fodor, Chirirgie I, Cluj-Napoca, Romnia
Definiia noiunii de cancer rectal primitiv local avansat poate prezenta variaii n funcie de centru. n aceast categorie intr tumorile T3 i T4 (5-45%). Pentru
tumorile rectale primitive T4 (cu invazii directe la organele i structurile pelvine adiacente), precum i pentru recidivele postoperatorii local extinse, exerezele
rectale cu excizie mezorectal total sunt insuficiente. Tratamentul acestor cazuri devine complex, multimodal, ntotdeauna iniiat de chimio-radioterapie cu scop
de downstaging/downsizing, urmat, la intervale variabile (6-8, 9-10, sau chiar 12 sptmni) de exerezele multiviscerale pelvine din categoria exenterailor.
Introdus de Brunschwig n 1948 ca procedeu extrem, dar cu scop paliativ, exenteraia pelvin total este indicat azi ca procedeu curativ, evidarea pelvin
constnd n exereza n bloc a rectului, sigmei, uterului i anexelor, a vezicii urinare i ureterelor distale, limfadenectomia i peritonectomia pelvin, cu sau fr
sacrectomie.
Doar 50% din aceste exereze sunt ns radicale (R0); mortalitatea, poate atinge valori mari n centre cu experien (3-18,9%), cu supravieuiri la 3 ani de 25-45%.
Restul de 50% din aceste exereze sunt incomplete (R1/R2-prognostic sever). Dificultile exerezei sunt dublate de cele ale reconstruciilor multidisciplinare (vagin,
urologice, pelvi-perineale), toate pe teren iradiat.
Morbiditatea foarte mare (70-86%), hemoragii, supuraii, necroze extinse, fistule perineale - urinare, fecale-, evisceraiile, eventraiile pelvine, durerile, refacerea
lent, altereaz profund calitatea vieii.
Disconfortul psihic profund, compromiterea vieii sexuale, familiale, divorialitatea, alterarea imaginii personale, servituile i limitrile legate de stome,
reintervenii, incapacitatea de munc, pierderea veniturilor, pensionarea, toate acestea fac ca pentru muli pacieni, viaa de dup s fie disproporionat de
grea.

Defining primary local advanced rectal cancers may vary, but usually T3 and T4 tumors are included (5-45%). For primitive T4 tumors (direct invading pelvic
organs and structures) and rectal recurrent advanced cancers, resection with TME is not sufficient. These cases require down-staging/down-sizing
chemo-radiotherapy, followed (after variable intervals of 6-8, 9-10, even 12 weeks) by extended multivisceral exenterative surgery. Originally described by
Brunschwig as palliation of advanced pelvic malignancies, total pelvic exenteration is used nowadays with radical intent, involving complete extirpation of the
anal canal, rectum, sigmoid colon, urinary bladder with distal ureters, internal reproductive system, pelvic lymphadenectomy and peritonectomy, with or without
sacrectomy.
Only 50% of these cases are suitable for this major surgery. 50% of the exenterations are radical (R0); mortality can be high even in experienced centers (3-18,9%)
and 3 years survival rates are 25-45%. 50% of these resections are incomplete (R1/R2 severe prognosis). Technical demanding resections are followed by
complex multidisciplinary reconstructions (genital tract, ureters, pelvi-perineal), all of them on irradiated tissues.
The high morbidity (70-86%) bleedings, wound infections and extensive necrosis, perineal fistulae (fecal, urinary), eviscerations, pelvic herniation, pain, long
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Physicians Session Oral Communications
recovery, do profoundly alter patients quality of life.
Deep psychological impact, sexual function disorders, familial problems, abandons, divorces, body image alteration, limitations generated by stomas, (in patients
with two stomas), discomfort generated by complications and reoperations, incomplete working capacity recovery, unemployment, significant decline of income,
well, all these are a disproportionate price to pay for many patients.

Tratamentul laparoscopic al litiazei colecisto-coledociene


Laparoscopic Management of Cholecysto-Choledocholithiasis
L. Alecu (1), Beatrice Linoiu-Ursu (1), Adriana Deacu (1), A. Tulin (1), I. Slavu (2), V. Braga (2), A. Kraft (3)
(1) Spitalul Clinic de Urgen Prof. Dr. Agrippa Ionescu, Clinica de Chirurgie General, Bucureti, Romnia
(2) Spitalul Clinic de Urgen Floreasca, Clinica de Chirurgie General, Bucureti, Romnia
(3) Spitalul Clinic Colea, Clinica de Chirurgie General, Bucureti, Romnia
Litiaza colecisto-coledocian apare n circa 5-15% din cazurile care se prezint pentru colecistectomie laparoscopic. Dei diagnosticul preoperator de rutin
rmne n continuare problematic, arsenalul terapeutic este redutabil. Chiar dac nu exist un consens pentru strategia terapeutic optim, tratamentul
laparoscopic este cel mai indicat n majoritatea cazurilor. Material i metod: Au fost studiate foile de observaie, protocoalele operatorii i n anumite cazuri
revzute nregistrrile, fiind notate indicaiile, contraindicaiile, dificultile i complicaiile. Rezultate: Prezentarea experienei clinicii, 42 de cazuri de litiaz
colecisto-coledociana rezolvate laparoscopic, n ceea ce privete indicaii, contraindicaii, dificulti, complicaii i rezolvarea lor. Concluzii: Explorarea
intraoperatorie ecografic asociat cu colangiofibroscopia transcistica sau prin coledocotomie reprezint atitudinea de ales pentru rezolvarea laparoscopic
concomitent a litiazei colecisto-coledociene, abordul transcistic fiind ideal. Complicaiile adiionale ale chirurgiei sunt legate de drenajul biliar extern.
Diagnosticul i tratamentul exclusiv laparoscopic este fezabil i de preferat, curba de nvare necesit cel puin 20 de intervenii, ns este setat n condiii de
dotare tehnic.

Colecistectomia laparoscopic n colecistita acut


Laparoscopic Cholecystectomy in Acute Cholecystitis
L. Alecu (1), Beatrice Linoiu-Ursu (1), Adriana Deacu (1), A. Tulin (1), I. Slavu (2), V. Braga (2), A. Kraft (3)
(1) Spitalul Clinic de Urgen Prof. Dr. Agrippa Ionescu, Clinica de Chirurgie General, Bucureti, Romnia
(2) Spitalul Clinic de Urgen Floreasca, Clinica de Chirurgie General, Bucureti, Romnia
(3) Spitalul Clinic Colea, Clinica de Chirurgie General, Bucureti, Romnia
n majoritatea rilor vestice i n Romnia, colecistectomia este cea mai frecvent intervenie chirurgical abdominal efectuat i fr ndoial cea mai frecvent
intervenie laparoscopic. Colecistita acut i anatomia aberant deschid drumul spre incidente intraoperatorii i/sau conversie. Obiectivul studiului a constat n
analiza cazurilor diagnosticate i operate pentru colecistita acut, n perioada 1997 - 2016.
Material i metod: Au fost analizate foile de observaie i protocoalele operatorii a peste 2000 de pacieni operai n clinic. Datele procesate au fost
reprezentate de: vrst, sex, diagnostic, metoda de investigaie preoperatorie i intraoperatorie, prezena sau absena litiazei veziculare, formele
anatomopatologice de colecistit acut, aspecte de tehnic utilizat, incidentele intraoperatorii, conversii la chirurgia deschis, complicaii postoperatorii,
reintervenii i durata de spitalizare.
Rezultate i concluzii:
1. Colecistita acut presupune dificulti intraoperatorii determinate de pericolecistit i pediculit.
2. Riscul de leziune a cii biliare principale este mai mare n colecistita acut.
3. Explorarea intraoperatorie prin ecografie i colangiografie permite lmurirea anatomiei locale i evitarea leziunilor de cale biliar principal.
4. Hemoragiile intraoperatorii, dar i postoperatorii, sunt mai frecvente n colecistita acut.
5. Complicaiile postoperatorii care au necesitat reintervenie au fost rezolvate tot pe cale laparoscopic.
6. Conversia la chirurgia deschis este n cea mai mare parte asociat cu colecistita acut.

Congresul Naional de Chirurgie 2016 01 - 04 iunie 2016 Centrul Internaional de Conferine Sinaia
National Congress of Surgery 01 - 04 June 2016 Sinaia International Conference Center
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55

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Physicians Session Oral Communications

Explorarea intraoperatorie a cii biliare principale n chirurgia laparoscopic


Intraoperative Exploration of Common Bile Duct in Laparoscopic Surgery
I. Slavu (1), Beatrice Linoiu-Ursu (2), Adriana Deacu (2), A. Tulin (2), V. Braga (1), A. Kraft (3), L. Alecu (2)
(1) Spitalul Clinic de Urgen Floreasca, Clinica de Chirurgie General, Bucureti, Romnia
(2) Spitalul Clinic de Urgen Prof. Dr. Agrippa Ionescu, Clinica de Chirurgie General, Bucureti, Romnia
(3) Spitalul Clinic Colea, Clinica de Chirurgie General, Bucureti, Romnia
Au existat i exist n continuare dezbateri n literatura de specialitate referitoare att la cazurile care ar necesita o explorare suplimentar intraoperatorie a cii
biliare principale pentru litiaz, dar i referitor la metoda optim care ar putea fi utilizat pentru a o putea identifica.
Material i metod: Am efectuat un studiu retrospectiv ce s-a desfurat pe o perioad de 18 ani n cadrul cruia au fost analizate un numr de 2780
colecistectomii laparoscopice efectuate n cadrul Seciei Clinice Chirurgie General a Spitalului Clinic de Urgen Prof. Dr. Arippa Ionescu. n cadrul studiului a
fost analizate eficiena i indicaia a trei metode laparoscopice de diagnostic a litiazei de cale biliar principal. Au fost investigate retrospectiv foile de observaie,
protocoalele operatorii, precum i investigaiile clinice i paraclinice, mpreun cu rezultatele histopatologice aferente.
Rezultate: S-au fost efectuat un numr de 83 ecografii laparoscopice intraoperatorii care au presupus o cretere a timpului operator cu 7-12 minute, rezultatele
fiind ns influenate de experiena echipei. Litiaza de cale biliar principal a fost identificat la 19% dintre cazuri. Au fost identificate un numr 54 de
colangiografibroscopii laparoscopice dintre care 33 s-au efectuat prin abord transcistic i 16 prin abord transcoledocian interveniile, avnd o durat medie de
120 min. Colangiografia fost efectuat la 34 pacieni, substana de contrast a fost administrat transcistic fr a exista reacii de tip alergic la aceasta. Selecia
pacienilor pentru fiecare metod a fost individualizat n funcie de investigaiile paraclinice i antecedentele personale patologice ale acestora.
Concluzii: Ultrasonografia laparoscopic are o curb lent de nvare. Colangiofibroscopia este o metod cost-eficient ce permite explorarea arborelui biliar i
rezolvarea unei litiaze de cale biliar principal n cadrul aceleiai intervenii laparoscopice. Colangiografia este o metod mai costisitoare dect ultrasonografia
laparoscopic, ns permite o mai bun identificare a anomaliilor anatomice ale arborelui biliar.

Abordul laparosopic n ulcerul perforat


Laparoscopic Approach in Perforated Ulcer
V. Braga (1), Beatrice Linoiu-Ursu (2), Adriana Deacu (2), A. Tulin (2), I. Slavu (1), A. Kraft (3), L. Alecu (2)
(1) Spitalul Clinic de Urgen Floreasca, Clinica de Chirurgie General, Bucureti, Romnia
(2) Spitalul Clinic de Urgen Prof. Dr. Agrippa Ionescu, Clinica de Chirurgie General, Bucureti, Romnia
(3) Spitalul Clinic Colea, Clinica de Chirurgie General, Bucureti, Romnia
Ulcerul perforat este o patologie a crei inciden este n scdere, datorit utilizrii tratamentului medicamentos antisecretor. Sutura primar a ulcerului perforat
este o metod des folosit n chirurgia de urgen. Abordul laparoscopic al ulcerului perforat a fost prima dat introdus n anii 1990, urmnd s fie utilizat din ce n
ce mai des datorit avantajelor chirurgie miniminvazive. Scopul studiului este de a evalua avantajele utilizrii laparoscopiei n tratamentul ulcerelor perforate.
Material i metod: A fost efectuat un studiu retrospectiv pe o perioad de 15 ani ntre 01.01.2000 i 31.12.2015, n cadrul Seciei Clinice Chirurgie General a
Spitalului Prof. Dr. Agrippa Ionescu. n studiu au fost insclusi 7 pacieni cu vrste cuprinse ntre 37 i 70 ani, diagnosticai cu ulcer perforat. n toate cazurile
localizarea ulcerului a fost la nivelul feei anterioare a duodenului. Pacienii inclui n studiu au suferit intervenii chirurgicale prin abord miniminvaziv n urgen
pentru inchiderea perforaiei peretelui digestiv. Au fost realizate suturi primare, efectuate cu fire separate n X sau utliznd EndoStitch, cu sau fr
epiploonoplastie. La 3 pacieni a fost necesar conversia datorita aderentelor peritoneale. Toti pacienii care au beneficiat de sutura laparoscopic a ulcerului
perforat au efectuat tratament postoperator cu antisecretorii.
Concluzii:
1. Tratamentul laparoscopic al ulcerului perforat este simplu i const n sutura perforaiei cu lavajul i drenajul corect al cavitii peritoneale.
2. Este obligatoriu tratamentul medicamentos antisecretor corect postoperator.

56

Congresul Naional de Chirurgie 2016 01 - 04 iunie 2016 Centrul Internaional de Conferine Sinaia
National Congress of Surgery 01 - 04 June 2016 Sinaia International Conference Center
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Sesiune Medici Comunicri orale


Physicians Session Oral Communications

Peritonit postoperatorie prin fistul de sutur mecanic dup gastrectomie longitudinal laparoscopic - Caz
clinic
Postoperative Peritonitis by Mechanical Suture Fistula After Longitudinal Laparoscopic Gastrectomy - Clinical Case
I. Slavu (1), Beatrice Linoiu-Ursu (2), Adriana Deacu (2), A. Tulin (2), V. Braga (1), A. Kraft (3), L. Alecu (2)
(1) Spitalul Clinic de Urgen Floreasca, Clinica de Chirurgie General, Bucureti, Romnia
(2) Spitalul Clinic de Urgen Prof. Dr. Agrippa Ionescu, Clinica de Chirurgie General, Bucureti, Romnia
(3) Spitalul Clinic Colea, Clinica de Chirurgie General, Bucureti, Romnia
Prezentm cazul pacientului SS n vrst de 44 care a fost supus unei intervenii chirurgicale de tip bariatric/metabolic - gastrectomie longitudinal laparoscopic
(IMC = 44kg/mp). La 5 zile postoperator pacientul prezint tablou clinic sugestiv pentru peritonit. Radiografia abdominal pe gol a identificat pneumoperitoneu.
Examenul ecografic a artat existena de lichid peritoneal n cantitate redus. Biologic s-a identificat leucocitoz i sindrom inflamator. S-a intervenit chirurgical
de urgen - laparoscopic iar intraoperator s-a identificat pneumoperitoneu i lichid peritoneal tulbure n cantitate mic. Continundu-se explorarea s-a identificat
un orificiu fistulos mic corespunztor unei dintre agrafele tranei de sutur mecanic. S-a practicat lavaj aspirativ abundent, drenaj multiplu peritoneal i
montarea unei sonde nazogastrice sub control laparoscopic. Evoluia postoperatorie a fost favorabil cu realuarea tranzitului intestinal i ndeprtarea progresiv
a tuburilor de dren. Pacientul a fost externat n ziua 7 postoperator dup reintervenie. Abordul laparoscopic poate fi utilizat cu succes n reinterveniile dup
chirurgia bariatric.

Apendicectomia laparoscopic
Laparoscopic Appendectomy
Beatrice Linoiu-Ursu (1), Adriana Deacu (1), A. Tulin (1), I. Slavu (2), V. Braga (2), A. Kraft (3), L. Alecu (1)
(1) Spitalul Clinic de Urgen Prof. Dr. Agrippa Ionescu, Clinica de Chirurgie General, Bucureti, Romnia
(2) Spitalul Clinic de Urgen Floreasca, Clinica de Chirurgie General, Bucureti, Romnia
(3) Spitalul Clinic Colea, Clinica de Chirurgie General, Bucureti, Romnia
Scopul acestei lucrri este de a prezenta experiena colectivului nostru n tratamentul laparoscopic al apendicitei acute.
Material i metod: Am analizat retrospectiv o serie de 151 de cazuri consecutive diagnosticate cu apendicit acut i la care apendicectomia s-a efectuat pe cale
laparoscopic, pe o perioad de 19 ani, ntre 1/01/1997 i 1/01/2016 n cadrul Seciei Clinice Chirurgie General a Spitalului Clinic de Urgen Prof. Dr. Agrippa
Ionescu.
Rezultate: Dintre cazurile operate 97 au fost de sex feminin i 54 de sex masculin. Vrsta medie a pacienilor a fost de 36,3 ani. 144 de cazuri au fost finalizate
prin abord laparoscopic. Astfel au fost operate: apendicit cataral (90 de cazuri), apendicit flegmonoas (48 cazuri), apendicit gangrenoas (18 cazuri),
precum i apendicit acut cu peritonit generalizat (5 cazuri). Rata de conversie a fost de 4,63% (7 cazuri), n principal din cauza lipsei de experien n primii
ani de utilizare a acestei metode. S-au folosit trei tehnici de apendicectomie: anterograd, retrograda i stapler. Durata medie de spitalizare a fost de 2,7 zile.
Evoluia postoperatorie a fost lipsit de evenimente pentru toate cazurile, cu excepia unui singur caz de hemoragie parietal provenit din orificiul de trocar
suprapubian ce a fost rezolvat prin reintervenie laparoscopic.
Concluzii: Abordul laparoscopic a fost utilizat cu succes n diagnosticul i tratamentul cazurilor cu apendicit acut. Metoda laparoscopic a fost util n
diagnosticul sindromului dureros de fos iliac dreapt, mai ales pentru femeile fertile. Abordul laparoscopic permite o explorare bun a ntregii caviti
abdominale, fiind astfel posibil diagnosticul i tratamentul chirurgical al altor patologii chirurgicale sincrone. Identificarea apendicelui aflat n poziii dificile este
mai facil decat n apendicectomia deschis.

Congresul Naional de Chirurgie 2016 01 - 04 iunie 2016 Centrul Internaional de Conferine Sinaia
National Congress of Surgery 01 - 04 June 2016 Sinaia International Conference Center
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57

Sesiune Medici Comunicri orale


Physicians Session Oral Communications

Abordul laparoscopic n ocluzia intestinal


Laparoscopic Approach in Intestinal Obstruction
V. Braga (1), Beatrice Linoiu-Ursu (2), Adriana Deacu (2), A. Tulin (2), I. Slavu (1), A. Kraft (3), L. Alecu (2)
(1) Spitalul Clinic de Urgen Floreasca, Clinica de Chirurgie General, Bucureti, Romnia
(2) Spitalul Clinic de Urgen Prof. Dr. Agrippa Ionescu, Clinica de Chirurgie General, Bucureti, Romnia
(3) Spitalul Clinic Colea, Clinica de Chirurgie General, Bucureti, Romnia
nc de la debut laparoscopia prin abordul minim invaziv pe care l ofer a fost rapid acceptat de ntreaga clas de chirurgi, iar indicaiile acesteia, dei limitate
la nceput, au fost extinse constant, fiind astzi utilizat cu succes pentru a trata cazuri chirurgicale din cele mai complexe printre care i ocluzia intestinal.
Material i metod: Am efectuat un studiu retrospectiv pe o perioad de 19 ani n care au fost identificate i analizate un numr de 26 de cazuri diagnosticate cu
ocluzie intestinal i operate prin abord minim invaziv n cadrul Seciei Clinice Chirurgie General a Spitalului Clinic de Urgen Prof. Dr. Agrippa Ionescu.
Rezultate: Cauzele de ocluzie intestinal identificate au fost: bridele aderentiale - 17 cazuri, volvulusul de colon - 1 caz, boala Crohn - 2 cazuri i tumor de colon
sau rect 6 - cazuri. Abordul laparoscopic n ocluziile intestinale prin tumori de colon a fost limitat i s-a finalizat cu conversie la chirurgie deschis atunci cnd
distensia important a anselor de intestin nu au permis efectuarea unei camere de lucru. Operaiile efectuate au constat n adezioliz, enterectomie segmentar
asistat laparoscopic, colectomie de transvers asistat laparoscopic i sigmoidectomie asistat laparoscopic. Conversia s-a realizat n 6 cazuri. Pincipala cauz de
conversie a fost lipsa camerei de lucru. Mortalitatea perioperatorie a fost 0.
Concluzii: Chirurgia laparoscopic poate fi utilizat cu succes pentru a trata cazurile de ocluzie intestinal atta timp ct nu exist o distensie important a
anselor intestinale. n cazul prezenei de bride, aceste pot fi secionate cu succes, iar abordul minim invaziv reduce substanial formarea altora noi n viitor. Este
foarte important s se cunoasc istoricul chirurgical al pacientului dac se opteaz pentru acest abord chirurgical. Morbiditatea postoperatorie este mai redus
fa de chirurgia deschis.

Abordul laparoscopic al urgenelor ginecologice


Laparoscopic Approach of Gynaecological Emergencies
A. Kraft (1), Beatrice Linoiu-Ursu (2), Adriana Deacu (2), A. Tulin (2), I. Slavu (3), V. Braga (3), L. Alecu (2)
(1) Spitalul Clinic Colea, Clinica de Chirurgie General, Bucureti, Romnia
(2) Spitalul Clinic de Urgen Prof. Dr. Agrippa Ionescu, Clinica de Chirurgie General, Bucureti, Romnia
(3) Spitalul Clinic de Urgen Floreasca, Clinica de Chirurgie General, Bucureti, Romnia
Am realizat un studiu analitic, de cohort, retrospectiv, ntocmit prin analizarea cazuisticii noastre, cu scopul de a prezenta o analiz a experienei privind
urgenele acute abdominale ginecologice, abordate pe cale laparoscopic. Prezenta lucrare, desfurat n Clinica de Chirurgie General a Spitalului Clinic de
Urgen Prof. Dr. Agrippa Ionescu Bucureti, include o serie consecutiv de 36 de paciente, internate n urgen, n ultimii 17 ani i sancionate chirurgical prin
abord laparoscopic, pentru urgene abdominale ginecologice. Pentru a ntregi diagnosticul, toate pacientele incluse n studiu au fost investigate n preoperator
prin ecografie abdominal. Am supus analizei: concordana dintre diagnosticul preoperator i leziunile identificate prin laparoscopie, apariia complicaiilor, rata
reinterveniilor, durata spitalizrii, impunerea drenajului, precum i instrumentul chirurgical folosit pentru disecie. Rezultatele noastre arat c abordul
laparoscopic aduce avantajul unei perioade mai sczute de spitalizare, dar, mai ales, al unei explorri temeinice a ntregii caviti peritoneale pentru a confirma
ipoteza diagnosticului preoperator. De asemenea, laparoscopia permite i tratamentul altor patologii prin folosirea aceleiai ci de acces, precum i reducerea
riscului formrii aderenelor postoperatorii i al complicaiilor de plag. Totodat, experiena noastr arat c frecvent se impune necesitatea unui diagnostic ct
mai corect i rapid al bolnavei, realizat n condiii optime de ctre o echip multi-disciplinar. Folosirea metodelor actuale de diagnostic paraclinic, mpreun cu
progresul tehnicii chirurgicale endoscopice, ofer chirurgilor toate mijloacele necesare pentru a considera laparoscopia o metod eficient n diagnosticul i
tratamentul urgenelor ginecologice.

58

Congresul Naional de Chirurgie 2016 01 - 04 iunie 2016 Centrul Internaional de Conferine Sinaia
National Congress of Surgery 01 - 04 June 2016 Sinaia International Conference Center
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Sesiune Medici Comunicri orale


Physicians Session Oral Communications

Reintervenii laparoscopice n urgen


Emergency Laparoscopic Interventions
A. Tulin (1), Beatrice Linoiu-Ursu (1), Adriana Deacu (1), I. Slavu (2), V. Braga (2), A. Kraft (3), L. Alecu (1)
(1) Spitalul Clinic de Urgen Prof. Dr. Agrippa Ionescu, Clinica de Chirurgie General, Bucureti, Romnia
(2) Spitalul Clinic de Urgen Floreasca, Clinica de Chirurgie General, Bucureti, Romnia
(3) Spitalul Clinic Colea, Clinica de Chirurgie General, Bucureti, Romnia
Creterea experienei n cirurgia laparoscopic a condus la utilizarea tot mai frecvent a abordului minim invaziv n reinterveniile dup operaiile efectuate pe
cale deschis sau laparoscopic. Scopul studiului a fost verificarea posibilitilor de utilizare, precum i a limitelor n abordul paroscopic n reinterveniile
chirurgicale. Am urmrit reinterveniile att dup operaii prin abord minim invaziv, ct i dup intervenii realizate pe cale deschis. Au fost inclui n studiu
pacieni la care reintervenia a fost impus de o afeciune chirurgical a aceluiai organ sau dezvoltat n aceeai regiune anatomic abordat la intervenia
primar, precum i cazuri la care aspecte patologice determinate de prima operaie au condus la reexplorarea pe cale minim invaziv. Studiul a fost realizat ntr-o
manier retrospectiv incluznd un numr de 20 de reintervenii prin abord laparoscopic din perioada 1.01.1997 - 31.12.2015. Majoritatea reinterveniilor au fost
efectuate dup operaii laparoscopice pentru patologia cilor biliare, dar i pentru hemoperitoneu aprut dup chirurgia laparoscopic. Periviscerita
postoperatorie cu ocluzie intestinal dup interveniile chirurgicale pe cale deschis a reprezentat o alt indicaie a reinterveniei prin abord minim invaziv. Un al
motiv este reprezentat fistula de sutur mecanic dup gastric-sleeve.
Concluzii: Abordul laparoscopic poate fi utilizat n siguran n reinterveniile pentru complicaii postoperatorii aprute dup chirurgia cilor biliare extrahepatice.
Folosirea abordului laparoscopic n reintervenii permite finalizarea cazului prin abord miniminvaziv. Abordul laparoscopic permite un bun control, lavaj i drenaj
al cavitii peritoneale. Reinterveniile prin abord laparoscopic n complicaiile ocluzive dup chirurgia deschis aduc pe lng avantajul abordului minim invaziv i
posibilitatea efecturii adeziolizei cu un risc redus de refacere a acestora ulterior. n ocluzia intestinal folosirea cu succes a chirurgiei laparoscopice presupune
posibilitatea efecturii unei camere de lucru eficiente care s permit explorarea cavitii peritoneale, identificarea i rezolvarea obstacolului.

Sindromul de abdomen acut chirurgical - atitudine diagnostic i curativ


Acute Surgical Abdomen Syndrome - Diagnostic and Curative Attitude
S. Revencu, S. Blan, V. Mustea, D. Revencu
Universitatea de Stat de Medicin i Farmacie Nicolae Testemianu, Clinica de Chirurgie, Chiinu, Republica Moldova
Abdomenul acut chirurgical (AAC) are indicaii pentru tratament chirurgical de urgen imediat, urgen sau urgen amnat. Pe o perioad de 10 ani (2005 2015) s-au urmrit 118 pacieni cu AAC fr diagnostic etiologic preoperator. Sindroamele prezente au fost: ocluzia intestinal acut (OIA) 60 cazuri; peritonit
acut - 26 cazuri; icter mecanic - 21 cazuri; hemoragie digestiv superioar (HDS) - 6 cazuri; hemoragie digestiv inferioar (HDI) - 5 cazuri. S-a intervenit n
urgen imediat n 3 cazuri de HDS, 26 cazuri peritonit, 39 cazuri de OIA, 3 cazuri de icter mecanic, celelalte fiind operate n urgen, urgen amnat.
Neoperai 2 cazuri cu HDI. Mortalitatea postoperatorie 25 cazuri (21,2%).
Concluzii: 1. Sindromul de AAC este o realitate clinic de o gravitate major. 2. Diagnosticul etiologic i atitudinea tehnico-tactic urmeaz a fi stabilit
intraoperator. 3. Mortalitatea nalt este motivat de sindromul clinic complex, grav, urgena interveniei, incertitudini etiologice.

The Acute Surgical Abdomen is liable to surgical treatment of immediate urgency, urgency and postponed urgency. 118 patients with Acute Surgical Abdomen
without pre-surgical etiological diagnosis have been observed during a period of 10 years (2005- 2015). The observed syndromes were the following: acute
intestinal obstruction (60 cases), acute peritonitis (26 cases), mechanical jaundice (21 cases), superior digestive bleeding (5 cases). The urgent surgical treatment
was applied in 3 cases of superior digestive bleeding, 26 cases of peritonitis, 39 cases of acute intestinal obstruction, 3 cases of mechanical jaundice, the others
being either urgent or postponed urgent operations. 2 cases of superior digestive bleeding were not operated. Postoperative mortality - 25 cases (21,2%).
Conclusions: 1. The Acute Surgical Abdomen syndrome is a clinical reality of major gravity. 2. The etiological diagnosis and the technical-tactical approach will
further be determined intraoperatively. 3. The high mortality is explained by the complex and severe syndrome, urgency of intervention and etiological
uncertainty.

Congresul Naional de Chirurgie 2016 01 - 04 iunie 2016 Centrul Internaional de Conferine Sinaia
National Congress of Surgery 01 - 04 June 2016 Sinaia International Conference Center
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59

Sesiune Medici Comunicri orale


Physicians Session Oral Communications

Un nou scor pentru diagnosticul apendicitei acute: scorul ripasa


A New Diagnosis Score for Acute Appendicitis: RIPASA Score
Iuliana Dogaru (1), Mihnea Avram (1), V. Moroan (1), M. Gherghinoiu (1), A. Chelaru (2)
(1) Spitalul Clinic Judeean de Urgen Sf. Apostol Andrei, Secia Chirurgie II, Constana, Romnia
(2) Spitalul Clinic Judeean de Urgen Sf. Apostol Andrei, Secia Chirurgie I, Constana, Romnia
Obiectiv: Apendicita acut reprezint una dintre cele mai frecvente urgene chirurgicale. Vrem s determinm rolul scorului RIPASA n diagnosticul apendicitei
acute, corelndu-l cu datele histopatologice.
Material i metod: Am recrutat n studiu 102 pacieni internai n perioada mai 2014 - martie 2015 n Secia Chirurgie II a SCJU Constana cu diagnosticul de
apendicit acut. Diagnosticul a fost pus pe baza criteriilor clinice asociate cu ecografia abdominal. Scorul RIPASA a fost calculat la admisia n spital. Tuturor
pacienilor li s-a efectuat apendicectomie, iar piesa a fost trimis ctre Serviciul de Anatomopatologie. Am corelat rezultatul celor 15 parametri ai scorului RIPASA
cu rezultatele histopatologice ale pieselor de apendicectomie.
Rezultate: Pe parcursul a 11 luni am recrutat 102 pacieni: brbai 42 (41.2%) i femei 60 (58.8%). 89 cazuri au fost confirmate ca apendicit acut. Rata
apendicectomiilor negative a fost 12.75%. Valoarea de referin optim a scorului a fost 7.5. Sensibilitatea scorului RIPASA a fost 97.75%.
Concluzii: Scorul RIPASA este folositor n diagnosticul apendicitei acute.
Cuvinte cheie: apendicit acut, scor RIPASA, anatomopatologie

Aim: Acute appendicitis is one of the most common surgical emergencies. We want to determine the usefulness of the RIPASA score for the diagnosis of acute
appendicitis, using histopathological results.
Materials and Methods: From May 2014 to March 2015, 102 patients were included in this study. The diagnosis of acute appendicitis was made clinically
associated with abdominal ultrasound. The RIPASA score was applied at admission to our surgical department. The resected appendices were sent for
histopathological examination. We correlated 15 parameters of RIPASA score with the anatomo-pathological results.
Results: Within 11 months, 102 patients were recruited to the study: 42 males (41.2%) and 60 females (58.8%). 89 patients were confirmed histologically for acute
appendicitis. The rate of negative appendectomies was 12.75%. The optimal cut-off threshold score was 7.5. Sensitivity of RIPASA score was 97.75%.
Conclusions: RIPASA score is useful to diagnose acute appendicitis.
Keywords: acute appendicitis, RIPASA score, histopathology

Thoma Ionescu: un chirurg ce a pus chirurgia romneasc pe harta mondial


Thoma Ionescu: A Surgeon Who Marked Romanian Surgery on the World Map
E. Brtucu, Snziana Octavia Ionescu, N. D. Straja, A. M. Marinca, V. M. Prunoiu, L. Simion
Institutul Oncologic Prof. Dr. Al. Trestioreanu, Chirurgie I, Bucureti, Romnia
Obiective: Autorii sunt interesai n sublinierea aspectelor recunoscute internaional, ce nc l pstreaz pe chirurgul Thoma Ionescu n centrul multor repere
anatomice descriptive, i, de asemenea, n cele legate de chirurgia oncologic.
Material i metod: Cteva metode i idei inovatoare au fost analizate n comparaie cu abordarea modern a pacientului chirurgical, dup cum o dicteaz rigorile
literaturii actuale. De asemenea, vederile largi avute de profesor sunt enumerate, trecndu-se n revist importana continu a perspectivei sale, cum ar fi herniile
interne retroperitoneale, evidare lombo-aortic extins n cancere de col uterin i de corp uterin, definirea mesorectului drept structur cu importan vital n
prevenirea recidivei locale.
Rezultate: Faptele studiate i interventiile chirurgicale effectuate dup cum au fost propuse de Thoma Ionescu cel puin unele dintre ele au avut un rol important
n evoluia chirurgiei oncologice romneti iar unele dintre noiuni nc se afl n centrul ateniei dezbaterilor internaionale.
Concluzii: Thoma Ionescu a fost unul dintre chirugii romni cei mai influeni, cunoscut internaional pentru descoperirile sale n domeniile antomiei i chirurgiei.
Cu ocazia celei de-a 90-a aniversri de la moartea sa, ne amintim de vsta sa, activitatea sa i preocuprile sale chirurgicale.

Objectives: The authors are interested in emphasizing the international renowned facts which still keep Prof. Dr. Thoma Ionescu in the spotlight of anatomical
description landmarks and those of surgical oncology.
Material and method: Several methods and innovative ideas with which Thoma Ionescu impacted the surgical world are analyzed in comparison with modern day
approach to the surgical patient, as dictated by literature nowadays. Also, his wide surgical and anatomical views are enumerated with a close eye on the
continuous importance of his perspectives, such as: retroperitoneal internal hernias, extended lumbar-aortic dissection of the lymph nodes in cancers of the
uterine cervix and of the body of the uterus, the definition of the mesorectum as a structure with vital impact on the prevention of the surgical relapse.
Results: The facts studied and the surgical interventions imagined, as proposed by Thoma Ionescu, at least some of them had an important role in the evolution
of Romanian surgical oncology, and some of the notions debated are still in the spotlight of the international debate.
Conclusions: Thoma Ionescu was one of the most influential Romanian surgeons, known worldwide for his discoveries in the domain of anatomy and surgery. On
the 90th anniversary of his death we remember his broad activity and surgical preoccupations.

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Folosirea combinat a unui pedicul epiploic i a terapiei cu presiune negativ pentru salvarea unei proteze
vasculare infectate
Combined Use of Omental Flap and Negative Pressure Wound Therapy for the Salvage of an Infected Vascular
Prosthesis
V. D. Constantin (1), B. Socea (1), A. C. Carp (1), Simona Bobic (1), P. Banu (1), L. Dumitrescu (2), C. Zamfir (3), A. C. Smaranda (1), Gabriela Cozmanciuc (3),
F. Popa (1)
(1) Spitalul Clinic de Urgen Sfntul Pantelimon, Secia de Chirurgie General, Bucureti, Romnia
(2) Spitalul Clinic de Urgen Sfntul Pantelimon, Secia de Chirurgie Plastic, Bucureti, Romnia
(3) Spitalul Clinic de Urgen Sfntul Pantelimon, Secia de Chirurgie Vascular, Bucureti, Romnia
Obiectiv: Aceast prezentare de caz i propune s evidenieze folosirea unui pedicul epiploic i a terapiei prin presiune negativ pentru salvarea unei proteze
vasculare infectate.
Materiale i metode: Prezentm cazul unui pacient de 20 de ani care s-a internat n clinica noastr pentru un hematom expansiv la nivelul coapsei drepte.
Deteriorarea clinic rapid a dus la intervenia chirurgical n urgen care a identificat un anevrism rupt de arter circumflex femural i un hematom voluminos.
O protez de PTFE a fost plasat ntre artera femural i artera poplitee. n a zecea zi postoperator s-a reintervenit pentru infecie la nivelul plgii (febr,
leucocitoz, durere intens, edem generalizat al membrului inferior). Debridarea chirurgical a presupus rezecia muchiului croitor i a tegumentului supraiacent.
Proteza a fost acoperit cu un pedicul epiploic realizat n urma unei laparotomii. S-a instituit terapie cu presiune negativ. Parcursul postoperator a fost favorabil
cu remiterea procesului septic.
Rezultate: Angio-CT postoperator a demonstrat patena protezei vasculare. Dup o serie de procedee de chirurgie plastic coapsa a putut fi nchis. Pacientul a
fost externat n stare general bun, fr dureri i cu funcie satisfctoare a membrului inferior.
Concluzii: Folosirea pediculului epiploic pentru a acoperi proteza vascular a fost util mpotriva procesului septic i a salvat membrul inferior. Adugarea terapiei
cu presiune negativ a grbit recuperarea bolnavului.

Objective: This case report aims to highlight the use of omental flaps and negative pressure wound therapy for the salvage of an infected vascular prosthesis.
Materials and Methods: We present the case of a 20-year-old male patient admitted to our department for a fast growing hematoma of the right thigh. Rapid
deterioration of vital signs prompted emergency surgery that found a ruptured aneurysm of the circumflex femoral artery and a large hematoma. A PTFE vascular
prosthesis was placed between the femoral artery and the popliteal artery. On the tenth postoperative day a second surgery was necessary due to surgical site
infection at the level of the incision (fever, leukocytosis, intense pain and swelling). Debridement was performed with the resection of the overlying skin and the
sartorius muscle. The prosthesis was covered with an omental flap created through a laparotomy. Negative pressure wound therapy (NPWT) was instituted.
Postoperative course was favorable with the resolution of the septic process.
Results: Contrast enhanced computed tomography showed the patency of the prosthesis in the postoperative period. Several plastic surgery procedures were
performed after the resolution of the septic process in order to achieve the closure of the thigh. The patient was discharged in good general condition, with no
pain and with satisfactory function of the right lower limb.
Conclusion: The use of the omentum for the covering of vascular prosthesis can be used to fight sepsis and salvage the limb. The added use of NPWT can speed
up the recovery.

Denudarea venei cefalice (cut-down) - metod de prim alegere n implantarea port-cateterelor


Cephalic Vein Cut-Down - First Choice in Port-A-Cath Implantation
F. Grama, G. Richiteanu, A. Bordea, T. Burco, D. Cristian
Spitalul Clinic Colea, Secia de Chirurgie General, Bucureti, Romnia
Obiectivul studiului: Evaluarea avantajelor aduse de abordul cefalic n montarea port-cateterelor n oncologie.
Materiale i metode: Am evaluat retrospectiv pacienii care au beneficiat de montarea unui port-cateter n Clinica de Chirurgie Colea n perioada 2014-2016. Am
analizat: tehnica utilizat, durata interveniei, complicaiile asociate procedurii.
Rezultate: 124 de porturi au fost implantate: prin tehnica percutanat Seldinger - bazat pe repere anatomice (25 cazuri - 20.16%) sau ghidat ultrasonografic (10
cazuri - 8.06 %) i 89 cazuri (71.77%) prin denudarea venei cefalice (cut-down). Rata de succes a implantrilor a fost de 98,38%. Durata medie a interveniei: 35
minute - pentru abordul percutan i 44 minute - pentru abordul venei cefalice. Incidentele peri-operatorii asociate abordului percutan au fost 1 caz de poziionare
incorent a cateterului (2,85%) i 2 cazuri de hematom cervical (5,71%). Am notat 4 cazuri (11,4%) de tromboz asociat cateterului, 3 dintre acestea au necesitat
extracia. n cazul abordului cefalic au fost 2 cazuri (2,24%) de eec al implantrii datorit unor vene cefalice foarte subiri/trombozate. Postoperator, n abordul
cefalic am notat 1 caz de tromboz (1,12%).
Concluzii: Dei dureaz mai mult i poate fi dependent de calibrul venei cefalice, metoda cut-down este mai sigur, avnd o rat mai mic a complicaiilor att
peri, ct i post-operator. Cu o rat de succes peste 98% i o rat mic de complicaii, considerm aceast metod de prim elecie n implantarea
port-cateterelor.

Objective: To assess the superiority of the cephalic vein cut-down method, for port-a-cath implantation in oncology.
Material and Methods: We retrospectively evaluated the patients who received a port-catheter between 2014 and 2016 in Colea Surgery Department. We
analyzed the implantation technique, duration and peri-operative complications.
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Results: 124 ports were implanted: 25 ports (20,16%) using anatomic landmarks based percutan Seldinger technique, 10 ports (8,06%) using ultrasonographic
guidance and 89 ports (71,77%) through cephalic vein cut-down. The implantation success rate was 98,38%. Mean duration 35 minutes for the Seldinger
technique and 44 minutes for the cephalic vein cut-down. In the percutan approach group we encountered 1 case of catheter malposition (2,85%) and 2 cases of
cervical hematomas (5,71%). We recorded 4 cases (11,4%) of associated catheter thrombosis, out of which 3 cases ended with port extraction. In the cephalic
cut-down group there were 2 cases of implantation failure (2,24%) due to insufficient cephalic vein calibre or thrombosis. In the post-op evolution we recorded 1
case of thrombosis (1,12%)
Conclusion: Although it has a higher mean duration and a cephalic vein calibre dependency, the cephalic vein cut-down is safer with a lower peri- and
post-operative complication rate. Given the high rate of implantation success - over 98% - we consider the cephalic vein cut-down to be the first choice in
port-catheter implantation.

Exenteraia pelvin - experiena noastr iniial pe 37 de paciente


Pelvic Exenteration - Our Initial Experience on 37 Cases
M. E. Cplna (1), B. Szabo (1), J. Becsi (1), Bogdan Moldovan (2)
(1) Universitatea de Medicin i Farmacie, Clinica de Obstetric i Ginecologie I, Trgu Mure, Romnia
(2) Spitalul Sf. Constantin, Secia de Chirurgie General, Braov, Romnia
Exenteraia pelvin reprezint o ultim terapie cu intenie curativ pentru pacientele cu cancere pelvine n stadii avansate sau recidivate. Este considerat ca o
intervenie chirurgical extrem de dificil att pentru chirurg, ct i pentru anestezist, cu o mortalitate intra- i perioperatorie cuprins ntre 0 i 9 %. ntre 2011 i
2016, 37 paciente au fost supuse unei exenteraii pelvine n clinica noastr. Indicaiile au fost reprezentate de cancere de col stadiul IVA sau recidivate (25 de
paciente), vaginale stadiul IVA (3 paciente), de endometru stadiul IVA (un caz), cancere ovariene stadiul IV sau recidivate (7 paciente) i de vezic urinar stadiul
IIIB (un caz). Vrsta pacientelor a fost cuprins ntre 36 i 73 de ani (n medie 54,2 ani). aisprezece dintre exenteraii au fost totale, 14 anterioare, iar 7
posterioare. n raport cu muchiul ridictor anal, 26 au fost supralevatoriene, 5 infralevatoriene, iar 6 infralevatoriene cu vulvectomie. La 29 din cele 30 de
exenteraii totale sau anterioare s-a practicat din ileon un rezervor urinar necontinent dup tehnica Bricker, iar la o pacient un rezervor urinar continent ortotopic
confecionat din cec tip Budapest pouch. Complicaii postoperatorii necesitnd reintervenii chirurgicale au aprut la 15 paciente (40.5%), dintre care 3 decese
perioperatorii (8.1%). Dintre cele 37 de paciente, 21 sunt n via i fr boal evolutiv, 15 sunt decedate din cauza bolii, iar una este pierdut din urmrire.
Exenteraia pelvin se asociaz cu supravieuiri de lung durat sau chiar vindecare la paciente bine selecionate. Totui, complicaiile postoperatorii sunt
frecvente i pot fi letale.

The pelvic exenteration became an ultimate, salvage therapy for patients with advanced or recurrent pelvic cancers. It is considered an extremely difficult and
demanding procedure for both surgeon and anaesthesiologist, with intra- and perioperative mortality between 0 and 9%. Our aim is to analyze the initial
experience of pelvic exenteration for gynaecological malignancies in a tertiary referral center. Between 2011 and 2016, 37 patients underwent a pelvic
exenteration for gynaecological malignancies. The indication was stage IVa or recurrent cervical (25 patients), stage IVa vaginal (3 patients), stage IVa
endometrial (1 patient), stage IV or recurrent ovarian (in 7 patients) and a stage IIIB urinary bladder cancer. Patients age ranged from 36 to 73 years (medium
54.2). Out of the 37 exenterations, 16 were total, 14 anterior and 7 posterior. In respect to levator ani muscle, 26 pelvic exenterations were supralevatorian, 5
infralevatorian and 6 infralevatorian with vulvectomy. A Bricker non-continent ileal urinary conduit was performed in 29 out of 30 anterior and total exenterations,
and a Budapest pouch ortotopic neo-bladder made from caecum in one. In-hospital complications with re-operation occurred in 15 patients (40.5%), of whom 3
perioperative deaths (8.1%). Among the 30 patients, at this moment, 16 are alive and free of disease; 13 are dead because of the disease and one is lost to
follow-up. Pelvic exenterantion for recurrent or advanced pelvic malignancies can be associated with long-term survival and even cure in properly selected
patients. However, postoperative complications are common and can be lethal.

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Investigaii postoperatorii cu valoare n reducerea costurilor la pacientul oncologic, n chirurgia abdominal


major
Postoperative Investigations Which Are Valuable in Cost Reduction in Major Abdominal Interventions Performed on
Cancer Patients
V. M. Prunoiu, Snziana Octavia Ionescu, E. Brtucu, N. D. Straja, A. M. Marinca
Institutul Oncologic Prof. Dr. Alexandru Trestioreanu, Clinica de Chirurgie I, Bucureti, Romnia
Obiectiv: Costurile n cretere n domeniul ngrijirii sntii sunt de interes tot mai mare i un factor major care afecteaz costurile de spitalizare sunt
complicaiile postoperatorii. Complicaiile dup interveniile chirurgicale abdominale majore (CAM) sunt asociate cu o morbiditate i mortalitate crescute. n acest
studiu sunt estimate costurile ngrijirilor postoperatorii asociate cu complicaiile.
Metod: Noi am efectuat un studiu retrospectiv-cohort de 200 de pacieni internai n clinica noastr, care au suferit CAM. Au fost analizate costurile totale de
spitalizare, complicaiile i tratamentul efectuat.
Rezultate: Pentru un pacient care a suferit CAM, costurile medii pentru intervenia chirurgical, fr complicaii, sunt de 6563,87 lei i ajung la 12111,79 lei dup
complicaii majore.
Concluzie: Rezultatele ofer o perspectiv asupra costurilor de spitalizare la pacienii oncologici operai. Complicaiile majore apar la 20% dintre pacienii care au
suferit CAM i reprezint 50% dintre costurile totale de ngrijire. Stabilirea i aplicarea unui protocol care vizeaz diagnosticarea precoce i tratamentul
complicaiilor ar putea duce la o scdere a morbiditii i a mortalitii, dar i a costurilor de spitalizare.

Objective: The increasing costs in the healthcare sector represent a theme of increasing interest, and the main factor which affects them are postoperative
complications. The complications encountered after major abdominal surgical procedures (CAM) are associated with increased morbidity and mortality. In this
study, one estimates the costs of the postoperative care in correlation with the complications.
Material and Methods: We performed a cohort retrospective study on 200 patients admitted to our clinic which developed CAM. The total of the hospital
admission costs, the complications and the treatment performed were analyzed.
Results: In a patient with CAM, the mean costs for the surgical, non-complicated, intervention are of 6563,87 lei, and may reach even 12111,79 lei after major
complications.
Conclusion: The results offer a perspective on the costs of daily hospital admission costs in operated cancer patients. The major complications appear in 20% of
the patients who suffered CAM and represent half of the total of the costs. The establishment and implementation of a protocol which is focused on the early
diagnostic and treatment of the complications may lead to a decrease in morbidity and mortality, but also of the cost of the hospital admission.

Complicaiile postoperatorii precoce majore dup Roux-en-Y gastric by-pass


Early Postoperative Major Complications After Roux-en-Y gastric By-Pass
S. Blan, S. Revencu, G. Contu, O. Contu, D. Revencu
Universitatea de Stat de Medicin i Farmacie Nicolae Testemianu, Catedra Chirurgie Nr. 1 Nicolae Anestiadi, Chiinu, Republica Moldova
Introducere: Dintre interveniile bariatrice, Roux-en-Y gastric bypass (RYGB) este cea mai utilizat la nivel mondial n tratamentul obezitii. Rata complicaiilor
postoperatorii precoce majore este mic i include dehiscena de anastomoz, hemoragia gastro-intestinal, ocluzia intestinal i sindromul obstructiv.
Responsabilitatea diagnosticrii complicaiilor postoperatorii i managementul acestora rmne chirurgului operator.
Obiectivul: Aprecierea factorilor ce stau la baza instalaiei complicaiilor postoperatorii precoce, ct i stabilirea unui algoritm diagnostico-curativ.
Materiale i metode: Studiul cuprinde 121 pacieni supui RYGB pe perioada 2009-2016 pentru obezitate morbid i perturbri metabolice. Vrsta a oscilat n
limitele 17-68 ani, cu media de 38,8 ani, raportul B:F=1:6, masa corporal a variat n limitele 86-265 kg, indicele masei corporale (IMC) a fost n limitele 44,6
(28,7-75,6) kg/m.
Rezultate: Complicaii postoperatorii majore au fost nregistrate n 7 cazuri (5,8%): dehiscen de anastomoz 1 caz, hemoragie digestiv - 3 cazuri, hemoragie
intraabdominal - 1 caz, dilatare acut gastric - 2 cazuri. ntr-un caz s-a evideniat succesiune hemoragie digestiv-dilatare acut gastric-pancreatit acut. Rata
reinterveniei chirurgicale a fost de 71,4%. Decese nu s-au nregistrat.
Concluzii: Diagnosticul de hemoragie gastro-intestinal la pacienii care au suportat Roux-en-Y gastric by-pass pentru obezitate morbid este dificil. Motivul
principal este inaccesibilitatea stomacului exclus din tranzit datorit anatomiei modificate.

Introduction: Among different bariatric procedures, Roux-en-Y gastric bypass (RYGB) is the most commonly performed operation worldwide for obese patients.
The percentage of early serious postoperative complications is low and includes anastomotic leak, gastrointestinal bleeding, ileus and obstruction. The
responsibility for the recognition of postoperative complications and their management belong to the operating surgeon.
Purpose: Appreciation of predictive factors in the early postoperative complications and the establishment of a diagnostic and curative algorithm.
Materials and Methods: This clinical study includes 121 patients with obesity and metabolic disorders who underwent RYGB from 2009 to 2016. The mean age of
the study group was 38,8 years (range 17 to 68), M:F ratio=1:6, body weight situated in the limits of 86-265 kg, and the average body mass index (BMI) prior to the
operation was 44,6 (range 28,7 to 75,6) kg/m.
Results: Seven patients (5,8 %) developed early major complications, including one case of anastomotic leakage, digestive bleeding - three cases,
intra-abdominal bleeding - one case, acute gastric dilatation - two cases. In one case succession digestive bleeding-acute gastric dilatation-acute pancreatitis
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was registered. Reoperation rate was 71,4 %. There were no deaths.
Conclusion: The diagnosis of gastrointestinal bleeding in patients who had Roux-en-Y gastric by-pass for morbid obesity is difficult. The main reason for this is the
inaccessibility of the excluded stomach because of the altered anatomy.

Rezecii dificile
Difficult Resections
C. Bradea (1), Isabela Afrsnei (2), Paulina Czidziak (2)
(1) Universitatea de Medicin i Farmacie Gr. T. Popa / Spitalul Clinic Judeean de Urgene Sf. Spiridon, Clinica I Chirurgie, Iai, Romnia
(2) Spitalul Clinic Judeean de Urgene Sf. Spiridon, Clinica I Chirurgie, Iai, Romnia
Obiectivul studiului: Am urmrit s demonstrm c rezeciile dificile necesit timp, experien, logistic, anestezie i terapie intensiv de clas nalt, c evoluia
este lent, plin de neprevzut, dar satisfacia este maxim.
Material i metod: Am urmrit prospectiv ultimele 10 cazuri, n special cu neoplazii avansate, operate de autor, n special n urgen, n aceeai echip. Am
urmrit capitolele fiei de observaie, protocoalele operatorii, rezultatele examenului microscopic.
Rezultate: Diagnosticul preoperaor s-a fcut clinic, echografic, radiologic, computer tomografic sau prin rezonan magnetic. Laparoscopia a adus date finale
macroscopice, iar examenul microscopic a definitivat diagnosticul, cu care bolnavul s-a adresat oncologului pentru continuarea chimioradioterapiei. Riscul
anestezic i operator a fost mare (3 ASA). Durata operatorie medie a fost de 4 ore. Pierderea sanghin medie intraoperatorie a fost de 500 ml. S-au rezecat sau
au fost vizate cu gesturi chirurgicale mai mult de 3 organe intraabdominale. A fost nevoie de un sejur postoperator n secia de terapie intensiv. Evoluia
postoperatorie a fost grevat de fistule, evisceraii, ocluzii postoperatorii, hemoragii i un deces tardiv.
Concluzii: Rezeciile dificile, e obicei pluriviscerale necesit curaj, druire, cunotine temeinice anatomo-chirurgicale, o echip performant de diagnosticieni,
anesteziti-reanimatori i chirurgi antrenai zilnic n intervenii mari clasice sau laparoscopice. Se consum timp, energie,materiale,costuri care se justific prin
prelungirea vieii bolnavilor.
Cuvinte cheie: echip, cancer invaziv loco-regional avansat, salvarea vieii

Aim: We want to demonstrate that the difficult resections need time, experience, logistics, high class anesthesia and intensive care; the patient evolution is slowly,
with unknown future but with maxim satisfaction.
Materiel and Method: We studied prospectively the last 10 cases, especially with advance neoplasia which were operated by the author, especially in emergency,
with the same operative team. The preop exam was made by clinical exam, echography, radiology, computed tomography or by magnetic resonance.
Laparoscopia has given final macroscopical results. Microscopically exam made the real diagnosis. With that, the patient was sent to the oncologist for
continuation the chemo-radio therapy. The anesthetic-surgical risk was big (3 ASA). The main operative time was 4 hours. Intraoperative blood lost was approx.
500 ml. More than 3 intraabdominal organs where operated. It was necessary a period for the patient to stay in the Intensive Care Unit. In evolution the patients
had fistulas, eviscerations, postop occlusions, hemorrhages and one death.
Conclusions: The dificult resections, in general multivisceral, need surgical courage, anatomo-surgical knowledge, a skillful team for diagnosis, anesthesia,
intensive care and surgery, daily trained in big classical or laparoscopic operations. There are time, energy, materials and costs spent, but justified by patients life
saving.
Key words: team, loco-regional advanced cancer, life saving

Camerele implantabile n chirurgie. Experiena unui singur centru


Implantable Ports in Surgery. A Single Center Experience
B. V. Micu (1), Carmen Maria Micu (2), V. Dudric (1), T. R. Pop (1), N. Constanea (1)
(1) Universitatea de Medicin i Farmacie Iuliu Haieganu, Clinica Chirurgie V, Spitalul Clinic Municipal, Cluj-Napoca, Romnia
(2) Universitatea de Medicin i Farmacie Iuliu Haieganu, Departamentul de Anatomie i Embriologie, Clinica Chirurgie V, Cluj-Napoca, Romnia
Obiecivul studiului: S analizm metoda utilizat de noi n montarea camerelor implantabile pentru chimioterapie (port-a-cath/PAC) i s evalum complicaiile
intra i postoperatorii.
Material i metod: Am efectuat un studiu prospectiv, n care am inclus pacieni operai n Clinica Chirurgie V a Spitalului Clinic Municipal Cluj-Napoca. Camera
implantabil s-a montat, n toate cazurile, prin puncionarea ecoghidat a venei jugulare interne.
Rezultate: Din cei 250 de pacieni inclui n studiu, 97 de pacieni (38,8%) au prezentat cancer de sn, 26 (10,4%) cancer bronho-pulmonar, 25 (10%) cancer
colorectal, 22 de pacieni (8,8%) neoplazii n sfera ORL. Pacienii au avut vrste cuprinse ntre 19 i 74 de ani. 58% dintre pacieni au fost n stadiul IV. Principalele
complicaii intraoperatorii au fost puncionarea/introducerea gresit a cateterului. Printre complicaiile postoperatorii s-au numrat tromboza venei jugulare
interne (1,2%), abcese la locul implantrii (1,6 %), extravazarea port-ului (2%).
Concluzie: Metoda de inserie a camerei implantabile prin puncionarea ecoghidat a venei jugular interne, folosit de noi, are rezultate foarte bune, numrul
complicaiilor intra i postoperatorii fiind minim, evitnd totodat ruperea cateterului, producerea pneumo sau hemotoracelui.

Aim: To analyze the method used by us in insertion of implantable ports for chemotherapy (port-a-cath/ PAC) and to evaluate intra and postoperative
complications.
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Material and Methods: We conducted a prospective study in which we included patients operated at the Fifth Surgical Clinic of the Municipal Hospital Cluj-Napoca.
Implantable chambers were installed in all cases, by ecoguided puncturing the internal jugular vein.
Results: Out of the 250 patients included in the study, 97 patients (38.8%) had breast cancer, 26 (10.4%) lung cancer, 25 (10%) colorectal cancer, 22 patients
(8.8%) neoplasms in ENT. Patients were aged between 19 and 74 years. 58% of patients were stage IV. The main intraoperative complications were incorrect
puncturing/introduction of the catheter. Among postoperative complications were internal jugular vein thromboses (1.2%), abscesses at the site of implantation
(1.6%), extravasation of the port (2%).
Conclusions: The method of insertion of implantable chamber through internal jugular vein, used by us, has very good results, the number of intra and
postoperative complications is minimal, also avoiding catheter breakage, hemothorax and pneumothorax.

Eforia spitalelor civile. ntemeiere i existen


The Eforia of the Civilian Hospitals. Foundation and Existence
Snziana Octavia Ionescu, E. Brtucu, L. Simion, A. M. Marinca, V. M. Prunoiu, N. D. Straja
Institutul Oncologic Prof. Dr. Al. Trestioreanu, Chirurgie I, Bucureti, Romnia
Obiectiv: Autorii prezin Instituia Eforiei Spitalelor Civile de la nfiinare la momentul disoluiei ei. Eforia a fost nfiinat n 1832 prin o decizie a generalului
Kiseleff.
Material i metod: Sunt prezentate documentele originale care au stat la baza constituirii celor trei fundaii care au format nucleul Eforiei Spitalelor. Au existat
trei uniti ale Eforiei: Colea, Pantelimon i Filantropia, fiecare administrat separat. n 1847, domnitorul Gheorghe Bibescu trece toate spitalele din ara
Muntenia sub controlul i administrarea Eforiei nou-nfiinate. Aproape permanent, Eforia Spitalelor Civile a avut un patrimoniu distinct de cel al statului. Bugetul
ei fiind ns supus controlului i votului Adunrii Deputailor ca i bugetul statului. Administrarea bunurilor sale s-a fcut dup legislaia de administrare a
bunurilor statului cu verificarea i controlul gestiunii financiare de ctre Curtea de Conturi.
Rezultate: Autorii urmresc pas cu pas impactul major al acestei instituii care a jucat un rol major n dezvoltarea asistenei medicale i a nvmntului medical
n ara Romneasc, rol similar cu cel jucat de Spiridonia n Moldova.
Concluzii: inem s subliniem faptul c dezvoltarea chirurgiei romneti moderne a fost strict legat de funcionarea acestei Instituii memorabile, ce a fost lsat
n uitare dup desfiinarea sa n 1948. S-a considerat c se cuvine o rememorare, cu att mai mult cu ct anul acesta se mplinesc 184 de ani de la nfiinare.

Objective: The authors present the institution of the Eforia of the Civilian Hospitals from its foundation until the moment of its dissolution. The Eforia was founded
in 1832, through a decision given by general Kiseleff.
Material and Method: We present the original documents which were at the base of the three foundations which formed the nucleus of the Eforia of The Civilian
Hospitals. There were three units forming the Eforia: Coltea, Pantelimon and Filantropia, each one administered separately. In 1847, the ruler Gheorghe
Bibescu decides to pass all the hospitals in Muntenia under the administration of the newly founded Eforia. Nearly continuously, the Eforia of the Civilian
Hospitals had a budget different from that of the state. Its own budget being under the control of the vote of the General assembly of The Deputees and also that
of the state budget. The administration of its goods was done after the legislation of the administration of the state goods with the verification and control of the
financial management by the Romanian Court of Auditors.
Results: The authors follow step-by-step the major impact of this institution in the development of the healthcare system and of the medical education system in
The Romanian Country, a similar role to that played by the Spiridonia in Moldavia.
Conclusions: We would like to emphasize that the development of modern Romanian surgery was strictly linked to the functioning of this memorable institution,
which was left in oblivion after its disappearance in 1948. It was considered that a recall is needed, more so as this year we celebrate 184 years since its
foundation.

Traiectorii ciudate i imprevizibile ale gloanelor n plgi ale trunchiului produse de arme de foc letale
Weird and Unpredictable Trajectories of Bullets in Torso Wounds Made by Lethal Firearms
M. Beuran (1), M. D. Venter (1), C. Ungherea Matei (2), D. P. Venter (3), I. Gheju (4)
(1) Spitalul Clinic de Urgen Floreasca, Clinica Chirurgie III, Bucureti, Romnia
(2) Expert SRTM Arme i Muniii, Colecionar autorizat arme foc, Bucureti, Romnia
(3) Spitalul Clinic de Urgen pentru Copii Grigore Alexandrescu, Bucureti, Romnia
(4) Spitalul Clinic de Urgen Floreasca, Bucureti, Romnia
Introducere: Plgile produse cu arme de foc letale sunt din ce n ce mai mult prezente la camera de gard a spitalelor de urgen. Ele presupun o decizie
terapeutic complex, alturi de o cunoatere amnunit a traiectoriei glonului prin rana produs de arm de foc.
Material i metod: Sunt prezentate trei cazuri de persoane mpucate, la care traiectoria gloanelor prin corpul victimelor nu a fost deloc previzibil; un caz a fost
reprezentat de un transfer din provincie la Spitalul Clinic de Urgen Bucureti, pentru manopere chirurgicale de cutare i extragere a glonului.
Concluzii: Cunoaterea de ctre echipa chirurgical de traum a traiectoriilor posibile ale gloanelor prin corpurile victimelor reprezint un important element n
decizia clinico-terapeutic. Rnile fcute de arme de foc sunt provenite din ricoete, din schije, din glon sau alice. Este important ca s se stabileasc cu precizie
traiectoria proiectilului balistic prin corpul victimei pentru extragere, toaletare i stabilizarea acesteia din punct de vedere hemodinamic.

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Introduction: Wounds made by firearms are more and more frequent in the emergency rooms of hospitals. They imply a complex therapeutic decision together
with a thorough knowledge of the bullet trajectory through the wound made by the firearm.
Material and Method: There are presented three cases of people that got shot to whom the trajectory of the bullets through the body of the victims was not
predictable at all, one of them even requiring a transfer from the province to the Emergency Clinical Hospital Bucharest for surgical maneuvers of searching and
extracting the bullet.
Conclusions: The knowledge possessed by the trauma surgical team regarding the possible trajectories of the bullets through the victims body represents an
important clinical therapeutics decision element. The wounds made by firearms are caused by ricochets, shrapnel, bullets or buckshots. It is important to
establish with accuracy the trajectory of the ballistic projectile through the victims body for extraction, grooming and stabilization of the victim from a
haemodynamic point of view.

Evoluia imprevizibil a pacientului politraumatizat. Soluii terapeutice


The Unforeseeable Evolution of the Polytraumatized Patient
C. Turcule (1), D. Ene (1), T. F. Georgescu (1), E. Ciuc (1), A. Vldscu (1), M. Beuran (2)
(1) Spitalul Clinic de Urgen Floreasca, Clinica Chirurgie I, Bucureti, Romnia
(2) Spitalul Clinic de Urgen Floreasca, Clinica Chirurgie III, Bucureti, Romnia
Introducere: Pacientul politraumatizat reprezint o preocupare constant i de actualitate n sistemul medical de urgen, incidena acestor cazuri crescnd
exponenial n ultima decad. Trauma este principala cauz a mortalitii n rndul pacienilor sub 40 de ani.
Materiale i metode: Studiul include 76 de pacieni politraumatizai tratai n clinica noastr n intervalul 2013-2016.Au fost analizai urmtorii parametrii: date
demografice, scorul de severitate al leziunilor (ISS), semnele vitale, hemodinamice, GCS la internare, mecanismul producerii politraumatismului, ratele de
intubaie, explorri bioumorale/imagistice, mortalitatea i complicatiile. La toi pacienii au fost evaluate tipul leziunilor i metodele de tratament.
Rezultate: Din totalul pacienilor 65,2% au avut nevoie de intervenii chirurgicale.
Dintre interveniile minim invazive, frecvente au fost drenajele pleurale minime urmate de laparotomiile exploratorii cu soluionarea leziunilor viscerale.
Media vrstei pacienilor a fost 45,7 ani. Cauza predominant a politraumatismelor este reprezentat de accidentele rutiere urmat de precipitri i agresiuni.
Media scorului ISS a ntregului grup a fost de 21.
Concluzii: Majoritatea politraumelor au fost accidente rutiere. Dei ne referim la pacieni politraumatizai drenajul pleural minim a reprezentat procedura
chirurgical predominant.

Introduction: Nowadays, the polytraumatized patient represents a constant concern in the emergency medical system, due to the case incidence that is in an
exponential ascend in the last decade. Furthermore, trauma is the main mortality cause in patients under the age of 40.
Materials and method: The study includes 76 polytraumatized patients treated in our clinic in between 2013 and 2016. The following parameters have been
analysed: demographic data, Injury Severity Score (ISS), vital signs, hemodynamics, admission GCS, the mechanism of injury, intubation rate,
paraclinical/imagistic exploration, complications and last but not least mortality. Methods of treatment and lesion type are two factors used in the evaluation of all
patients in our study.
Results: 62.5% of all patients needed surgical intervention. In terms of minimal invasive surgeries, the most frequent resulted to be minimum pleural drainage
followed by exploratory laparotomy. The mean patient age was of 45.7 years. The predominant cause of polytrauma is represented by car crashes, followed by
falls and aggressions. The mean ISS score of the entire group was 21.
Conclusions: The majority of polytraumas were represented by car accidents. Although we are referring to polytraumatized patients the predominant surgical
procedure in our study resulted to be minimal pleural drainage.

Mai este laparoscopia util in traumatismele abdominale?


Is Laparoscopy Still Recommended in Abdominal Trauma?
A. Nicolau, Raluca Vasile
Spitalul Clinic de Urgen Floreasca, Secia de Chirurgie, Bucureti, Romnia
Utilizarea laparoscopiei este acceptat n plgile abdominale (PA), dar n contuziile abdominale (CA) este controversat. Lucrarea noastr evalueaz utilizarea
laparoscopiei diagnostice (LD) i a laparoscopiei terapeutice (LT) n traumatismele abdominale, n perioada 2006-2015. S-au analizat diagnosticul imagistic
preoperator, leziunile viscerale, LT, conversiile, complicaiile, decesele, durata spitalizrii.
LD s-a efectuat la 48 de pacieni stabili hemodinamic, 41 de brbai, vrsta medie 36,6 ani. Au fost 19 PA i 29 CA. Indicaii au fost: diagnosticul penetraiei n PA,
suspiciunea de leziune de organ cavitar sau diafragm, hemoragia activ n leziunile de organ solid n CA. Preoperator, 12/47 ecografii abdominale i 2/28
examene CT au fost fals negative. 17/19 PA au fost penetrante, 11 cu leziuni viscerale, la 6 pacieni a fost posibil LT. Pacienii cu CA au avut 9 perforaii de organ
cavitar, 3 leziuni mezenterice, 12 leziuni de organe solide i 2 leziuni de diafragm. Au fost 8 conversii. Au fost 8 LT i 6 LT asistate (5 enterorafii i o enterectomie).
Nu au fost leziuni omise. Au fost 4 complicaii i 3 decese (6,25%), fr legatur cu laparoscopia. Spitalizarea medie n sectia de chirurgie a fost de 6,26 7,3 zile
la pacienii cu laparoscopie i de 7,38,3 la cei convertii. O laparotomie a fost evitat la 32/48 de pacieni (66,66%). n cazuri selectate de PA i CA cu diagnostic
clinic i imagistic echivoc, laparoscopia este o modalitate dignostic util, cu potenial terapeutic, care reduce laparotomiile nenecesare.

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Laparoscopy is accepted for penetrating abdominal trauma (PAT), but for blunt abdominal trauma (BAT) its use becomes controversial. Our paper assesses the
use of diagnostic laparoscopy (DL) and therapeutic laparoscopy (TL) in abdominal trauma during 2006-2015.
DL was performed on 48 hemodynamically stable patients. There were 19 PAT and 29 BAT. The main indications for laparoscopy were: peritoneal violation for
patients with PAT, suspicion of hollow viscus injury, active bleeding with solid organ injuries and diaphragmatic injuries for patients with BAT. Prior to surgery, 12
out of 47 abdominal ultrasounds and 2 out of 28 CT scans were false negatives. 17/19 stab wounds were penetrating injuries, 11 with organ lesions, and TL was
possible for 6 patients. Patients with BAT had 9 hollow viscus perforations, 3 mesenteric lesions, 12 solid organ lesions and 2 diaphragmatic lesions. Conversion
was necessary for 8 patients. 8 TLs and 6 assisted TLs were possible. There were no omitted lesions. There were 4 complications and 3 deaths. The average
hospital stay in the surgical ward was of 6.26 7.3 days for laparoscopic patients and of 7.38.3 for those with conversion. Laparotomy was avoided for 32/48
patients (66,66%).
In selected PAT cases, but also in selected BAT cases with unclear clinical and imaging diagnosis, laparoscopy is a useful diagnostic tool, with therapeutic
potential, which reduces the need for laparotomy and the hospital stay.

Analiza mortalitii pacienilor politraumatizai n Spitalul Clinic de Urgen Bucureti


Mortality Analysis of Polytrauma Patients in Bucharest Emergency Hospital
M. Beuran, B. Stoica, I. Tnase, I. Negoi, S. Pun
Spitalul Clinic de Urgen Floreasca, Chirurgie General, Bucureti, Romnia
Introducere: Principiul fundamental al unui sistem de traum este de a trimite pacientul potrivit, la spitalul potrivit, n momentul potrivit.
Metod: Analiza retrospectiv a datelor din cadrul registrului de traum a pacienilor internai n centrul de traum de nivel I, n anul 2012, cu NISS mai mare de 15.
Rezultate: Din totalul de 183 de pacieni internai n cadrul Spitalului Clinic de Urgen Bucureti, 59 de cazuri au decedat (32%); din totalul pacienilor 54 dintre
cazuri au ajuns intubai la camera de gard. n ceea ce privete etiologia traumei n cadrul pacienilor decedai, o proporie aproximativ egal au reprezentat-o
accidenele rutiere (20 cazuri) i respectiv accidentele n care au fost implicai pietonii (18 cazuri). 10% dintre pacienii decedai au prezentat semne ale sepsisului
n serviciul de ATI. 19 pacieni au fost instabili hemodinamic (TAs >90 mmHg) la camera de gard. Aproximativ jumtate (30 cazuri) din pacienii decedai au fost
transferai din alte uniti spitaliceti ctre centrul nostru.
Concluzii: Avnd n vedere gravitatea traumatismelor, pacienii ar trebui transferai ct mai rapid ctre centre de traum de nivel superior, pentru a scdea att
morbiditatea ct i mortalitatea n traum.

Patternul erorilor contributive la mortalitatea pacienilor politraumatizai


Errors Contributing to Trauma Mortality - Retrospective Analysis in Level 2 Trauma Hospital
M. Anastasiu, R. Dedu, Rdia Popescu, N. Micu, D. Vicol
Spitalul Judeean de Urgen, Secia de Chirurgie, Buzu, Romnia
Studiul si-a propus identificarea incidenei, tipului si clasei de erori implicate n mortalitatea pacienilor politraumatizai.
Material i metode: Au fost revizuite toate dosarele pacienilor cu traum, internai n serviciul nostru n perioada 2011-2015 (2870 cazuri) i analizat eantionul de
mortalitate la o selecie de 490 politraume (18% din cohorta iniial). O sut douzeci i opt pacieni au fost exclui din analiza statistic, nentrunind criteriile de
omogenitate ale eantionului (fie incomplete, absena cuantificat a criteriilor de gravitate sau a explorrilor imagistice, proceduri ATI nemenionate sau lipsa
protocolului necropsic). n final a fost reinut n studiu un numr de 362 pacieni cu o mortalitate de 13% (47 decese).
Rezultate: n 12 cazuri (3.3% din cei internai) au fost identificate erori contributive la deces: rezolvare ntrziat i/sau diagnostic inadecvat al hemoragiei
abdominale sau intra-toracice (6.3%), absena controlului i securizrii cilor respiratorii (4.2%), management inadecvat al pacienilor instabili hemodinamic n
8.5% din cazuri (intervenii chirurgicale prelungite, pacieni n oc trimii la CT sau transferai interhospitalier), diagnostic greit sau ntrziat (4.2%), profilaxie
anti-trombotic ignorat (2.1%). Corelat clasificrii etiologice, n 25% din cazuri au fost reinute erori de input, 41.7% au fost erori de intenie i 33.3% erori de
execuie. Raportat la faza algoritmului decizional, 16.6% din erori s-au produs n UPU, 25% n timpul supravegherii i investigaiilor suplimentare, 33.3% n blocul
operator, 16.6% n timpul transferului la CT sau interhospitalier i 8.3% n ATI.
Concluzii: Studiul analizeaz i identific cauzal erorile contributive de deces i propune remedierea acestora prin analize periodice interdisciplinare i
respectarea protocoalelor specifice.

This study was conducted to identify the incidence, type and setting of errors leading to mortality in trauma patients.
Material and Methods: All trauma patients that died during their initial hospital admission for 5-year period (January 2011 to December 2015) were analyzed.
During the study period, 2870 patients with trauma injuries were admitted and a total of 490 cases (18%), fulfilling polytrauma criteria, have been reviewed. One
hundred and twenty eight patients were excluded from statistical analysis (incomplete folder, missed values of ISS or imagistic findings, unmentioned
manoeuvres in ICU or omitted autopsy protocol) and finally from 362 patients remained we retained 47 deaths (13% of patients included).
Result: Twelve patients (3.3% admissions) had recognized errors in care that contributed to their death. Important errors patterns included: delayed control of
abdominal and intra-thoracic haemorrhage or inadequate recognition (6.3%), failure to secure or protect airway (4.2%), inappropriate management of unstable
patients in 8.5% of deaths (long operative procedures, unstable patients sent to CT or to interhospital transfer), missed or delayed diagnoses (4.2%) and
inadequate DVT prophylaxis (2.1%). By the internal processing classification of causes, 25% were input errors, 41.7% were intentions errors and 33.3% were
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execution errors. By phase of trauma management, 16.6% of errors occurred in the ED, 25% during the secondary survey and initial diagnostic, 33.3% during
surgery, 16.6% during transport to CT or interhospital transfer and 8.3% in the ICU stay.
Conclusion: This study combines contemporary understanding of error causation, classification and proposes their remediation with a specific process and
protocols.

Leziunile posttraumatice ale splinei


Traumatic Injuries of the Spleen
C. Crdeiu (1), . O. Georgescu (1), Liliana Foru (1), Felicia Crumpei (2), A. Hristov (1), Larisa Avarvarei (1), M. Niu (1), D. Vintil (1)
(1) Spitalul Clinic Judeean de Urgene Sf. Spiridon, Clinica II Chirurgie, Iai, Romnia
(2) Spitalul Clinic Judeean de Urgene Sf. Spiridon, Radiologie, Iai, Romnia
Trauma este prima cauz de mortalitate n grupul de vrst 1-46 ani. Este a III-a cauz de mortalitate n toate categoriile de vrst (dup bolile cardiovasculare i
neoplazii). n rile civilizate accidentele rutiere sunt principala cauz de mortalitate i morbiditate n cadrul patologiei traumatice (NTI). Splina este cel mai
frecvent organ lezat n patologia traumatic (45%). Aceti pacieni necesit tratament n urgen (operator), monitorizare activ sau angioembolizare. n
continuare vom prezenta evoluia tratamentului unui grup de 103 pacieni cu leziuni posttraumatice ale splinei, internai n perioada 2010-2015 n serviciul nostru.
Cea mai mare pondere au avut-o pacienii de sex masculin, n numr de 70, cu vrste cuprinse ntre 40-60 ani. Cauzele cele mai frecvente ale traumei au fost
cderile (33%), agresiunile (17,5%), accidentele rutiere (16,5%). S-a efectuat CT la 38,9%, pacienii instabili hemodinamic (10,7%) fiind imediat transportai n blocul
operator. Leziunile splenice decelate imagistic au fost de gradul I-II (32%) i gradul III-IV (68%). 14,5% au prezentat fracturi costale, 4,8% pneumothorax,
necesitnd drenaj pleural, 8,7% fracturi ale membrelor, 5,8% leziuni hepatice i 9,7% contuzii cerebrale. S-a efectuat splenectomie la 70 pacieni. Postoperator
s-au nregistrat 3 decese la pacienii cu leziuni multiple (hepatice, pulmonare, cerebrale). Complicaii postopratorii au prezentat 5 pacieni: 1 pacient fistul
pancreatic, 4 pacieni supuraii parietale.
Analiza grupului prezent arat c managementul rapid i eficient al pacientului traumatizat, prezervarea splinei n leziunile de grad I-II, reduc semnificativ
mortalitatea i morbiditatea la aceti pacieni.

Introduction: Trauma is the first cause of mortality in the age group 1-46 years. It is the third cause of death in all age groups (after cardiovascular diseases and
cancers). In civilized countries, road accidents are the main cause of morbidity and mortality in traumatic pathology. Spleen is the most frequently injured organ in
trauma (45%). These patients require emergency surgical treatment, active monitoring or angioembolisation as therapeutical options.
Method: Our retrospective study presents the evolution of 103 patients with traumatic spleen injuries, hospitalized between 2010-2015 in our Surgery Department.
Results: In our lot the majority were male patients (67,9%), with the mean age of 50 years old. The most frequent causes of trauma were falls (33%), assaults
(17.5%), traffic accidents (16.5%). CT was performed in 38.9% of cases. 10.7% of patients were hemodynamically unstable and emergency surgery was performed.
Splenic lesions were graded using imagistic as: grade I-II (32%), grade III-IV (68%). In our lot 14.5% associated costal fractures, pneumothorax 4.8%, required
pleural drainage, fractured limbs were found in 8.7%; associated liver damage and brain contusion were found in 5.8% and 9.7% of cases. Splenectomy was
performed in 67,9% of patients. In polytrauma cases we registered 3 deceases in patients with multiple lesions (liver, lung, brain). Post-operative complications
were registered in 5 patients: 1 patient associated pancreatic fistula, and 4 patients had parietal suppuration.
Conclusion: We can conclude that in our experience preserving spleen in grade I-II injuries significantly reduces mortality and morbidity in these patients.
Discussion: The analysis shows efficient management of trauma patients in this group with emergency protocols implementation.

Sindromul de compartiment abdominal - posibiliti terapeutice


ACS - Surgical Therapeutic Possibilities
B. M. Ciuntu, C. Vasilu, Mihaela Blaj, . O. Georgescu
Spitalul Clinic Judeean de Urgene Sf. Spiridon, Chirurgie II, Iai, Romnia
Sindromul de compartiment abdominal are o relevan extraordinar n practica chirurgical i ngrijirea pacienilor n stare critic, din cauza efectelor presiunii
crescute n spaiul nchis al abdomenului pe sisteme de organe multiple. Problema sindromului de compartiment merge dincolo de ngrijirea pacienilor
chirurgicali, cuprinznd mai multe stri de boal i diverse scenarii clinice. Date recente sugereaz c unele dintre efectele adverse ale IAP crescute apar la
niveluri mai mici dect se credea anterior i se manifest nainte de dezvoltarea unui sindrom de compartiment fulminant. Prin urmare, Sindromul de
compartiment trebuie privit ca rezultatul final al unei creteri progressive a IAP nedetectate datorit unei multitudini de tulburri, care duce n cele din urm la
disfuncie multipl de organ. Prezentarea propune o revizuire a tratamentului chirurgical al sindromului de compartiment.

The abdominal compartment syndrome (ACS) has tremendous relevance in the practice of surgery and the care of critically ill patients, because of the effects of
elevated pressure within the confined space of the abdomen on multiple organ systems. The problem of ACS goes well beyond the care of surgical patients,
encompassing many diverse disease states and clinical scenarios. Recent data suggest that some of the adverse effects of elevated IAP occur at lower levels
than previously thought and manifest prior to the development of a fulminant ACS. Therefore, the ACS should be viewed as the end-result of a progressive,
unchecked rise in IAP from a myriad of disorders that eventually leads to multiple-organ dysfunction. This article is proposing a review of the surgical treatment of
the ACS.

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Traumatisme abdominale la copii rezolvate pe cale chirurgical
Children Abdominal Trauma, Surgically Solved
A. N. Szabo
Spitalul Municipal, Chirurgie, Trgu Secuiesc, Romnia
Aceast lucrare, lund n studiu o problem de interes particular, are un caracter interdisciplinar i avnd ca finalitate dezvoltarea armonioas a copilului.
Traumatismele n general sunt foarte frecvente la copil.
Componenta abdominal confer traumatismului un dramatism particular, motiv pentru care ea constituie unul dintre cele mai importante i interesante capitole
ale chirurgiei.
Importana studiului traumatismelor este justificat de gravitatea deosebit, de complexitatea problemelor de diagnostic i tratament i de letalitatea nc ridicat
a acestora.
Traumatismele abdominale reprezint o problem de mare actualitate a chirurgiei de urgen, datorit vulnerabilitii peretelui abdominal, numrului mare de
organe pe care abdomenul le adpostete i datorit interferenelor abdominale cu zone anatomice nvecinate de mare importan.
n lucrare sunt expuse concepiile i atitudinile clasice, unanim acceptate, evitnd controversele i achiziiile mai recente dar neverificate de practic.
Dar am acordat o atenie particular propriei experiene, atitudinilor i modalitilor care i-au demonstrat valabilitatea i valoarea real n cazuistica noastr.

This presentation carries a theme of a particular interest for many specialists in a wide variety of medical fields, having a clearly interdisciplinary character, aiming
for the better management of the traumatized child.
Traumas are particularly frequent in children. The abdominal component of the injury only aggravates matters further, making it one of the most important
chapters of general surgery.
A thorough study of traumas is fully justified by the complexity of these cases, the high mortality and morbidity rate they carry and the challenges they present to
the diagnosing clinician. Abdominal traumas represent a matter of great importance in emergency medicine, given the vulnerability of the abdominal cavity to a
wide variety of injuring agents and the high number of vital organs it houses, as well as its interactions with other important anatomical regions of the body.
This study discusses the classical, widely acclaimed concepts and attitudes, avoiding controversial applications of more recent acquisitions of yet unproven value,
with a greater emphasis on own experience, attitudes and techniques which have stood the test of time and have proven their value through our casuistry.

Tratamentul complex al leziunilor asociate toraco-abdominale


Complex Treatment of Thoraco-Abdominal Lesions
V. Kusturov, G. Ghidirim, V. Lescov, Anna Kusturov, Irina Paladii
Universitatea de Stat de Medicin i Farmacie Nicolae Testemianu, Clinica de Chirurgie Nr. 1 Nicolae Anestiadi, Chiinu, Republica Moldova
Introducere: Leziunile toraco-abdominale domin i provoac mortalitatea pn 40 - 50% la accidentai. Principalele cauze sunt gravitatea traumei, dezvoltarea
proceselor patologice cu dereglri a grilajului costal, hemo/pneumotorace, cu dereglarea ventilaiei pulmonare.
Scopul: Analiza metodelor de tratament i rezultatele lor.
Material i metode. Studiul a inclus analiza fielor medicale ale 134 pacieni cu leziuni multiple i asociate toraco-abdominale nchise. n 74,37% cauzele leziunilor
au fost accidente de circulaie. La pacienii studiai s-a constatat asocierea: fracturile costale multiple (n=112), fracturi ale sternului (n=23), claviculei (n=19),
scapulei (n=18), fracturile oaselor tubulare (n=87) cu leziuni cranio-cerebrale (n=120) i abdominale (n=47, 2 cazuri - leziune a duodenului). La internare
accidentaii s-au investigat complex, conform schemei adoptate n clinic.
Rezultate: La 59 pacieni s-a efectuat stabilizare precoce a fracturilor extremitilor superioare, sternului i coastelor. Indicaii pentru stabilizarea de urgen a
grilajului toracic - leziunile dominante a cutiei toracice, cu prezena respiraiei paradoxale, nasociere cu o fractur pelvian sau fractur a treimii proximale a
femurului.
La 75 pacieni s-a aplicat drenarea cavitii pleurale cu examenarea rentgenologic n dinamic. n perioada de reabilitare s-a efectuat tratamentul complex
medicamentos, inhalarea aerosolilor i magnetoterapie, sanarea traheobrohial bronhoscopic dup indicaii.
Concluzii: Stabilizarea precoce a grilajului costal: fracturi a coastelor, sternului, scapulei i claviculei, n asociere cu tratamentul conservativ tradiional, a redus
semnificativ rata complicaiilor cu 20,8% i perioada de tratament n staionar.

Introduction: Thoraco-abdominal lesions dominate and cause mortality up to 40-50% of injured. The main causes are trauma severity, development of
pathological processes with disruption of the costal grid, hemo/pneumothorax, with disorders of pulmonary ventilation.
Goal: Analysis of treatment methods and their outcomes.
Material and Methods: The study included analysis of medical records of 134 patients with multiple lesions and thoraco -abdominal closed associated. In 74,37%
-injury causes were traffic accidents. In studied patients was found the association: multiple rib fractures (n=112), fractures of the sternum (n=23) , collar (n=19),
scapula (n=18 ), tubular bones fractures (n=87) with cranio-cerebral injuries (n=120 ) and abdominal (n=47, 2 cases- duodenum lesions).
On admission, the injured were completely investigated in accordance with the scheme adopted in clinics.
Results: In 59 patients was performed early stabilization of the upper extremity fractures, sternum and ribs. Indications for emergency stabilization of grid chestdominant chest injuries, presence of paradoxal breathing, in association with pelvic or proximal femur fracture.
75 patients have applied draining pleural cavity with dynamic X-Ray examination. During rehabilitation was carried out complex medical treatment, inhalation of
aerosols and magnetotherapy, tracheobronchial readjustment by indications.
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Conclusions: Early stabilization of the grid rib: fractures of the ribs, sternum, scapula and clavicle, in combination with traditional conservative treatment,
significantly reduced complication rate with 20.8% and hospital treatment period.

Conduita n leziunile duodenale nchise


Management of Duodenal Closed Lesions
V. Lescov (1), G. Ghidirim (1), M. Beuran (2), G. Rojnoveanu (1), V. Cernei (1)
(1) Universitatea de Stat de Medicin i Farmacie Nicolae Testemianu, Clinica Chirurgie N1 Nicolae Anestiadi, Chiinu, Republica Moldova
(2) Spital Clinic de Urgen Floreasc, Secia de Chirurgie General, Bucureti, Romnia
Introducere: Leziunile duodenale prezint o provocare, o ncercare major i complex n diagnostic i tratament att preoperator ct i intraoperator. Fiind
permanent n vizorul savanilor i chirurgilor necesit studiere continu.
Scopul: Studierea metodelor de tratament i rezultatele lor.
Materiale i metode: Lotul de studiu include 72 traumatizai, tratai n Institutul de Medicin Urgent Chiinu (n=39), Spitalul Clinic de Urgen Bucureti (n=33), n
perioada aa.1990 2016 (februarie), cu politraumatism nchis-58 (80,6%), cu izolat nchis -14 (19,4%), b:f -3,8:1, vrsta variind ntre 19 i 81 ani. Mecanismul
traumei: accident rutier-32 (44,4%), catatraum-15 (20,8%), agresiune fizic-21 (29,16%), corp strin-2 (2,8%), altele-2 (2,8%). Au fost spitalizai: n ebrietate-11
(15,3%), n oc-34 (47,2%). Examinai paraclinic-58 (80,6%): X-ray abdomen-21, USG-44, CT-17 (3 cazuri: 1-emfizem r/p; 2-retropneumoperitoneum),
laparocentez-17, laparoscopie-15. Toi pacienii au fost operai dup indicaii vitale pentru peritonit sau hemoperitoneum. Soluionarea leziunilor duodenale i
viscerale a fost determinat intraoperator n raport cu condiiile intraoperatorii, gravitatea i severitatea lor. n leziunile duodenului gr. I, II-sutur primar a
defectului; n leziunile duodenului gr. III-V-excluderea duodenului din pasaj.
Rezultate: Letalitatea-34(47,22%), politraumatism nchis-28(38,9%), izolat nchis-6 (8,3%), relaparotomii-5, rerelaparotomii-4.
Concluzii: Analiznd rezultatele tratamentului pacienilor cu leziuni duodenale nchise s-a constatat c interveniile pe duoden nu au influenat mortalitatea.
Letalitatea n traumatismele nchise rmne nalt din cauza gravitii i severitii leziunilor i complexitii lezionale.

Introduction: Duodenal lesions present a challenge, a complex attempt in diagnosis and treatment-preoperative and intraoperative. It remains permanently in
surgeons attention, requiring continuous studying.
Aim: To study treatment methods and their results.
Study treatment methods and their results: The study group includes 72 patients, treated in Emergency Medicine Institute Chisinau (n=39), Emergency Hospital
Bucharest (n=33) during aa.1990-2016 (February), with closed polytrauma -58(80,6%), isolated trauma-14(19,4%) m:f-3,8 :1, age between 19-81 years. The
mechanism of trauma: -road accident -32(44,4%), katatraumas-15(20,8%), physical aggression-21(29,16%), foreign body-2(2,8%), others-2(2,8%).
All patients were hospitalized: drunkness-11(15-3%), shock -34 (47.2%). Paraclinically examinated-58(80,6%):abdominal X-ray -21, US -44, CT- 17(3 cases: 1 -r/p
emphyseme; 2 -retropneumoperitoneum), laparocentesis -17, laparoscopy -15. All patients were operated by vital indications because of peritonitis or
hemoperitoneum. Settlement of duodenal and visceral lesions was determined intraoperatively compared with intraoperative conditions, gravity and their
severity. In duodenal lesions I, II gr. - primary suture; in duodenal lesions III-V gr. -excluding duodenum of the passage.
Results: Lethality rate-34(47.22%); multiple closed trauma-28(38.9%), isolated trauma -6(8.3%), relaparotomy-5, rerelaparotomy-4.
Conclusion: Analysing the results of the patients treatment with closed duodenal lesions was found out that duodenal surgeries didn't have any impact on
mortality. Lethality in closed trauma remain high because of the gravity, severity and complexity of the lesions.

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Consideraii despre dou cazuri de hemobilie sever secundare colecistectomiei laparoscopice


About Two Cases of Massive Hemobilia Following Laparoscopic Cholecistectomy
M. Beuran (1), M. D. Venter (1), M. Popiel (2), L. Gulie (2), Irina Bejenaru (3), D. P. Venter (4), I. Gheju (5), C. Oprescu (1), B. Popa (2)
(1) Spitalul Clinic de Urgen Floreasca, Clinica Chirurgie III, Bucureti, Romnia
(2) Spitalul Clinic de Urgen Floreasca, Departamentul de Radiologie, Bucureti, Romnia
(3) Spitalul Clinic de Urgen Floreasca, Clinica Chirurgie II, Bucureti, Romnia
(4) Spitalul Clinic de Urgen pentru Copii Grigore Alexandrescu, Bucureti, Romnia
(5) Spitalul Clinic de Urgen Floreasca, Bucureti, Romnia
Introducere: Hemobilia reprezint o complicaie tardiv, sever a colecistectomiei laparoscopice. Hemobilia sever secundar colecistectomiei laparoscopice
este considerat actual o complicaie vascular cu risc vital, nepredictibil, aprut dup minimum 4 sptmni de la intervenia chirurgical.
Material i metode: Sunt prezentate dou cazuri la care colecistectomia laparoscopic a prezentat complicaii tardive manifestate prin hemobilie sever aprut
la 3 luni i respectiv 3 ani postoperator. Cauza hemoragiei bilio-digestive a fost reprezentat de ctre un pseudoanevrism al arterei hepatice drepte rupt n cile
biliare; complicaia a fost rezolvat prin embolizare angiografic one-stage cu evoluie favorabil la un pacient; n cel de al doilea caz a fost necesar un abord
chirurgical clasic.
Rezultate: Pseudoanevrismele arterei hepatice drepte dezvoltate adiacent clip-urilor aplicate n cursul colecistectomiei laparoscopice au fost demonstrate la
ambii pacieni la examinarea angiografic selectiv hepatic.
Acestea apar la 60% dintre cazuri; PSA arterei hepatice comune sunt citate la 30% din cazuri, iar cele ale arterei cistice la 10% din cazuri. Angioembolizarea
reprezint tratamentul definitiv n 80% din cazuri, uneori fiind necesar reembolizarea; atunci cnd abordul angiografic nu este posibil este indicat chirurgia
clasic.
Concluzii: Hemobilia, complicaie vascular a colecistectomiei laparoscopice, este considerat actual o leziune cu potenial fatal la care rezolvarea (angiografic
sau chirurgical) trebuie s fie rapid i eficient.

Background: Hemobilia is a rare, jeopardizing complication of laparoscopic cholecystectomy. Severe hemobilia complicating laparoscopic cholecystectomy (LC) is
a rare, unpredictable, and life-threatening vascular complication commonly occurring after 4 weeks from surgery.
Materials and Methods: We describe the case history of two patients in which laparoscopic cholecystectomy was complicated 3 months and 3 years later by
massive hemobilia. The cause of haemorrhage was a pseudoaneurysm of a right hepatic artery ; this complication was successfully managed by one-stage
angiographic embolization with full recovery in one patient; in the second case it was necessary an open approach.
Results: Pseudoaneurysms of the hepatic artery adjacent to cholecystectomy clips were demonstrated in all these patients at selective right hepatic angiography.
LC-related iatrogenic pseudoaneurysms of right hepatic artery account for around 60% of cases, those of common hepatic artery for around 30% and those of
cystic artery for around 10%.
In more than 80% of cases, angiographic embolization is the first and definite treatment; in some cases, reembolization is necessary; the open surgery is
indicated when the angiographic approach is not possible.
Conclusion: Hemobilia complicating LC has become a well-known serious event reported in plenty of issues. Right hepatic artery pseudoaneurysm with
associated hemobilia, following LC, is a rare, potentially life-threatening emergency.

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Opiuni chirurgicale n chistul arborelui biliar


Surgical Approach to the Cysts of Bile Ducts
V. Hotineanu (1), A. Hotineanu (1), V. Tiron (1), A. Cazac (2), A. Iliadi (1), V. Srghi (3)
(1) Universitatea de Stat de Medicin i Farmacie Nicolae Testemianu, Catedra 2 Chirurgie, Chiinu, Republica Moldova
(2) Universitatea de Stat de Medicin i Farmacie Nicolae Testemianu, Catedra 2 Chirurgie, LC Chirurgie Reconstructiv a Tractului Digestiv, Chiinu,
Republica Moldova
(3) Universitatea de Stat de Medicin i Farmacie Nicolae Testemianu, LC Chirurgie Reconstructiv a Tractului Digestiv, Chiinu, Republica Moldova
Introducere: Chistul arborelui biliar prezint o dilatare sacciform sau fuziform a cilor biliare intra- sau extrahepatice, de genez congenital, de regul fiind
problema chirurgiei pediatrice 80%, totui n 20% din cazuri diagnosticul este stabilit la aduli. Spre deosebire de copii, la aduli aceste chisturi se asociaz cu
patologii hepato-biliare, ce necesit diverse obiuni chirurgicale.
Scop: Elaborarea tacticii de diagnostic i tratament n chisturile arborelui biliar.
Material i metod: Studiul include 11 pacieni cu chisturi ale arborelui biliar (6(54,55%) cazuri - chisturi coledociene; 4(36,36%) cazuri - Boala Caroli i 1(0,09%)caz
- sindromul Caroli) tratai n Clinica I a Catedrei 2 Chirurgie. Au fost analizate semnele clinice, datele de laborator, investigaiile imagistice (Radiografia cu mas
baritat a stomacului, duodenului, USG, ERCP, CT, IRM).
Rezultatele: Operaiile de elecie pentru pacienii cu chist coledocean au inclus: rezecii de chist coledocian - 5(45,45%) cazuri, coledocojejunostomie - 1(0,09%)
caz. La pacienii cu boala Caroli: hepaticojejunostomie cu ansa n Y a la Roux 3(27,27%) cazuri.
1(0,09%) caz cu semne de ciroz hepatic, este inclus n lista de ateptare pentru transplant hepatic. 1(0,09%)caz vrsta 12 ani la moment asimptomatic;
Perioada postoperatorie trenant la un pacient dup rezecie de chist coledocian a impus un ir de intervenii chirurgicale: hepaticolitotomie, urmat ulterior de
fistul biliar nedirijat, peritonit biliar, rezolvat prin redrenarea cavitii peritoneale. Deces a fost apreciat intr-un singur caz.
Concluzii: Opiunea chirurgical trebuie s fie individualizat n dependen de tipul i sediul leziunii i a comorbiditilor. Examenul ecografic este valoros, ns
pentru aprecierea cert a modificrilor anatomice este necesar de efectuat ERCP, CT, colangio-RMN. Supravegherea n dinamic este argumentat.

Introduction: Cyst of biliary tree presents a sacciform or fusiform dilatation of the intra- or extrahepatic bile ducts, congenital by genesis, usually being a problem
of pediatric surgery in 80% of the cases however, in 20% of the cases the diagnosis is established in adults. In comparison with children, in adults this pathology
usually is associated with other hepatobiliary problems which require different surgical approach.
Purpose: Developing of tactics in diagnosis and treatment of biliary tree cysts.
Material and methods: The study included 11 patients with cysts of biliary tree (6(54.55%) cases cysts of choledoch, 4(36.36%) cases - Caroli disease and
1(0.09%) case - Caroli syndrome) treated in Surgical Clinic 2. Clinical signs, laboratory data, imaging tests (radiography with barium of stomach, duodenum, USG,
ERCP, CT, MRI) were analyzed.
Results: The operations of choice for patients with cyst of choledoch included: bile duct cyst resection- 5(45.45%) cases, choledochojejunostomy - 1(0.09%) case.
In patients with Caroli's disease: hepaticojejunostomy with Roux-Y loop 3(27.27%) cases.
1(0.09%) case with signs of liver cirrhosis is included in the waiting list for liver transplantation.
1(0.09%) case at age 12 and in present is asymptomatic;
Postoperative period in 1 patient after resection of the cyst of choledoch duct was very difficult and imposed a series of surgeries: hepaticolithothomy, followed
later by uncontrolled biliary fistula, biliary peritonitis, resolved by redrainage of peritoneal cavity. Death was established in 1 case.
Conclusions: Surgical options should be individualized depending on the type and location of the lesion and comorbidities. Ultrasound examination is evaluable,
but for assessing of certain anatomical changes its necessary to perform ERCP, CT, cholangio-MRI. Supervision in dynamics is justified.

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Metodele de tratament minim invaziv - o nou cale de tratament n boala hidatic hepatic
The Minimally Invasive Techniques - A New Way of Treatment for the Hydatid Hepatic Disease
C. Popa (1), Carmen-Michaela Creu (2), M. Petruescu (1), Loredana Popa (2), Carmen Constantin (2), Patricia Mihilescu (2), Cerasela Dragomirescu (2),
Ioana Simion (1), O. Akhan (3), C. Botezatu (4), B. Mastalier (4)
(1) Spitalul Clinic Colentina, Clinica de Chirurgie, Bucureti, Romnia
(2) Spitalul Clinic Colentina, Clinica de Parazitologie, Bucureti, Romnia
(3) Universitatea Hacettepe, Departamentul de Imagistic, Ankara, Turcia
(4) Spitalul Clinic Colentina, Clinica Chirurgie, Bucureti, Romnia
Background: PAIR (Puncture, Aspiration, Injection, Re-Aspiration) este folosit larg n momentul actual n rile endemice pentru echinococoz ca tratament
pentru CHH mai mari de 5cm, notate tip CE I, CE II dup clasificarea WHO-Informal Working Group on CE (WHO-IWGE). A fost propus n 1986 de ctre o echip
tunisian condus de Ben-Amor i dezvoltat n anii 90 de Filice i Brunetti n Italia. Posibilitatea de a plasa la sfritul interveniei un cateter PAIR-D este
recomandat n chisturile mari. Akhan O., n Turcia, modific metoda prin creterea diametrului cateterului i amplasarea sub control fluoroscopic, asociind-o cu
lavaj prelungit cu NaCl 0,9% ( MoCAT), recomandnd-o pentru chisturi CE IIIa i CE3b.
Material i metod: Secia Clinic Chirurgie II a Spitalului Clinic Colentina a implementat acest tip de tehnici minim invazive n tratamentul bolii hidatice n
parteneriat cu Universitatea de medicin Hacettepe din Ankara Turcia, n cadrul programului european FP 7 HERACLES, dedicat bolii hidatice.
n perioada 03.2014 03.2016 s-au efectuat 18 proceduri Mo-CAT i 19 PAIR la 32 de pacieni (2 pacieni au prezentat cte 2 CHH i s-au efectuat cte 2
proceduri; la ali 2 pacieni a fost necesar o a doua procedur pe parcursul evoluiei) dintr-un total de 47 de cazuri n aceast perioad.
Rezultate: Rezultatele au fost favorabile, pacienii fiind n supraveghere minim 2 ani. Nu s-au nregistrat efecte adverse majore de natur chirurgical. Un singur
caz la care s-a practicat drenaj tip MoCAT a dezvoltat n evoluie abces de cavitate rezidual, care a fost drenat percutan. Drenajul MoCAT la ali 2 pacieni
suspectai de recidiv a CHH a demonstrat existena abceselor de cavitate rezidual, realizndu-se astfel i tratamentul acestora. Acelai drenaj a fost utilizat la o
cavitate rezidual post PAIR, care nu a involuat la 1 an dup procedura iniial, datorit unei fistule bilio-chistice. Rezultatele au fost bune.
Concluzii: Considerm tehnicile de abord minim invaziv de tip PAIR i MoCAT ca fiind opiuni importante n tratamentul chistelor hidatice. Rezultatele sunt bune i
ncurajeaz la utilizarea lor ca prim intenie, rolul chirurgiei deschise restrngndu-se la cazurile cu complicaii severe. Chiar i evoluia dificil a cavitilor
restante (dezvoltare de abcese, absena remisiei) beneficiaz de tratamentul n aceast manier.
Cuvinte cheie: chist hidatic, minim invaziv, PAIR, Mo-CAT, cavitate rezidual
Recunotin: Proiect finanat n cadrul FP7 Project Heracles - Grant agreement 602051.

Background: PAIR (Puncture, Aspiration, Injection, Re-Aspiration) is considered in this moment the standard-treatment method for hydatid hepatic cysts larger
than 5cm type CE I, CE II according to WHO-Informal Working Group on CE (WHO-IWGE) clasification. It was proposed in 1986 by a tunisian team led by Ben-Amor
and subsequently implemented in the 90s by Filice and Brunetti, in Italy. Placing a catheter at the end of the procedure (PAIR-D) is recomended for larger cysts.
Akhan, in Turkey, has modified this technique increasing the catheters diameter and setting it under fluoroscopic control (MoCAT), successfully using it for type
CE IIIa and CE3b cysts.
Material and methods: As a part of the European Project FP7 HERACLES, in the General Surgery Clinic of Colentina Teaching Hospital, a major step has been
done to implement these kind of minimally invasive techniques in order to treat the intraabdominal hydatid disease.
During 03.2014 07.2015, 14 Mo-CAT and 17 PAIR procedures have been performed on 28 patients (2 patients had 2 hydatid hepatic cysts and 2 procedures
were performed; in the case of other 2 patients, the same procedure had to be performed a second time during the surveillance period).
Results: The course of the disease was favorable, and the pacients remained under surveillance the next 2 years post-intervention, according to the HERACLES
protocol. There were no major side effects. In a single case who underwent MoCAT procedure, an abscess of the residual cavity was developed, which was
drained percutaneously. Using MoCAT for other 2 pacients who were diagnosed with relapse of the hydatic cyst, we were able to prove and also to treat
abscesses of the residual cavities. The same type of drainage was used to treat a residual cavity after PAIR, which didnt shrink after 1 year, due to a biliary fistula.
The results were also good.
Discussion: We believe that the minimally invasive techniques such as PAIR and MoCAT are indeed methods of election to treat the hydatid hepatic cysts. Their
results are good and invite us to use them as the first choice; the role of the open surgery remains for those cases with severe complications. Even the difficulties
during the evolution of the remaining cavities (abscesses, lack of remission) could be solved with the minimally invasive techniques.
Key words: hydatid cyst, minimally invasive techniques, PAIR, Mo-CAT, residual cavity
Acknowledgements: Work funded by FP7 Project- Heracles- Grant agreement 602051

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Transplantul hepatic adult - adult de la donator viu


Adult Liver Transplant from Living Donor
V. Hotineanu (1), Adrian Hotineanu (2), Vlada Dumbrav (3), Natalia Taran (4), Sergiu Burgoci (5), A. Peltec (6), G. Ivancov (7), A. Cazac (1)
(1) Universitatea de Stat de Medicin i Farmacie Nicolae Testemianu, Catedra 2 Chirurgie, LC Chirurgie Reconstructiv a Tractului Digestiv, Chiinu,
Republica Moldova
(2) Universitatea de Stat de Medicin i Farmacie Nicolae Testemianu, Catedra 2 Chirurgie, Chiinu, Republica Moldova
(3) Universitatea de Stat de Medicin i Farmacie Nicolae Testemianu, Catedra Gastroenterologie, Chiinu, Republica Moldova
(4) Universitatea de Stat de Medicin i Farmacie Nicolae Testemianu, Laborator de cercetri tiinifice, Chiinu, Republica Moldova
(5) Universitatea de Stat de Medicin i Farmacie Nicolae Testemianu, LC Chirurgie Reconstructiv a Tractului Digestiv, Chiinu, Republica Moldova
(6) Universitatea de Stat de Medicin i Farmacie Nicolae Testemianu, Catedra Terapie, Chiinu, Republica Moldova
(7) Universitatea de Stat de Medicin i Farmacie Nicolae Testemianu, Spitalul Clinic Republican, Chiinu, Republica Moldova
n structura mortalitii prin bolile aparatului digestiv, R.M. ocup primul loc n Europa i unul dintre primele locuri n lume. TH (transplantul hepatic) de la donator
viu reprezint o opiune important de tratament pentru recipienii cu boal hepatic terminal. Primul TH, realizat n R.M., ncepe n 2013, acesta fiind de la
donator viu.
Material i metode: n perioada 2013- 2016, s-au realizat 10 transplanturi hepatice de la donator viu. Principala indicaie au reprezentat-o cirozele de etiologie
viral: VHD (60%), VHB (20%), VHC (20%). Studiul a inclus 20 pacieni: 10 donatori, vrsta medie 34,8111,59 ani i 10 recipieni, vrsta medie 44,57 9,91ani. Toi
pacienii evaluai clinic, biochimic, instrumental conform protocolului instituional. Steatoza hepatic (25-30%) confirmat prin puncie biopsie hepatic la 6
(60%) donatori. Scorul MELD a variat ntre 14-19 puncte. Tratamentul de imunosupresie: standard, conform protocolului.
Rezultate: Supraveuirea postoperatorie imediat estimat la 90% (9). Supraveuirea pacientului i a grefei la 1 an 70%. Morbiditatea postoperatorie 2,
complicat cu rejet acut 2 (20%). Complicaii precoce: a) tromboz de arter hepatic, cu retransplant 1 (10%); b) rejet acut 2 (20%), 1 tratat prin pulsterapie;
c) complicaii medicale: pulmonare 4 (40%), neurologice 2 (20%); d) complicaii biliare fistul tran seciune hepatic 1 (10%), peritonit biliar 1 (10 %).
Complicaii tardive: a) biliare prin stenoz anastomotic - 1 (10%), b) complicaii medicale obezitate 1 (10%); c) recidiva afeciunilor primare post-transplant:
VHB 1 (10%), VHC 1 (10%).
Concluzii: Transplantul hepatic de la donator viu prioritizeaz recipienii din lista de ateptare, identific i micoreaz factorii de risc preoperator, oferind o gref
optimal.

In the structure of mortality from digestive diseases, Republic of Moldova ranks first in Europe and one of the first in the world. LT (liver transplant) from a living
donor represents an important treatment option for recipients with terminal liver disease. The first LT in the Republic of Moldova was conducted in 2013, from a
living donor.
Material and Methods: Between 2013 2016, 10 liver transplants from living donors were performed. The main indication was represented by cirrhosis of viral
etiology: VHD (60%), VHB (20%), VHC (20%). The study included 20 patients: 10 donors, average age 34.81 11.59 years old and 10 recipients, average age 44.57
9,91 years old. All patients assessed clinically, biochemically and instrumentally according to institutional protocol. Hepatic steatosis (25-30%) confirmed by liver
biopsy to 6 (60%) donors. MELD score ranged from 14 to 19 points. Immunosuppression treatment: standard, according to protocol.
Results: Estimated immediate postoperative survival of 90% (9). Patient and graft survival after 1 year - 70%. Postoperative morbidity 2, complicated with acute
rejection 2 (20%). Early complications: a) hepatic artery thrombosis, with repetitive transplant -1 (10%); b) acute rejection - 2 (20%), 1 treated through
pulse-therapy; c) medical complications: pulmonary - 4 (40%), neurological - 2 (20%) d) biliary complications - liver fistula installment section - one (10%), biliary
peritonitis - 1 (10%). Late complications: a) biliary through stenosis anastomotic - 1 (10%), b) medical complications - obesity - 1 (10%) c) relapse of primary disease
post-transplantation: HBV - 1 (10%), HCV - 1 (10%).
Conclusions: Liver transplantation from living donor prioritizes recipients from the waiting list, identifies and reduces preoperative risk factors, providing optimal
graft.

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Hemoperitoneul spontan - cauz rar de abdomen acut chirurgical la pacientul cirotic


"Spontaneous" Hemoperitoneum - A Rare Cause of Acute Surgical Abdomen in Cirrhotic Patients
M. Liescu (1), L. Drghici (1), V. Borca (2), Maria Berechet (3), D. Baboi (3), I. Dina (4), N. Iordache (4)
(1) Universitatea de Medicin i Farmacie Carol Davila Bucureti, Spitalul Clinic de Urgen Sf. Ioan, Clinica de Chirurgie General, Bucureti, Romnia
(2) Spitalul Clinic de Urgen Sf. Ioan, Clinica de Chirurgie General, Bucureti, Romnia
(3) Spitalul Clinic de Urgen Sf. Ioan, Clinica de Gastroenterologie, Bucureti, Romnia
(4) Universitatea de Medicin i Farmacie Carol Davila, Spitalul Clinic de Urgen Sf. Ioan, Clinica de Gastroenterologie, Bucureti, Romnia
Conform definiiei, hemoperitoneul spontan este provocat de ruptura nontraumatic a ficatului, a splinei sau a unor vase intraperitoneale la pacieni cu
hipertensiune portal, coagulopatii sau tratamente anticoagulante. Hemoperitoneul spontan este o cauz rar de abdomen acut. Atunci cnd debitul sngerrii
este masiv, evoluia poate s fie catastrofal chiar i in situaiile n care exist asisten medical de specialitate la dispoziie. Hemoperitoneul recunoate o
multitudine de cauze cu mult mai frecvente, ruptura spontan a vaselor intraperitoneale n contextul hipertensiunii portale fiind printre cele mai rare, conform
datelor din literatura (sub 0,5%).
Prezentm dou cazuri de hemoperitoneu masiv prin ruptur de vene de la nivelul intestinului subire, fr a putea evidenia un eveniment traumatic care s fi
precipitat declanarea accidentului hemoragic.
n ambele cazuri degradarea rapid a strii generale a pacienilor a impus intervenia chirurgical de urgen imediat pentru diagnosticul de abdomen acut, oc
hemoragic. Abia dup efectuarea explorrii chirurgicale s-a putut stabili diagnosticul corect i s-a rezolvat cauza hemoragiei.
Lucrarea i propune s atrag atenia asupra pacienilor cirotici cu hipertensiune portal. La acetia, explorrile imagistice (ecografie, tomografie computerizat)
evideniaz frecvent revrsat lichidian intraperitoneal, adesea voluminos, dar care n rare situaii este snge i nu ascit asa cum se constat n majoritatea
cazurilor. Astfel de condiii trebuie recunoscute rapid pentru ca pacienii respectivi s primeasc rapid tratamentul potrivit, hemostaza chirurgical fiind singurul
tratament adecvat n aceste cazuri.

By definition, "spontaneous" hemoperitoneum is caused by a nontraumatic fracture of the liver, of the spleen or any of the intraperitoneal vessels in patients with
portal hypertension, coagulopathy or anticoagulant treatments. "Spontaneous" hemoperitoneum is a rare cause of acute abdomen. When the rate of bleeding is
massive, changes can be catastrophic even in situations where specialist care is available.
Hemoperitoneum recognizes many causes far more frequent, spontaneous rupture of vessels in the context intraperitoneal portal hypertension being among the
rarest, according to data from literature (below 0.5%).
We present two cases of massive haemoperitoneum produced by the rupture of veins in the small intestine without being able to highlight a traumatic event that
has precipitated the onset hemorrhagic stroke.
In both cases the rapid degradation of the general state of the patients required immediate emergency surgery for the diagnosis of acute abdomen, hemorrhagic
shock. Only after surgical exploration, the team was able to establish the correct diagnosis and to resolve the bleeding.
The present paper aims to draw attention to cirrhotic patients with portal hypertension. In their cases, imaging examinations (ultrasound, computed tomography)
frequently highlight intraperitoneal fluid effusion, often bulky, but which in rare cases is not ascites but blood.
This situation must be rapidly recognized in order for the patients to quickly receive the right treatment, surgical hemostasis being the only appropriate treatment
in these cases.

Opiuni terapeutice n tratamentul chirurgical al chistului hidatic hepatic


Therapeutic Options in Surgical Treatment of the Hepatic Hydatid Disease
I. S. Coman, Violeta Elena Radu, Oana Ilona David, V. A. Porojan, A. R. Stoian, V. T. Grigorean
Spitalul Clinic de Urgen Prof. Dr. Bagdasar-Arseni, Clinica de Chirurgie General, Bucureti, Romnia
Obiective: Prezentm experiena Clinicii de Chirurgie General a Spitalului Clinic de Urgen Bagdasar-Arseni Bucureti privind tratamentul chirurgical al bolii
hidatice hepatice, comparnd rezultatele diverselor metode de tratament chirurgical i stabilind limitele abordului laparoscopic.
Material i metod: Am avut n vedere o perioada 2010-2015, cazurile din aceast perioad facnd obiectul studiului. Tuturor pacienilor li s-a aplicat tratament
chirurgical, att prin procedee clasice ct i laparoscopice. Selecia pacienilor n vederea abordului laparoscopic a fost fcut dup criterii anatomo-topografice
i clinice bine precizate.
Rezultate: n chirurgia laparoscopic procedeul aplicat a constat n perichistectomie parial Mobit-Lagrot (dup neutralizarea parazitului cu ser hiperton,
evacuarea coninutului cu extragerea membranei proligere) i drenaj al cavitii restante chistice, completat opional de colecistectomie i drenaj transcistic al
cii biliare principale.
Concluzii: n chirurgia clasic s-a procedat dup neutralizarea parazitului (cu ser hiperton) la perichistectomie parial/ideal, evacuarea coninutului (extragerea
membranei proligere) i drenaj al cavitii restante i subhepatic sau la derivaii perichisto-digestive, strategie operatorie stabilit n funcie de situaia
anatomo-topografic i intraoperatorie a fiecrui caz.
Considerm benefic abordul laparoscopic al chistului hidatic hepatic, pe cazuri selecionate, pentru c permite abordul i vizualizarea mai facil a unor spaii
(intraabdominale i intrachistice) greu accesibile chirurgiei clasice; scurtarea timpului operator, a perioadei postoperatorii i implicit a spitalizrii.
n opinia noastr, chirurgia laparoscopic este o soluie viabil, sigur i eficient n arsenalul terapeutic al chistului hidatic hepatic, dar nu reprezint nc o
metod de elecie.
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Objective: We present the experience of the General Surgery Clinic from Bagdasar Arseni Clinical Emergency Hospital concerning the surgical treatment of the
hydatid hepatic disease, comparing the results of the varied surgical treatments and establishing the limits of the laparoscopic approach.
Material and method: We studied the period between 2010 and 2015, the cases included in this time period being the study objective. Surgical treatment was
applied to all patients, using either the classic or the laparoscopic surgical approach. Patient selection for the laparoscopic treatment was made after
well-defined clinical and pathological criteria.
Results: The laparoscopic approach consisted in partial pericystectomy Mobit-Lagrot (after parasite neutralization with hypertonic saline, content evacuation with
the extraction of the proligerous membrane) and, in addition with optional cholecystectomy and transcystic drainage of the principal bile duct.
Conclusion: In the classic approach, after the parasite neutralization (with hypertonic saline solution) the following were performed: partial/ideal pericystectomy,
content evacuation (extraction of the proligerous membrane) and drainage of the residual cavity and of the lesser peritoneal cavity, or pericystic- digestive
derivations, therapeutic strategy established concerning the intraoperative and topographic localization of each case.
We consider benefic the laparoscopic approach of the hepatic hydatid cyst, on selected cases, because it permits facile visualization and approach of certain
spaces (intraabdominal or intracystic) that are hard to approach using classic surgery; smaller operation time, postoperatory period and admission.
From our point of view laparoscopy is a viable, safe and efficient solution in therapeutic measures of hydatid hepatic disease, but is not an election method.

Rezeciile hepatice pe ficatul cirotic - rezultate postoperatorii


Hepatic Resections on Cirrhotic Liver - Postoperative Results
S. Aldoescu (1), S. V. Petrea (1), Mihaela Vlcu (1), Z. Filipovski (1), Raluca Hanes (1), V. Braoveanu (2), R. Zamfir (2), I. Brezean (1)
(1) Spitalul Clinic Dr. Ioan Cantacuzino, Chirurgie General II, Bucureti, Romnia
(2) Institutul Clinic Fundeni, Chirurgie General, Bucureti, Romnia
Introducere: Carcinomul hepatocelular (HCC) este cea mai frecvent neoplazie primar hepatic fiind n cele mai multe cazuri asociat cirozei hepatice. Rezectia
hepatic poate fi considerat opiune terapeutic cu potenial curativ pentru pacienii cu HCC, atunci cnd transplantul nu este o opiune rapid disponibil.
Scop: Evidenierea rezultatelor postoperatorii imediate a rezeciilor hepatice pentru hepatocarcinom grefate pe ficat cirotic din perspectiva unei singure echipe
chirurgicale.
Metod: n intervalul ianuarie 2014-ianuarie 2016 au fost urmrii retrospectiv i prospectiv 19 pacieni prezentnd carcinom hepatocelular grefat pe ficat cirotic
pentru care s-au practicat rezecii hepatice n funcie de inventarul lezional intraoperator.
Concluzii: Managementul chirurgical al HCC se bazeaz n egal msur pe dimensiunea i localizarea tumorii dar mai ales pe statusul functional hepatic. innd
cont de stadiul bolii i disponibilitatea sczut pentru transplant, rezeciile hepatice pot constitui o soluie temporar n ateptarea transplantului.

Introduction: Hepatocellular carcinoma is the most frequent primary hepatic neoplasia and, in most cases, it is associated with liver cirrhosis. Liver resection can
be considered a potential curative therapy for HCC patients when liver transplantation is not an option or it is not immediately available.
The aim of the presentation is to bring forward the immediate postoperative results of liver resections for hepatocellular carcinoma of the cirrhotic liver, based on
a single surgical teams experience.
Methods: Between January 2014-January 2016, we retrospectively and prospectively followed 19 patients who presented with hepatocellular carcinoma on a
cirrhotic liver and for whom we performed hepatic resections according to the intraoperative lesions evaluation.
Conclusions: Hepatocellular carcinoma management is based both on the size and location of the tumor, as well as on the preexisting liver function. Given the
stage of the disease and the time to liver transplantation, liver resections may be feasible in the absence of comorbidities in cirrhotic patients with HCC.

Evaluarea managementului chirurgical i a rezultatelor la distan a pacienilor cu stricturi biliare post-operatorii


Assessment of Surgical Management and Remote Outcomes of Patients with Postoperative Biliary Strictures
A. Ferdohleb
Universitatea de Stat de Medicin i Farmacie Nicolae Testemianu, Clinica Chirurgie Nr. 2, Chiinu, Republica Moldova
Managentul chirurgical adresat pacienilor cu leziuni biliare i stricturi biliare benigne este o problem actual de discuie i trezete actualmente multe direcii
de cercetare tiinific. Scopul studiului dat a fost de a sistematiza experiena noastr n tratamentul stricturilor biliare benigne, analiznd n complex rezultatele
att imediate ct i cel la distan.
Metode: n perioada 1989-2015, n Clinica 1 Catedra 2 Chirurgie a USMF N.Testemianu au fost spitalizai 203 pacieni cu stricturi iatrogene a cilor biliare.
Evaluarea clinic a bolnavilor a inclus cteva etape consecutive: 1) stabilirea diagnosticului etiopatogenetic; 2) decompresiunea preoperatorie a arborelui biliar; 3)
actul chirurgical reconstructiv. 56,3% din pacienii cu leziuni biliare au suferit o intervenie chirurgical pentru o colecistit acut. 95% au reprezentat leziuni
biliare majore, clasele D-E, cu preponderena sexului feminin (F/B=3.6/1). n cazul stricturilor biliare, dup cuparea icterului i a infeciei biliare, am efectuat
derivaiile bilio-digestive n dependen direct de nivelul obstacolului, prefernd cele bilio-jejunale pe ansa izolat n Y a la Roux. Deces post-operator s-a
nregistrat n 6 (2.63%) cazuri.
Concluzii: Stricturile iatrogene ale cii biliare principale au o evoluie complicat, cu multe intervenii chirurgicale, necesitnd numeroase internri. Trebuie
depuse eforturi pentru a fi depistate n timp oportun i a preveni complicaiile septice. n prima etap se va recurge la decompresiune de arbore biliar, iar dup
cuparea procesului inflamator se va realiza reconstrucia bilio-digestiv. Aceti pacieni necesit un program complex de monitorizare i analiz la distan a strii
de sntatea a pacienilor ce au suporta intervenii reconstructive.
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Surgical management to patients with benign biliary strictures and biliary lesions is a current issue for discussion and awakens many directions now. The purpose
of this study was to systematize our experience in the treatment of benign biliary strictures, analyzing the complex results at both immediate and remote.
Methods: Over the 1989-2015 years, were hospitalized 203 patients and benign biliary strictures in the Clinic 1 2nd Department of Surgery of SMPU
N.Testemianu. Clinical evaluation included several consecutive steps: 1) setting the ethiopatogenic diagnosis; 2) pre-operatory decompression of the biliary
tree; 3) reconstructive surgical act. 56.3% of patients with biliary lesions underwent a surgery for acute cholecystitis. 95% presented major biliary lesions of D-E
classes, mainly females (F/B=3.6/1) In case of biliary strictures, following the cut of jaundice and biliary infection, bilio-digestive derivations have been performed
according to the level of the obstacle, preferring the bilio-jejunal on isolated loop in Y a la Roux. The post-operatory lethality was of 6 (2.63%) cases.
Conclusions: The iatrogenic stricture of bile duct had a complicated evolution, with more surgeries, requiring many hospitalizations. It should be endeavored to
be detected in a timely manner and prevent septic complications. The first phase will use tree biliary decompression, and after cropping inflammatory process
will take biliary-digestive reconstruction. These patients require a complex remote monitoring and analysis of health status of patients who have undergone
reconstructive interventions.

Hipertensiunea portal extrahepatic n pancreatita cronic: inciden, factori de risc i impactul asupra
tratamentului chirurgical
Extrahepatic Portal Hypertension in Chronic Pancreatitis - Incidence, Risk Factors and Implications for Surgical
Treatment
S. T. Barbu (1), T. Cerciu (1), Narcisa Balea (2), Alexandrina Murean (2)
(1) Universitatea de Medicin i Farmacie Iuliu Haieganu, Clinica Chirurgie IV, Cluj-Napoca, Romnia
(2) Spitalul Clinic Ci Ferate, Anestezie i Terapie Intensiv, Cluj-Napoca, Romnia
Introducere: Tromboza venei porte (TVP) este o complicaie rar, dar bine cunoscut a pancreatitei cornice (PC).
Obiectiv: Analiza tratamentului i evoluiei TVP la bolnavii cu PC; gsirea de factori de risc.
Material i metod: 115 bolnavi cu PC operai ntre 2005-2014 au fost inclui n studiu. Durata medie a evoluiei PC=12,33 ani. Am analizat prevalena TVP,
caracteristicile clinice, tratamentul i evoluia. Regresia logistic a fost utilizat pentru gsirea factorilor de risc.
Rezultate. Opt brbai (etiologia PC: 7 alcoolic, 1 hipertrigliceridemic; vrsta medie=54 ani; durata medie PC=11,51 ani) au prezentat TVP (6,9%). Simptomele
prezentate au fost ascit (3), scdere n greutate (7), splenomegalie (8), necroz segmentar hepatic (2). Trombul nu s-a extins pe vena mezenteric. Tromboza
venei splenice era preexistent la toti bolnavii. Coleciile peripancreatice infectate (6 bolnavi) au fost tratate cu drenaj percutan. ase bolnavi au necesitat o
operaie pentru PC (2 splenopancreatectomii distale, 4 operaii Frey). n timpul urmririi medii (4,7 ani) niciun bolnav nu a prezentat sngerare din varicele
esofagiene. Factori de risc semnificativi pentru TVP au fost : etiologia etanolic, durata PC >10 ani, episoade acute recente, colecii lichidiene infectate i
prezena trombozei venei splenice.
Concluzii: TVP apare trziu n evoluia PC, la bolnavii cu modificri morfologice severe pancreatice i episoade acute recente complicate cu colecii lichidiene
infectate. Dezvoltarea cavernomului portal i a hipertensiunii portale extrahepatice face ca operaiile adresate PC s fie mult mai dificile, riscante, cu necesar
crescut de transfuzii de snge, morbiditate crescut, dar oferind o caliatate a vieii comparabil cu a bolnavilor fr TVP operai pentru PC.

Introduction: Portal vein thrombosis (PVT) is an uncommon, well-recognized complication of chronic pancreatitis (CP).
Purpose: to assess PVT treatment and outcome in CP patients, to find possible risk factors.
Material and Methods: 115 CP patients operated between 2005-2014 were included in the study. Average CP duration was 12.33 years. PVT prevalence, clinical
characteristics, treatment and outcome were described. Logistic regression was used to find potential risk factors for PVT.
Results: PVT prevalence was 6.9%. Eight males (CP etiology: 7 alcoholic; 1 hypertrigliceridaemic) developed PVT (mean age=54 years, mean CP duration=11.51
years). Symptoms included low protein ascites (3), weight loss (7), splenomegaly (8), segmental hepatic necrosis (2). Mesenteric vein was not involved by
thrombus, while splenic vein thrombosis was associated in all patients. Infected fluid collections, present in 6 patients were treated by percutaneous drainage.
One patient died due to severe sepsis. During evolution, 6 patients suffered surgery addressing CP (2=distal spleno-pancreatectomy, 4=Frey procedure). None of
the patients had bleeding from eso-gastric varices during 4.7 years mean follow-up. Statistical analysis found as PVT risk factors: alcoholic etiology, CP duration
>10 years, recent acute episodes, infected fluid collections and previous splenic vein thrombosis.
Conclusion: PVT usually occurs after >10 years of CP evolution, in patients with severe pancreatic morphological changes, infected fluid collections and
preexistent splenic vein thrombosis. Development of extrahepatic portal hypertension makes CP surgery difficult, increasing morbidity and need for blood
transfusion, but offering a postoperative QOL almost similar to patients without PVT operated for PC.

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Physicians Session Oral Communications

Strategia tratamentului chirurgical al pancreatitei cronice i complicaiilor ei


Modern Trends in Surgical Treatment of Chronic Pancreatitis and its Envolving Complications
V. Hotineanu, A. Cazac, A. Hotineanu, G. Ivancov, C. Iliadi, Elena Moraru, A. Cotone
Universitatea de Stat de Medicin i Farmacie Nicolae Testemianu, Catedra 2 Chirurgie, LC Chirurgie Reconstructiv a Tractului Digestiv, Chiinu,
Republica Moldova
Introducere: Identificarea pancreatitei cronice (PC) i a complicaiilor ei ntr-o faz precoce are ca scop obinerea unor indici performani i oblig la ajustarea
opiunii chirurgicale.
Material i metod: Studiul prezint rezultatele tratamentului chirurgical aplicat la 480 pacieni cu PC i complicaiile ei, desfurat n perioada anilor 1992-2015 n
Clinica Chirurgie Nr. 2. Operaiile de elecie au inclus: n cazurile PC complicate cu pseudochist pancreatic (PP)-chistpancreaticojejunoanastomoz (CPJA) pe ans
Roux 175 (38,04%), drenare extern a PP 67 (13,96%) cazuri; drenare ecoghidat a PP- 10 (2,08%) cazuri. Pentru cazurile de PC complicat cu icter
mecanic-pancreatojejunoanastomoza cu colecisto- sau coledoco-jejunoanastomoz pe ans bispiculat a l Roux - 5 (1,04%) cazuri, CPJA cu colecisto-sau
coledoco-jejunoanastomoz pe ans bispiculat a l Roux 30 (6,24%) cazuri, colecisto-(coledoco) jejunoanastamoz pe ans Roux - 32 (6,67%) cazuri,
duodenpancreatectomie cefalic -3 (0,62%)cazuri, rezecie pancreatic caudal cu derivaie pancreatico-jejunal, splenectomie-2(0,42%)cazuri, enuclearea
chistului pancreatic 1(0,21%) caz. Soluionarea farmacoterapeutic a fistulelor pancreatice a fost eficace n 6 (1,24%) cazuri, celelalte 8 (1,67%) cazuri au necesitat
tratament chirurgical.
Rezultate: Evoluia pacienilor a fost favorabil n 384 (80,0%) cazuri. Rata complicaiilor precoce a constituit 40 (8,33%) cazuri. Complicaiile tardive s-au
manifestat n 20 (4,16%) cazuri necesitnd reintervenie chirurgical clasic la 20 (4,16%) pacieni i miniinvaziv la 18 (3,75%) pacieni. Letalitate postoperatorie
nul.
Concluzii: Derivaiile pancreato-jejunale reprezint o metod terapeutic eficient cu rezultate bune, corelate cu selecia candidailor, tehnica chirurgical de
elecie i prevenirea complicaiilor.
Cuvinte cheie: pancreatit cronic, tratament chirurgical, complicaii

Introduction: Chronic pancreatitis (CP) and its envolving complications in an early phase is indented to get performing results and require the optimal surgical
procedure.
Material and methods: The study presents the results of surgical treatment applied to 480 patients with CP and its complications, held during 1992-2015 in the
Surgical Clinic No. 2.
The elective surgeries included: In CP with pancreatic pseudocyst (PP) - Cyst pancreato-jejunoanastomosis (CPJA) on the loop by Roux - 175 (38.4%) cases,
external drainage of the PP in 67 (13,96%) cases and endoscopic drainage under ultrasound - in 10 (2,08%) cases. For the CP with mechanical jaundice - PJS with
cholecysto or choledocho-jejuno-anastomosis on the loop by Roux- 5 (1.04%) cases, CPJS with cholecysto- or choledocho-jejuno-anastomosis on the loop by
Roux 30 (6.24%) cases, cholecysto- or choledocho-jejuno-anastomosis on the loop by Roux 32 (6.67%) cases, cephalic duodenopancreatectomy - 3 (0,62%)
cases, distal pancreatectomy with pancreato-jejuno-anastomosis and splenectomy - 2 (0,42%) cases, enucleation of the cyst one (0,21%) case. Medicamentous
management of the pancreatic fistula was efficient in 6 (1,24%) cases and 8 (1,67%) cases required surgical treatment.
Results: The patients evolution was favorable in 384 (80.0%) cases. The rate of early complications was in 40 (8,33%) cases. Late complications were recorded in
20 (4,16%) cases, reason for 20 (4,16%) of them required a new classical surgery and 18 (3,75%) a minimally invasive. Letality was 0.
Conclusions: The PJA (pancreato-jejuno-anastomosis) represents an efficient procedure with good results, related with each case, the elective procedure and
prevention of complications.
Key words: chronic pancreatitis (CP), surgical treatment, complications

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Transplant hepatic integru de la donatori vrstnici aflai n moarte cerebral


Integral Liver Transplantation from Elderly Donors with Brain Death
V. Hotineanu (1), A. Hotineanu (1), G. Ivancov (2), S. Burgoci (3), V. Srghi (2), Dumitru Cazacu (2), N. Taran (2), Angela Peltec (2), A. Cazac (1)
(1) Universitatea de Stat de Medicin i Farmacie Nicolae Testemianu, Catedra 2 Chirurgie, LC Chirurgie Reconstructiv a Tractului Digestiv, Chiinu,
Republica Moldova
(2) Universitatea de Stat de Medicin i Farmacie Nicolae Testemianu, Spitalul Clinic Republican, Chiinu, Republica Moldova
(3) Universitatea de Stat de Medicin i Farmacie Nicolae Testemianu, LC Chirurgie Reconstructiv a Tractului Digestiv, Chiinu, Republica Moldova
Obiectivul studiului: Recent, n literatura de specialitate apar tot mai multe discuii despre utilizarea grefelor cadaverice de la donatori vrstnici. Asemenea
ntrebri se abordeaz din cauza disproporiei ntre pacienii de pe lista de ateptare i donatorii aflai n moarte cerebral. De aceea, multe centre de transplant
au majorat limita de sus a vrstei de la precedenta de 50 ani la 70 ani, unii chiar la 75 ani.
Material i metode: Insuficiena critic de donatori de organe aflai n moarte cerebral ne-a impus s utilizm pe o scar larg organele prelevate de la donatori
vrstnici (55-78 ani). Transplant hepatic cu ficat integru de la donator vrstnic a fost efectuat n 8 cazuri (80%). Perioada de spitalizare este de la 16 pn la 42 zile.
ntr-un caz recipientul a decedat din cauza rejetului acut a grefei. Ali 7 recipieni nu au prezentat complicaii la un termen de 3 ani de supraveghere.
Rezultate: Dei calitatea grefei de la donatori vrstnici este sub-optim dect cea de la donatori tineri non-funcia primar a grefei nu s-a ntmplat. Pe de alt
parte, o supravieuire pe termen lung nu poate fi calculat din cauza termenului scurt de cercetare a recipienilor.
Concluzie: Ca rezultate preliminare putem constata c transplantul hepatic cu ficat integru de la donatori vrstnici aflai n moarte cerebral este o metod relativ
sigur. Cu toate acestea, donatorii n vrst i recipienii corespunztori trebuie s fie atent selectai nainte de transplant.

Objectives: Recently in literature there are more and more discussions about the use of cadaver grafts from older donors. Such types of questions appear
because of a disproportion between patients from waiting lists and brain-dead donors. That's why many transplantation centers have increased the upper limit of
the previous age of 50 years to 70 years and some of them even 75 years.
Material and Methods: Critical insufficiency of brain-dead organ donors forced us to use a large scale of obtained organs from elderly donors (55-78 years).
Integral liver transplantation from elderly donors was performed in 8 cases (80%). Hospital stay varied from 16 to 42 days. In one case the recipient died from
acute graft rejection. Other seven recipients had no complications during 3 years of supervision.
Results: Although the quality of the donor graft from older brain-dead donors is sub-optimal than those taken from young donors, the primary graft non-function
has not happened. On the other hand, long-term survival cannot be calculated because of short period of observations.
Conclusion: As preliminary results, we can say that integral liver transplantation from older brain-dead donors is a relatively safe method. However, older donors
and appropriate recipients should be carefully selected before transplantation.

Imagistic hepatic n oncologie - detecia i caracterizarea metastazelor i a modificrilor post-terapeutice


Imaging the Liver in Oncology - Detection and Characterization of Metastasis and Post Therapeutic Changes
Elisabeta Popa (1), Irina Igntescu (1), Diana Fatoi (1), Alexandra Cecilia Nicolaescu (2), M. Alecu (2), L. Simion (2), N. D. Straja (2)
(1) Institutul Oncologic Prof. Dr. Al. Trestioreanu, Radiologie, Bucureti, Romnia
(2) Universitatea de Medicin i Farmacie Carol Davila, Chirurgie I, Institutul Oncologic Prof. Dr. Al. Trestioreanu, Bucureti, Romnia
Ficatul este organul cel mai frecvent implicat n afeciunile metastatice, avnd originea cel mai adesea n tumori colo-rectale, de sn, plmn, pancreas sau
stomac. Detectarea metastazelor la momentul diagnosticului sau n timpul tratamentului este crucial n managementul terapeutic al pacientului.
Att examinarea CT spiral multi-fazic ct i imagistic prin rezonaa magnetic, joac un rol esenial n identificarea metastazelor dar i a modificrilor hepatice
survenite post-chimioterapie, avnd n vedere c orice chimioterapic poate produce hepatotoxicitate, cu modificri consecutive n parenchimul hepatic, ce fac
dificil evaluarea rspunsului la tratament.
Lucrarea i propune s prezinte rolul diverselor modaliti imagistice n detecia i caracterizarea metastazelor hepatice n evaluarea preterapeutic, dar i n
stabilirea rspunsului la tratament. De asemenea, se introduc n discuie tehnici noi de examinare, de tipul scanrii cu energie dual, aportul informaiilor aduse
prin post-procesare i relevana clinic a acestora n practica actual.

Liver is the most common site involved in metastatic diseases, from colorectal, breast, lung, pancreas or gastric cancer as the most frequent primary tumors. The
detection of metastases at the time of diagnosis, or during treatment, remains crucial in the therapeutic management.
Both Multiphasic Dynamic CT (MDCT) and MRI play an essential role in identification of liver metastasis, but also in the evaluation of posttreatment changes, that
may cause problems in follow-up examinations, regarding the hepatotoxicity of any chemotherapeutic drug.
The purpose of the paper is to present the diagnostic performance values of the different imaging modalities in detection and characterization of liver metastasis,
in pretreatment evaluation and in the treatment response assessment. Novel imaging technologies like dual-energy CT are brought into focus, as well as the
added-value of post processing techniques and their clinical relevance in daily routine.

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Chirurgia carcinomului vezicular - ntre exereze limitate i atitudini eclectice


Surgery Gallbladder Carcinoma - Between Limited Exer and Eclectic Attitudes
M. Glod, M. V. Burduloi, A. Chico, I. Costea
Universitatea de Medicin i Farmacie Gr. T. Popa, Clinica IV Chirurgie, Iai, Romnia
Incidena sczut, atipia simptomatic, dificultile de diagnostic i strategia terapeutic incomplet standardizat, fac din cancerul vezicular una dintre cele mai
redutabile i sumbre localizri neoplazice.
Material i metod: Lucrarea prezint 24 de observaii de neoplasm vezicular operate n perioada 1989-2015 a cror numitor comun a fost surpriza
intraoperatorie i /sau histologic. Indicaia chirurgical a fost dictat n toate cazurile de o suferin biliar mai mult sau mai puin sistematizat dar prelungit, cu
litiaz biliar confirmat ecografic (23 cazuri), la care s-au descoperit: tumor palpabil (7 cazuri), icter (7 cazuri), sindrom anemic (20 cazuri), respectiv semne de
impregnare neoplazic (8 cazuri). Dintre acestea, 20 observaii au fost ntlnite la femei, cu limite de vrst cuprinse ntre 55 si 79 ani. S-au practicat 11
colecistectomii pentru vezicule litiazice fr aspecte macrolezionale suspecte (stadiu II Nevin), 11 colecistectomii lrgite n pat pe un bloc tumoral subhepatic i
respectiv o colecistolitotomie cu evacuarea a trei abcese pericolecistice, finalizat prin colecistostomie de necesitate (ambele n stadiul III Nevin). n ultimul caz,
care prezent un icter mecanic prin neoplasm cefalopancreatic pe piesa de colecistectomie (cu litiaz asociat) s-au evideniat i elemente microscopice ale unui
adenocarcinom vezicular (stadiul II Nevin) sincron. Explorarea intraoperatorie nu a fcut dect s ridice suspiciunea (n 10 cazuri) sau s transeze limita
operabil-inoperabil (un caz). Mentionm c pacienii nu au beneficiat de terapie complemetar radiochimioterapic pre, intra sau postoperator.
Rezultate: Rezultatele postoperatorii n seria noastr au purtat amprenta agresivitii marcate a acestei localizri neoplazice, cu 8 decese n primele 7 luni, 6
decese la 12 luni, 5 supravieuiri la 6 ani i 5 observaii sub monitorizare (la 6, 8 respectiv 12 luni postoperator). Corelnd supravieuirea n timp cu stadiul lezional,
constatm c din 13 pacieni stadiul II Nevin avem doar 5 supravieuiri la 6 ani (pacient n observaie, asimptomatic) n timp ce ceilali 11 plasai n stadiul III Nevin
(8) respectiv V (3) au supravieuiri sub 1 an.
Discuii i concluzii: Apreciem c triada: suferin biliar prelungit cu litiaz confirmat-anemie-vrsta peste 60 de ani reprezint un element de suspiciune
important, n aceste condiii colecistectomia impunnd executarea de rutin a examenului histologic extemporaneu i eventual lrgirea interveniei la exereza
hepatic i evidare ganglionar. Incidena n cretere (cinci cazuri n ultimii doi ani), prognosticul evolutiv infaust (doar 7 cazuri de supravieuire la un an, dou la 5
ani) determinat de agresivitatea lezional (topografie, form histologic, grading) i imposibilitatea unui diagnostic precoce, ct i posibilitile chirurgicale
limitate impun o reorientare n abordarea acestei patologii.

Low incidence of atypical symptoms, difficulties in diagnostic and therapeutic strategy incompletely standardized, make gallbladder cancer one of the most
powerful and grim neoplastic localizations.
Material and method: The paper presents 24 gallbladder cancer observations made during 1989-2015, whose common denominator was the surprise
intraoperative STI / or histological. Surgical indication was dictated in all cases of a suffering biliary more or less systematic but extended with gallstones
confirmed by ultrasound (23 cases), which were palpable tumor (7 cases), jaundice (7 cases), anemic syndrome (20 cases) and signs of neoplastic impregnation (8
cases). Out of these, 20 observations were encountered in women with age limits between 55 and 79 years. They practiced 11 cholecystectomies for blisters
lithiasic without issues macrolezionale suspect (stage II Nevin), 11 cholecystectomies widened in bed on a block tumor subhepatic and that a colecistolitotomie
the evacuation of three abscesses pericolecistice, completed by colecistostomie required (both in stage III Nevin). In the latter case which pose a cancer jaundice
by cefalopancreatic on track cholecystectomy (with associated stones) were found and microscopic elements of a gallbladder adenocarcinoma (stage II Nevin)
synchronously. Intraoperative exploration has only raised suspicion (in 10 cases) or inoperable chop-operable limit (one case). We mention that patients did not
receive chemoradiation therapy, complementary pre-, intra- or postoperatively.
Results: Postoperative results in our series wore the footprint of aggressiveness marked to this locale neoplastic with 8 deaths in the first 7 months, 6 deaths in 12
months, five survivals 6 years and 5 observations under monitoring (at 6, 8 and 12 months postoperatively). Correlating survival time prelesional find that of 13
patients with stage II Nevin just 5 survivals to 6 years (patient observation, asymptomatic) while the other 11 place in stage III Nevin (8) or V (three) has survival
under 1 year.
Discussion and conclusions: We appreciate that triad of suffering gall stones extended confirmed anemia-aged over 60 years is an important element of
suspicion in these circumstances cholecystectomy necessary to comply with routine histology and possibly widening extemporaneously intervention in liver
excision and neck dissection. Increasing incidence (five cases in the past two years), the prognosis evolutionary infaust (only 7 cases of survival at one year, two
to five years) determined by the aggressiveness of the lesion (topography, shape histological grading) and the impossibility of an early diagnosis and limited
surgical options require a shift in addressing this condition.

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Managementul chistelor hidatice hepatice voluminoase


Management of Bulky Hepatic Hydatid Cysts
C. Turcule (1), D. Ene (1), T. F. Georgescu (1), E. Ciuc (1), A. Vldscu (1), M. Beuran (2)
(1) Spitalul Clinic de Urgen Floreasca, Clinica de Chirurgie I, Bucureti, Romnia
(2) Spitalul Clinic de Urgen Floreasca, Clinica de Chirurgie III, Bucureti, Romnia
Introducere: Chistul hidatic este o boal parazitar ce se produce prin dezvoltarea chistic n organism a larvei de Taenia Echinococcus Granulosus, o cestod ce
triete n intestinul subire al cinelui. La om afectarea frecvent este la nivelul ficatului. Lsat netratat, chistul hidatic crete n dimensiuni i produce complicaii
precum: fistule cu organele adiacente sau cu arborele biliar, ruptur n cavitatea peritoneal sau chiar deces.
Scop: Scopul acestei lucrri const n analiza experienei clinicii noastre n managemetul chistelor hidatice hepatice voluminoase i de a propune noi metode de
abordare a acestei patologii.
Materiale i metode: Am studiat o serie de 16 pacieni cu chiste hidatice hepatice voluminoase internai n perioada ianuarie 2013 - decembrie 2015 n secia
Chirurgie I a Clinicii de Chirurgie General a Spitalului Clinic de Urgen Bucureti.
Rezultate: Dimensiunile chistelor au variat ntre 7/6 cm i 24/23 cm, n 5 din cazuri fiind prezente chiste hidatice hepatice multiple. n majoritatea cazurilor (13) s-a
recurs la intervenie chirurgical pentru tratamentul chistului hidatic hepatic. ntr-un caz s-a practicat hepatectomie stng (segmente II i III). n 3 cazuri
intervenia chirurgical s-a practicat pe cale laparoscopic. n 4 cazuri pacienii au prezentat complicaii precum angiocolita, ruperea chistului n cile biliare,
pleurezie sau pericardit.
Concluzii: n cazul chistelor hidatice hepatice voluminoase tratamentul chirurgical este unicul capabil a soluiona aceast patologie. Tratamentul conservator
poate fi folosit ca pregtire properatorie n cazuri selecionate. Abordul laparoscopic este o abordare sigur i ar trebui luat n considerare n toate cazurile de
boal hidatic hepatic, dac topografia leziunii o permite. Chistele hidatice hepatice ar trebui tratate timpuriu deoarece netratate pot ajunge la dimensiuni
crescute, cu complicaii redutabile, ajungndu-se la hepatectomii n unele cazuri.

Introduction: Hydatid cyst is a parasitic disease which is produced by the cystic development of larva of Taenia Echinococcus granulosus, a Cestoda who lives in
the small intestine of dogs. The most common site of hydatid cyst development in humans is the liver. Left untreated hydatid cyst grows in size and produces
complications such as fistulas with adjacent organs or biliary tree, rupture into the peritoneal cavity or even death.
Aim: The aim of this paper is to analyze our clinic experience in bulky hepatic hydatid cysts management and propose new approaches to this pathology.
Materials and Methods: We analyzed a series of 16 patients with bulky hepatic hydatid cysts hospitalized in the period January 2013 - December 2015 in Surgical
Clinic Department of General Surgery Emergency Hospital Bucharest.
Results: The dimensions of cysts ranged between 7/6 and 24/23 cm, in 5 cases we registered multiple hydatid cysts. In most cases (13) we resorted to surgery for
the treatment of hepatic hydatid cyst. In one case it was practiced left hepatectomy (segment II and III). In 3 cases surgery was performed laparoscopically. In 4
cases patients experienced complications such as cholangitis, rupture of the cyst in the bile ducts, pleurisy or pericarditis.
Conclusions: Surgical treatment is the only one which can solve the bulky hepatic hydatid cysts. Conservative treatment can be used as preoperative therapy in
selected cases. Laparoscopic approach is a safe approach and should be considered in all cases of hepatic hydatid disease, if the localization permits it. Hepatic
hydatid cysts should be treated early because untreated can reach increased sizes, leading to hepatectomies in some cases.

Tumorile neuroendocrine pancreatice


Pancreatic Neuroendocrine Tumors
Mihaela Mdlina Gavrilescu, Mihaela Buna-Arvinte, Ana-Maria Muin, B. Filip, I. Huanu, I. Radu, Maria Gabriela Aniei, A. Panu, D. V. Scripcariu, V. Scripcariu
Institutul Regional de Oncologie / Universitatea de Medicin i Farmacie Gr. T. Popa, Clinica I Chirurgie Oncologic, Iai, Romnia
Introducere: Tumorile neuroendocrine pancreatice (PNETs) sunt tumori pancreatice rare, clasificate n tumori secretante i non-secretante, toate avnd un fenotip
comun cu imunoreactivitate pentru markerii pan-neuroendocrini: cromogranina A i sinaptofizina.
Material i metode: Studiu retrospectiv care include pacienii diagnosticai cu tumori neuroendocrine pancreatice i tratai n cadrul Clinicii I Chirurgie Oncologic,
n perioada mai 2012- februarie 2016. Au fost evaluate caracteristicile clinice, biologice ale tumorilor, tipul de tratament efectuat i rezultatele postoperatorii
precoce.
Rezultate: Lotul de studiu a inclus 9 pacieni cu vrsta cuprins ntre 35 i 79 de ani. Tumorile secretante au fost ntlnite la 7 pacieni, clinic pacienii prezentnd
episoade hipoglicemice cu dozarea plasmatic a insulinemiei i a peptidului C. Localizarea tumorii pancreatice a fost posibil la 7 pacieni (cefalic 5 cazuri, corp 1
caz, corp i coad 1 caz). Intervenia chirurgical cea mai frecvent efectuat a fost enucleorezecia formaiunii tumorale pancreatice (n=6), 2
spleno-pancreatectomii corporeo-caudale i o spleno-pancreatectomie corporeo-caudal asociat cu o rezecie gastric 2/3. Remisiunea episoadelor
hipoglicemice s-a obinut la 7 pacieni, 2 pacieni au dezvoltat o pancreatit acut form uoar postoperator. Rezultatele histopatologice arat 1 caz de
nesidioblastoz, 1 micro tumor neuroendocrin multicentric, 4 tumori neuroendocrine G2 i 3 cazuri de NET G1 (imunohistochimia a fost efectuat n toate
cazurile).
Discuii: Tumorile neuroendocrine pancreatice funcionale reprezint o entitate rar, particularitatea acestora fiind localizarea dificil preoperatorie, ceea ce
ghideaz extensia actului rezecional. Suspiciunea de tumor neuroendocrin pancreatic trebuie s apar la un pacient diagnosticat cu un nodul pancreatic la
care markerii tumorali sunt n limite normale.

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Introduction: Pancreatic neuroendocrine tumors (PNETs) are rare pancreatic tumors, classified into functional and non-functional tumors, with a common
immunoreactivity phenotype for pan-neuroendocrine markers: chromogranin A and synaptophysin.
Material and methods: Retrospective study in which we included patients diagnosed with pancreatic neuroendocrine tumors and treated in Ist Surgical Unit, Iai,
Regional Cancer Institute, between 1 May 2012 and February 2016. We analyzed the patient and tumor characteristics, the type of surgery and the postoperative
outcomes.
Results: The study group included 9 patients aged between 35 and 79 years. Functional pancreatic tumors were found in 7 patients with symptoms and signs of
hypoglycemia. Essential chemistry tests and baseline hormone measurements (insulin and C peptide) were performed. Pancreatic tumor location was possible for
7 patients (head-5 cases, body-1 case, body and tail-1 case). Most patients underwent tumor enucleation (n=6), corporocaudal subtotal pancreatectomy and
splenectomy (n=2) and in 1 case a spleno-pancreatectomy with 2/3 gastric resection was performed. Remission of hypoglycemic symptoms was achieved in 7
patients, 2 patients developed postoperative mild acute pancreatitis. Histopathological reports observed 1 case of nesidioblastosis, 1 case of multifocal
neuroendocrine tumor, NET G2 (n=4), NET G1 (n=3) (immunohistochemistry was performed for all patients).
Discussion: Functional pancreatic neuroendocrine tumors are very rare, with the particularity that preoperative localization is of utmost importance in the surgical
management. Suspicion of pancreatic neuroendocrine tumor should appear in a patient diagnosed with pancreatic node in which tumor markers are normal.

Incidena marginilor R1 n duodenopancreatectomia cefalic este influenat de protocoale standardizate de


examinare histopatologic
R1 Incidence in Cephalic Duodenopancreatectomy Is Influenced by Standardized Histopathological Protocols
E. I. Mois (1), F. Graur (2), R. Elisei (1), A. Coe (3), N. Al Hajjar (2), C. Puia (2), F. Zaharie (2), A. Barto (2), Raluca Bodea (2), C. Iancu (2)
(1) Institutul Regional de Gastroenterologie i Hepatologie Prof. Dr. Octavian Fodor, Chirurgie General, Cluj-Napoca, Romnia
(2) Universitatea de Medicin i Farmacie Iuliu Haieganu / Institutul Regional de Gastroenterologie i Hepatologie Prof. Dr. Octavian Fodor, Chirurgie
General, Cluj-Napoca, Romania
(3) Spitalul Clinic Judeean de Urgen Oradea / Universitatea de Medicin i Farmacie Iuliu Haieganu Cluj-Napoca, Chirurgie General, Oradea, Romnia
Introducere: Gold standardul duodenopancreatectomiei cefalice este obinerea unor margini de rezecie tumoral negative (R0). Avnd n vedere datele din
literatur, n care unii autori au demonstrat c incidena marginilor R1 crete dup folosirea unor protocoale histopatologice standardizate de colorare i
preparare a piesei de duodenopancreatectomie cefalic (DPC), am considerat necesar efectuarea unui studiu, n acest sens, n Institutul nostru. n acest rezumat
prezentm date preliminarii ale acestui studiu.
Material i metod: Au fost studiate 103 cazuri de adenocarcinom ductal pancreatic cefalic la care s-a efectuat DPC cu intenie de radicalitate. Cele 103 cazuri au
fost imprite n dou loturi: un lot de 60 de cazuri (retrospectiv) la care marginile de rezecie nu au fost preparate i un lot de 43 de cazuri (prospectiv) la care
piesele au fost preparate i colorate conform unui protocol standardizat. Astfel, dac n cazul lotului retrospectiv marginea circumfereniala nu a fost detaliat, n
cazul lotului prospectiv aceast margine a fost mprit n: medial, anterioar, superioar i posterioar.
Rezultate: Incidena marginii R1 n lotul retrospectiv a fost de 38.3 %, iar n lotul prospectiv a fost de 55.8 %. Marginea de rezecie cea mai des R1 a fost marginea
circumferenial (82.6%) n cazul lotului retrospectiv, iar marginea medial (mezopancreasul) (58.3%) urmat de cea posterioar (33.3%) au predominat n lotul
unde s-a folosit un protocol standardizat.
Concluzii: Folosirea unor protocoale standardizate de preparare i colorare a pieselor de DPC duce la creterea incidenei marginilor R1. Mezopancreasul
reprezint locul de elecie pentru apariia marginilor R1 n DPC.

Background: Obtaining negative microscopically margins (R0) in the cephalic duodenopancreatectomy (CDP) is the gold standard. Regarding data from literature
that a standardized histopathological examination increases the rate of R1, we considered necessary to perform a study in our Institute. Here we present
preliminary data.
Methods: We analyze 103 cases of cephalic pancreatic ductal adenocarcinoma operated with curative intentions. We separate these cases in two groups: first of
60 cases (retrospective) where the margins were not marked and second of 43 cases (prospective) for which we used a standardized histopathological
examination of the resected margins. While for the retrospective group circumferential margin was not detailed, in the prospective group we separated this
margin in: medial, anterior, superior and posterior.
Results: R1 incidence in the retrospective group was 38.3%, while in the prospective group was 55.8%. Circumferential margin was most R1 in retrospective group
(82.6%), and medial (58.3%) and posterior (33.3%) in the prospective group.
Conclusion: R1 incidence in cephalic duodenopancreatectomy is influenced by standardized histopathological protocols. The mesopancreas represents the
primary site for positive resection margins.

82

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Vizualizarea intraoperatorie a tumorilor neuroendocrine pancreatice cu verde de indocianin i fluorescen n


infrarou
Intraoperative Viewing of Neuroendocrine Pancreatic Tumors Using Indocyanin-Green with Near-Infrared
Fluorescence Visualization
V. Muntean (1), Alina Tanu (2), M. V. Muntean (3), . Strilciuc (4), D. Deceanu (5), O. Cebotari (5), R. Galasiu (5), D. Vlean (5), G. E. Petre (1), D. Slceriu (5)
(1) Spitalul Clinic Ci Ferate, Universitatea de Medicin i Farmacie Iuliu Haieganu, Clinica Chirurgie IV, Cluj-Napoca, Romnia
(2) Spitalul Clinic Ci Ferate, Universitatea de Medicin i Farmacie Iuliu Haieganu, Clinica Medical IV, Cluj-Napoca, Romnia
(3) Spitalul Clinic de Recuperare, Universitatea de Medicin i Farmacie Iuliu Haieganu, Clinica de Chirurgie Plastic, Cluj-Napoca, Romnia
(4) Universitatea Babe-Bolyai, IT, Cluj-Napoca, Romnia
(5) Spitalul Clinic Ci Ferate, Clinica Chirurgie IV, Cluj-Napoca, Romnia
Obiectivele studiului: Identificarea intraoperatorie a tumorilor neuroendocrine pancreatice de mici dimensiuni sau multiple i a metastazelor regionale ale
acestora se bazeaz pe explorarea imagistic preoperatorie extensiv i completarea explorrii chirurgicale cu ecografie intraoperatorie. Prezentm experiena
noastr referitoare la vizualizarea intraoperatorie a tumorilor neuroendocrine pancreatice cu verde de indocianin i fluorescen n infrarou.
Material i metode: Dup inspecia abdominal completat de palpare (manevra Kocher) i ecografie intraoperatorie se administreaz verde de indocianin
0.1mg/kg iv. Explorarea prin fluorescen n infrarou a fost fcut cu NIRF-800, ArteMIS Handheld System, Quest Medical Imaging BV, Wieringerwerf, Olanda.
Valorile absolute ale fluorescenei au fost calculate cu Image J 64.
Rezultate: La prima pacient cu sindrom Zollinger-Ellison i tumor primitiv ocult, s-a evideniat florescen de 92% la nivelul unui ganglion metastatic
juxta-duodenal i alta de 90% la nivelul peretelui duodenal juxtapapilar. S-a fcut rezecia unui gastrinom duodenal submucos (3 mm) i a metastazei ganglionare.
Evoluia postoperatorie a fost simpl, cu normalizarea aciditilor bazale i gastrinei serice. La a doua pacient, cu tumor neourendocrin pancreatic
nesecretant (8 mm) localizat la nivelul procesului uncinat, examinarea intraoperatorie cu verde de indocianin i fluorescen n infrarou a evideniat tumora
(inel de florescen 96%) i a ghidat rezecia acesteia prin enucleere. Evoluia postoperatorie a pacientei a fost simpl.
Concluzii: La dou paciente cu tumori neuroendocrine pancreatice, vizualizarea intraoperatorie cu verde de indocianin i fluorescen n infrarou s-a dovedit
eficient n identificarea tumorilor i ghidarea exerezei chirurgicale. Alte studii sunt necesare pentru clarificarea rolului acestei metode n explorarea
intraoperatorie a tumorilor neuroendocrine pancreatice/duodenale.

Study objectives: Intraoperative identification of small-size/multiple pancreatic neuroendocrine tumors (P-NET) and also of their regional metastases is based on
the preoperative extensive imaging findings combined with surgical exploration and intraoperative ultrasound. We present our experience with intraoperative
visualization of P-NET using Indocyanin-green (ICG) with near-infrared fluorescence (NIRF) visualization.
Patients and methods: After complete inspection of the abdominal cavity, regional palpation (Kocher manoeuver) and intraoperative ultrasonography of the
region, 0,1 mg/kg ICG is administered intravenously. NIRF exploration used NIRF-800 probe, ArteMIS Handheld System, Quest Medical Imaging BV, Wieringerwerf,
The Netherlands. The absolute values of fluorescence were calculated with OS Image J 64 quantitative software.
Results: In one patient (Zollinger-Ellison syndrome and occult primary tumor) a 92% fluorescence signal showed on the juxta-duodenal metastatic lymph node
and another 90% fluorescent signal showed on the duodenal wall adjacent to the major duodenal papilla. A 3 mm duodenal gastrinoma of the submucosa and a
regional lymph node metastasis were resected. Postoperative outcome was uneventful, retrieving normal values of basal acid output and fasting serum gastrin
concentration. In another patient (nonfunctional P-NET of the uncinate process) intraoperative examination NIRF visualization with ICG identified the tumor (96%
fluorescent ring signal) and also guided resection by enucleation. The postoperative outcome of the patient was uneventful.
Conclusion: In two patients with P-NET intraoperative NIRF visualization with ICG proved efficient in identifying the tumor and also in guiding its surgical removal.
Further studies are needed to clarify the role of NIRF in intra-operative management of pancreatic and duodenal NETs.

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Metastazele hepatice ale cancerului colorectal. Diagnostic i tratament chirurgical


Liver Metastases in Colorectal Cancer. Diagnosis and Surgical Treatment
V. Hotineanu (1), A. Hotineanu (2), S. Burgoci (3), G. Ivancov (4), A. Cazac (1)
(1) Universitatea de Stat de Medicin i Farmacie Nicolae Testemianu, Catedra 2 Chirurgie, LC Chirurgie Reconstructiv a Tractului Digestiv, Chiinu,
Republica Moldova
(2) Universitatea de Stat de Medicin i Farmacie Nicolae Testemianu, Catedra 2 Chirurgie, Chiinu, Republica Moldova
(3) Universitatea de Stat de Medicin i Farmacie Nicolae Testemianu, LC Chirurgie Reconstructiv a Tractului Digestiv, Chiinu, Republica Moldova
(4) Universitatea de Stat de Medicin i Farmacie Nicolae Testemianu, Spitalul Clinic Republican, Chiinu, Republica Moldova
Introducere: Metastazele hepatice ale cancerului colorectal au devenit o problem deosebit n chirurgia digestiv i ofer discuii permanente i controversate.
Jumtate dintre pacienii cu cancer de colon dezvolt metastaze hepatice. Criteriile de rezecabilitate a metastazelor colorectale au fost extinse n ultimii ani n
jurul valorilor de rezecie R0 cu un volum de ficat rezidual suficient.
Scop: Evaluarea unei selecii corespunztoare, unui tratament adecvat i tehnicii perioperatorii chirurgicale corecte, ceea ce duce la o rat sczut a mortalitii
i morbiditii.
Material i metode: Pe parcursul anilor 2007 pn n 2015 au fost operai 42 de pacieni. La 28 de pacieni metastazele hepatice s-au dezvoltat dup
ndeprtarea tumorii primare pentru o perioad de 4 luni - 3 ani. n 10 cazuri, s-au efectuat rezecii sincrone i n 4 cazuri rezecia tumorii primare a fost efectut
dup 1-3 luni dup ndeprtarea metastazelor hepatice. Cu scopul de a exclude insuficiena hepatic postrezecie la 4 pacieni rezecia hepatic a fost realizat n
etape, la 7 pacieni rezecia hepatic s-a realizat dup ocluzia venei port.
Rezultate: Tratamentul metastazelor colorectale este multimodal i include rezecia chirurgical, chimioterapie, ablaia local. Dar numai intervenia chirurgical
este singura soluie care permite obinerea unei rate mai mari de supravieuire la aceti pacieni. Supravieuirea la 5 ani a fost de 30,9% (n-13).
Concluzii: Rezecia hepatic este o opiune extrem de important pentru a crete rata de supravieuire i rmne o metod potenial curativ cu un risc acceptabil
perioperator. Toi pacienii cu metastaze hepatice pot fi considerai candidai pentru un tratament chirurgical. Limita principal a rezeciei fiind calitatea i funcia
esutului hepatic restant.

Introduction: Colorectal Metastases have become a particular problem in digestive surgery and offer permanent and controversial discussions. Half of the
patients with colon cancer develop liver metastases. Colorectal metastases resectability criteria were extended in recent years and revolve around R0 resection
with sufficient residual liver volume.
Purpose: Evaluation of corresponding selection, appropriate perioperative treatment and correct surgical technique, which leads to a low rate of mortality and
morbidity.
Material and Methods: In surgical clinic N2 during the years 2007 to 2015, 42 patients were operated. In 28 patients, liver metastasis was developed after
removal of the primary tumor for a period of four months - 3 years. In 10 cases synchronous resection was performed and in 4 cases primary tumor resection was
performed 1-3 months later, after liver metastases removal. With the aim to exclude postresectional hepatic failure in 4 patients staged hepatic resection was
performed, in 7 patients hepatic resection was performed after hepatic portal vein occlusion.
Results: The treatment of colorectal metastases is multimodal and includes surgical resection, chemotherapy, and local ablation. But surgery is the only solution
that allows achieving higher survival rate in these patients. Survival at 5 years was 30.9% (n-13).
Conclusions: Liver resection is an extremely important option to increase survival rate and remains a potentially curative method with acceptable perioperative
risk. All patients with liver metastases can be considered candidates for surgical treatment. The main limitation of the resection is the quality of the remaining
tissue.

Rezecii hepatice - nceputuri


Liver Resections - The Beginnings
Z. Filipovski (1), S. V. Petrea (1), S. Aldoescu (1), Mihaela Vlcu (1), Raluca Hanes (1), Lorena Keil (1), Diana Bogatu (1), V. Braoveanu (2), R. Zamfir (2), I. Brezean (1)
(1) Spitalul Clinic Dr. Ioan Cantacuzino, Secia de Chirurgie General, Bucureti, Romnia
(2) Institutul Clinic Fundeni, Centrul de Chirurgie General i Transplant Hepatic Dan Setlacec, Bucureti, Romnia
Obiectivul studiului: Analiza preliminar a cazurilor de patologie chirurgical hepatic din perspectiva unei singure echipe operatorii - tipuri de intervenii n
functie de patologie, analiz histopatologic a pieselor rezecate, complicaii i decese postoperatorii precoce.
Material i metode: Au fost analizai 55 de pacieni cu patologie chirurgical hepatic, operai n perioada 2014-2016. Pacienii au fost selectai pe criterii
demografice, boli asociate, istoric medical semnificativ, constante biologice (inclusiv markeri tumorali), tipuri de leziuni cu tipuri de intervenii, rezultate
histopatologice ale pieselor rezecate dar i din perspectiv morbiditii i a mortalitii perioperatorii.
Rezultate: Din numrul total de pacieni operai, am constatat un procent semnificativ al pacienilor cu suferin cronic hepatic, predominnd pacienii cu
determinri secundare hepatice de etiologie colo-rectal. Tipurile de intervenii au fost n egal msur metastazectomii i rezecii hepatice cu morbiditate i
mortalitate perioperatorie n limitele literaturii de specialitate.
Concluzii: Indiferent de patologia i de tipul interveniilor chirurgicale la nivelul ficatului, selecia atent a pacienilor (din perspectiva diagnosticului preoperator),
pregtirea minuioasa a strategiei chirurgicale i suportul de terapie intensiv n perioada postoperatorie, pot conduce la rezultate satisfctoare n minile unei
echipe operatorii aflat nc n perioada curbei de nvatare.
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Background: The aim of the study was to review the preliminary surgical cases in hepatic pathology of a single surgical team - types of interventions, diversity of
the hepatic pathology, histopathological review of the resected specimens, complications and mortality in the immediate postoperative period.
Materials and methods: 55 patients with hepatic surgical pathology were retrospectively reviewed, in a period between 2014-2016. The selection of the patients
was based on: demographics, associated pathology, previous surgical interventions, laboratory findings (including tumor markers), types of diagnosed lesions
with the types of surgical interventions, histopathology, perioperative morbidity and mortality.
Results: We found a significant number of patients with underlying cirrhosis of viral etiology. Most of the patients presented colo-rectal liver metastasis. We
performed in an equal manner tumor excisions, metastasis excisions and various liver resections, with perioperative morbidity and mortality rates comparative to
the literature.
Discussion: In spite of the pathology and the types of surgical interventions, careful selection of the patients (preoperative diagnostic studies), with well
conducted surgical strategy and the intensive care in the postoperative period, can lead to successful results by the surgical team undergoing the learning curve.

Predicia biochimico-imagistic a etiologiei biliare pentru pancreatita acut (scor asalt-cbd)


Biochemical-Imagistic Prediction of Biliary Etiology for Acute Pancreatitis (ASALT-CBD Score)
N. O. Zrnescu, E. C. Zrnescu, R. V. Costea, . Neagu
Spitalul Universitar de Urgen, Chirurgie II, Bucureti, Romnia
Obiective: n prezent, nu exist niciun instrument pentru a diagnostica corect i cu uurin toate cazurile cu pancreatit acut biliar. Sensibilitatea ecografiei
abdominal este n jur de 80%, care poate fi chiar i mai mic n anumite condiii.
Metode: Am analizat retrospectiv datele a 180 de pacieni internai pentru pancreatit acut ntre ianuarie 2010 i mai 2015. Analiza bivariat pentru variabilele
clinice i biochimice au fost efectuate n ceea ce privete etiologia pancreatit acut (biliar versus non-biliare). Analiza multivariat a fost realizat utiliznd
regresie logistic binar.
Rezultate: Au fost 95 pacieni de sex masculin (52,8%) i 85 de sex feminin (47,2%), cu o vrst medie de 60,8 + 16,8. Etiologia pancreatitei acute a fost biliar la
140 de pacieni (77,8%), alcool la 18 pacieni (10%), hipertrigliceridemie la 8 pacieni (4,4%) i idiopatic la 14 pacieni (7,8%). Scorul Charlson pentru comorbiditi
medicale a fost mai mare de 3 la 115 pacieni (65,7%). Analiza bivariat i apoi analiza de regresie logistic binar au identificat factorii de asociere semnificativ
(p = 0,001), cu pancreatit biliar: vrsta naintat (peste 60 de ani), sex feminin, valori crescute ale ALT (> 150 U / ml) i dilatate CBP (> 5 mm) la ecografie. Scorul
ASALT-CDB a fost evaluat cu ajutorul curbelor ROC i aria de sub curb este 0,845.
Concluzii: Scorul ASALT-CBD poate ajuta pentru a depista cazurile cu etiologie biliar de pancreatit acut.
Cuvinte cheie: pancreatit acut, calculi biliari, pancreatit biliar, scorul de risc, predicie biochimice

Background/Aims: Currently there is no tool to easily and correctly diagnose all cases with biliary acute pancreatitis. The sensitivity of abdominal ultrasound is
around 80% and can be even lower in certain conditions.
Methods: We have retrospectively reviewed data of 180 patients admitted for acute pancreatitis between January 2010 and May 2015. Bivariate analysis for
clinical and biochemical variables was performed in respect to etiology of acute pancreatitis (biliary versus non-biliary). Multivariate analysis was performed using
binary logistic regression.
Results: There were 95 males (52.8%) and 85 females (47.2%), with a mean age of 60.8+16.8. The etiology of acute pancreatitis was biliary in 140 patients
(77.8%), alcohol in 18 patients (10%), hypertriglyceridemia in 8 patients (4.4%) and idiopathic in 14 patients (7.8%). Charlson index score for medical comorbidities
was higher than 3 in 115 patients (65.7%). Bivariate and then binary logistic regression analysis founded as significant association (p=0.001) with biliary
pancreatitis: older age (above the age of 60), female gender, elevated ALT (>150 U/mL) and dilated CBD (>5 mm) on ultrasound. The ASALT-CBD score was
evaluated with the ROC curves and the area under curve is 0.845.
Conclusions: The ASALT-CBD score can aid to identify cases with biliary etiology of acute pancreatitis.
Keywords: acute pancreatitis, gallstone, biliary pancreatitis, risk score, biochemical prediction

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Prevenirea leziunilor de ci biliare principale n colecistectomia laparoscopic pentru formele complexe de


colecistit acut
Preventing Main Biliary Duct Injuries During Laparoscopic Cholecystectomy for Complex Forms of Acute Cholecystitis
T. Bratiloveanu (1), S. Rmboiu (1), M. Bica (1), Adina Popescu (2), E. F. Georgescu (1), A. Goganau (2), M. . Ghelase (3), V. urlin (1)
(1) Universitatea de Medicin i Farmacie, Clinica I Chirurgie, Craiova, Romnia
(2) Spitalul Clinic Judeean de Urgen, Clinica I Chirurgie, Craiova, Romnia
(3) Universitatea de Medicin i Farmacie, Disciplina Bioetic, Craiova, Romnia
Colecistectomia laparoscopic (CL) aprut n urm cu 30 de ani, a devenit n prezent conform ghidului Sages-2010, standardul de aur i n tratamentul
chirurgical al colecistitelor acute (CA). Totui, ea rmne asociat cu un risc major de leziuni de ci biliare principale(CBP). Cazurile complexe de CA sunt
considerate situaiile de canal cistic scurt, calcul inclavat i sindromul Mirizzi.
Leziunile de CBP cresc morbiditatea i mortalitatea postoperatorie, cresc costurile de ngrijire medical, reduc sperana de via.
Prevenirea leziunilor de CBP presupune o pregtire riguroas a chirurgilor i respectarea anumitor reguli: folosirea de echipament cu imagini de calitate nalt,
disecia triunghiului Calot, atenie mare n prezena neasteptat a unei alte structuri ductale, nu se va clipa nicio structur vasculo-biliar dect dac a fost
identificat anatomic sau imagistic, folosirea colangiografiei intraoperatorii, folosirea echografiei laparoscopice, modificarea de tehnic chirurgical.
Utilizarea colangiografiei intaroperatorii n special n cazurile de anatomie neclar, a dus la o scdere a incidenei cu 29% a leziunilor de CBP. Echografia
laparoscopica dei are o curb mare de nvatare, are i o rat de succes de 95%. Tehnicile alternative sunt reprezentate de: colecistectomia anterograd,
colecistectomia subtotal sau parial i conversia. Conversia la laparotomie nu este o eroare tehnic, dar nu exclude riscul de leziuni CBP.
Analiza datelor din literatur arat c incidena leziunilor CBP n colecistectomia laparoscopic pentru CA, este de 3 ori mai mare fa CL electiv i de dou ori
mai mare fa de tehnica clasic, iar pentru prevenirea lor este necesar respectarea regulilor enumerate anterior.

After the first laparoscopic cholecystectomy (LC) 30 years ago, it has now become under the Guidelines Sages-2010 the gold standard in surgical treatment of
acute cholecystitis (CA). Yet, it remains a major risk associated with main biliary duct injuries. Complex cases of acute cholecystitis are considered the situations
of short cystic duct, impacted biliary stone in the duodenal papilla or Mirizzi syndrome.
Main biliary duct injuries increase postoperative morbidity and mortality, and also healthcare costs, reduce life expectancy.
Preventing the injury of the main biliary duct requires a rigorous training of surgeons and compliance with certain rules: to use equipment with high-quality
images, dissection of Calot triangle, attention to any anatomical variations, identification of every vascular or biliary structure before clipping, use of
intraoperative cholangiography and/or laparoscopic ultrasound, modification of surgical technique.
The use of intraoperative cholangiography especially in cases of unclear anatomy resulted in a 29% decrease in the incidence of injuries of main biliary duct.
Although laparoscopic ultrasound has a high learning curve, it has a success rate of 95%. Alternative techniques are: anterograde cholecystectomy, subtotal or
partial cholecystectomy and conversion. The conversion to laparotomy is not a technical error, but does not exclude the risk of main biliary duct injury.
Literature analysis revealed a three folds higher incidence of main biliary duct injuries after laparoscopic cholecystectomy, than in the case of elective
laparoscopic cholecystectomy and two folds higher than in the case of classic/open cholecystectomy. In order to prevent these injuries from happening, it is
necessary to keep in mind the rules listed above.

Tratamentul minim invaziv al litiazei colecisto-coledociene n acelai timp anestezic


The Minimally Invasive Treatment of Cholecystocholedoco-Lithiasis under the Same Anaesthesia
D. Cristian, T. Burco, N. Jitea, C. Dimitriu, . Voiculescu, A. Ionic, F. Grama
Spitalul Clinic Colea, Secia de Chirurgie General, Bucureti, Romnia
Obiectivul studiului: Am evaluat beneficiile i dezavantajele abordrii secveniale ale litiazei colecisto-coledociene prin colecistectomie laparoscopic, urmat de
extragerea endoscopic a calculilor coledocieni, ambele proceduri fiind realizate sub aceeai anestezie general.
Materiale i metode: Am analizat retrospectiv 221 cazuri de litiaz colecisto-coledocian tratate n perioada 2010-2015 prin aceste proceduri combinate, sub
aceeai anestezie general. Am evaluat timpul operator, morbiditatea asociat, rata de succes, durata spitalizrii, percepia pacienilor asupra tratamentului ales.
Rezultate: Prin continuarea colecistectomiei laparoscopice cu extracia endoscopic a calculilor timpul operator a fost prelungit n medie cu 23 minute, interval n
care s-a realizat pregtirea pacientului i a slii operatorii, urmate de extragerea endoscopic a calculilor coledocieni. Morbiditatea asociat acestui tip de abord
a fost redus comparativ cu cea indus de efectuarea separat a fiecrei intervenii sub o alt anestezie. Rata de succes a fost influenat de abilitatea extragerii
endoscopice a calculilor migrai. n 4 cazuri (1,8%) nu s-au putut extrage calculii din calea biliar principal, la aceti pacieni recurgndu-se la coledocolitotomie
clasic n acelai timp anestezic. Perioada de spitalizare postoperatorie a fost cuprins ntre 1 i 7 zile, prelungirea timpului de spitalizare fiind determinat de
apariia complicaiilor post colecistopancreatografie endoscopic retrograd.
Concluzii: Tratamentul colecistocoledocolitiazei ntr-o singur etap este o tehnic minim invaziv eficient realizat sub aceeai anestezie general. Ea
simplific procedura chirurgical, reduce timpul operator i frecvena complicaiilor. Pacienii sunt rapid externai i costurile sczute.

Objective: We evaluated the advantages and disadvantages of the sequential approach of cholecystocholedocolithiasis through the laparoscopic
cholecystectomy followed by the endoscopic extraction of biliary stones, both procedures performed under the same general anaesthesia.
Materials and Methods: We retrospectively analyzed 221 cases of cholecystocholedocolithiasis treated between 2010-2015 through these combined procedures,
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performed under the same general anaesthesia. We evaluated the operative time, the associated morbidity, the success rate, the length of hospital stay and the
patients perception regarding the treatment.
Results: By continuing the laparoscopic cholecystectomy with the endoscopic extraction of biliary stones, the operative time increased by 23 minutes on average.
This was the time required for setting up the operating room and for positioning the patient, followed by endoscopic extraction of biliary stones. The morbidity
associated with this combined approach decreased as compared to the sum of each procedure time performed under individual anesthesia. The success rate
was influenced by the ability to achieve endoscopic extraction of the migrated stones. In 4 cases (1,8%) the endoscopic stone clearance was not realized,
therefore an open choledochotomy was required under the same anaesthesia. The postoperative hospital stay was 1-7 days, being increased by the endoscopic
retrograde cholangiopancreatography complications.
Conclusions: The treatment of cholecystocholedocholithiasis in a one-stage operation is an efficient minimally invasive technique, performed under the same
general anaesthesia. It simplifies the surgical procedure, reduces the operation time and the frequency of complications. The patients are quickly discharged and
the costs are decreased.

Avantajele anastomozei pancreatogastrice dup duodenopancreatectomia cefalic


Advantages of Pancreaticogastric Anastomosis after Pancreatoduodenectomy
B. Mastalier, A. Croitoru, C. Botezatu, S. Bacaliuc, M. Leoveanu, Violeta Deaconescu
Spitalul Clinic Colentina, Clinica Chirurgie II, Bucureti, Romnia
Introducere: Prevenirea scurgerilor pancreatice dup duodenopancreatectomie cefalic (DPC) rmne nc motiv general de preocupare. Exist mai multe
argumente pentru pancreaticogastroanastomosis (PGA), ca procedur mai sigur, cu utilizarea de anastomoz duct-la-mucoas. In caz de pancreas moale exist
un risc mai mare de fistul anastomotic. n caz de fistul anastomotic pancreatic trebuie reconstruit anastomoza pancreatico-digestiv prin anastomoz
pancreaticojejunal cu intubare a bontului pancreatic pe o ans intestinal separat n Y tip Roux. Lungimea buclei de tip Roux trebuie s fie suficient de mare
pentru a preveni contaminarea bontului pancreatic cu coninut bilio-alimentar.
Material i metod: n ultimii 10 ani n Departamentul Chirurgical Colentina au fost operate 105 cazuri cu tumori pancreatice cefalice sau ampulom vaterian la care
s-a practicat DPC. n 79 de cazuri a fost preferat PGA, restul de 26 de cazuri fiind finalizate cu anastomoz pancreaticojejunal (PJA).
Rezultate: Fistula pancreatic a fost ntlnit n 5 cazuri din primul grup i n 4 cazuri din al doilea grup. Toate cazurile au necesitat reintervenie cu utilizarea
anastomozei pancreaticojejunale cu intubare pancreatic pe ans jejunal separat tip Roux. Au existat 3 cazuri de deces din cauza complicaiilor generale dup
reintervenii (bronhopneumonie, MSOF). Supravieuirea la 1 an a fost de 85%, iar la 5 ani de 37% (mai mare pentru ampulom vaterian).
Concluzie: Anastomoza pancreaticogastric cu sutur duct-la-mucoas este o alternativ sigur pentru restabilirea continuitii pancreaticodigestive n cazul DPC.
Cuvinte cheie: DPC, anastomoz pancreatico-gastric

Introduction: Prevention of pancreatic leakage after cephalic duodenopancreatectomy (DPC) still remains a general concern. There are many reasons for
pancreaticogastroanastomosis (PGA) as being a safer procedure, with use of duct-to-mucosa anastomosis. In case of soft pancreatic stump there is a higher risk
of leakage. In case of anastomotic leakage one has to reconstruct the pancreatic digestive anastomosis by means of invagination pancreaticojejunostomy on an
isolated Roux-type separated loop. The length of the Roux-type loop has to be long enough to prevent the contamination of the pancreatic stump with
biliary-alimentary content.
Matherial and method: In the last 10 years, in Colentina Surgical Department were operated 105 cases with pancreatic cephalic tumors or Vater ampouloma that
were submitted to DPC. In 79 cases the PGA was preferred, the rest of 26 cases underwent for pancreaticojejunal anastomosis (PJA).
Results:The pancreatic leakage was encountered in 5 cases of the first group and in 4 cases of the second group. All cases required reinterventions with use of
invagination pancreaticojejunostomy on isolated Roux-type separated loop. There were 3 cases of death due to general complications after reinterventions
(bronchopneumonia, MSOF). One year survival rate was of 85%, 5 year survival rate is of 37% (better for Vaterian ampouloma).
Conclusion: Pancreaticogastroanastomosis with duct-to-mucosa suture is a safe procedure for reestablishing of pancreatico-digestive continuity after DPC.
Key words: pancreatodudenectomy, pancreaticogastric anastomosis

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Opiuni terapeutice n formaiunile chistice neparazitare ale ficatului


Therapeutic Options in Nonparasitic Cystic Liver Formations
V. Hotineanu (1), A. Hotineanu (1), A. Cazac (2), A. Ferdohleb (1), A. Iliadi (1), V. Srghi (3), A. Graur (1)
(1) Universitatea de Stat de Medicin i Farmacie Nicolae Testemianu, Catedra 2 Chirurgie, Chiinu, Republica Moldova
(2) Universitatea de Stat de Medicin i Farmacie Nicolae Testemianu, Catedra 2 Chirurgie, LC Chirurgie Reconstructiv a Tractului Digestiv, Chiinu,
Republica Moldova
(3) Universitatea de Stat de Medicin i Farmacie Nicolae Testemianu, Spitalul Clinic Republican, Chiinu, Republica Moldova
Introducere: Opiunile terapeutice n formaiunile chistice neparazitare hepatice (FCNH), constituie o veche tem de controverse, care continu i la ora actual.
Scop: Evaluarea atitudinii medico-chirurgicale n cazurile de FCNH.
Material i metod: Este analizat un lot de 22 bolnavi cu FCNH tratai n clinica I Catedra 2 Chirurgie, n perioada anilor 2006-2015. Vrsta pacienilor - 20-71 de
ani. Raportul brbai: femei - 1:2.
Investigaiile imagistice au inclus: USG efectuat la toi pacenii cu o sensibilitate de 96,0%, CT- n 5(22,5%) cazuri, RMN - 2(9,9%) cazuri.
Rezultate: Chisturi hepatice solitare au fost depistate n 11(50,0%) cazuri ((lob drept - 4(19.8%) cazuri, lob stng - 7(31.5%) cazuri), chisturi hepatice multiple n
11(50,0%) cazuri, inclusiv 2(9.9%) cazuri de polichistoz renal).
Intervenii chirurgicale au fost efectuate n 16(72,0%) cazuri (fenestrarea chistului hepatic-15(67.5%) cazuri, rezecia ficatului -1(2,2,0%) caz). Complicaii
postoperatorii nu au fost nregistrate. 6(27%) pacieni nu au fost supui interveniei chirurgicale fiind monitorizai n dinamic.
Concluzii: Chisturile simple hepatice asimptomatice cu diametrul mai mic de 5,0cm nu necesit tratament chirurgical, fiind monitorizate n dinamic. Indicaie
ctre tratament chirurgical sunt FCNH simptomatice cu complicaii. Chistectomia parial (fenestrarea chistului) dei prezint riscul recidivei este o metod sigur
i eficient de abordare a chisturilor hepatice neparazitare.

Introduction: The treatment options for nonparasitic liver cystic formations (NPLCF) are an old topic of controversy that continues today.
Purpose: Evaluation of surgical attitude in cases of NPLCF.
Material and methods: A group of 22 patients with clinical signs of NPLCF treated in Surgical Clinic 2 during the period of 2006-2015 were analyzed. The patients'
age was between 20-71 years old. Men: women ration - 1: 2.
Imaging investigations included: USG -performed to all patients with a sensitivity of 96.0%, CT-5 (22.5%) cases, MRI - 2 (9.9%) cases.
Results: Solitary liver cysts were found in 11 (50.0%) cases ((right lobe - four (19.8%) cases, left lobe - 7 (31.5%) cases), multiple hepatic cysts - in 11 (50.0 %) cases,
including 2 (9.9%) cases of renal polycystic disease).
Surgical procedures were performed in 16 (72.0%) cases (hepatic cyst fenestration-15 (67.5%) cases, liver resection -1 (2, 20%) case). Postoperative complications
were not recorded. 6 (27%) patients didnt undergo surgical intervention, being dynamically monitored.
Conclusions: Simple hepatic asymptomatic cysts with sizes smaller than 5,0cm in diameter dont require surgical treatment, being dynamically monitored. In
cases of NPLCF, the indication for surgery is the symptomatic one with complications. Partial cystectomy (cyst fenestration) is a safe and effective approach to
nonparasitic liver cysts, although there is a risk of recurrence.

Cum securitatea donatorului viu dup hepatectomia efectuat pentru donare depinde de gradul steatozei
hepatice nonalcoolice preexistente
How Living Donor Security after Hepatectomy Performed for the Donation Depends on the Degree of Preexisting
Non-Alcoholic Liver Steatosis
Angela Peltec
Universitatea de Stat de Medicin i Farmacie Nicolae Testemianu, Disciplina Gastroenterologie, Departamentul de Medicin Intern, Chiinu, Republica
Moldova
Introducere: Nu este bine definit influena steatozei grefei asupra securitii donatorului viu dup hepatectomie efectuat pentru donare. Gradul steatozei
hepatice la donator viu poate influena i afecta recuperarea dup hepatectomia parial.
Scopul acestui studiu a fost evaluarea impactului steatozei hepatice macroveziculare minimale asupra evoluiei postoperatoprii i securitii donatorului.
Material i metode: Noi am examinat 9 donatori de ficat vii care au fost divizai n dou grupe n dependen de prezena steatozei hepatice macroveziculare
minimale la examen histopatologic efectuat pretransplant. Grupele au fost analizate din punct de vedere demografic, al caracteristicilor antropometrice, evoluiei
intraoperatorii i prevalenei complicaiilor postoperatorii.
Rezultate: Diferena statistic semnificativ la grupa ce prezenta steatoza macrovezicular minimal vs fr steatoz a fost observat privind indicele masei
corporale (32,152,13 vs 24,172,77, p=0,050), durata interveniei (361,25 54,52 min vs 266,6736,17 min; p=0,05), nivelul maximal ALAT (709,0416,5 vs
164,755,7; p=0,05) i durata normalizrii nivelului ALAT (ALAT a 7-a zi post operator 197,570,8 vs 86,839,6; p=0,05). Prezena steatozei hepatice nu a
influenat prevalena complicaiilor postoperatorii, volumul hemoragiei intraoperatorii.
Concluzii: Supravieuirea donatorului i prevalena de complicaii postoperastorii nu a fost afectat de prezena steatozei hepatice macroveriscculare minime (mai
puin de 30%) preexistent la donator.

Introduction: The influence of graft steatosis on the safety of the living donor hepatectomy performed for the donation is not well defined. The degree of hepatic
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steatosis in living donor could influence and affect the potential donor recovery after partial hepatectomy.
The aim of this study was to evaluate the impact of minimal macrovesicular steatosis on the postoperative outcome and donor security.
Material and Methods: We examined 9 living liver donors who were divided into two groups depending on the presence of minimal macrovesicular hepatic
steatosis in the morphological examination. The groups were analyzed in terms of demographic, anthropometric characteristics, intraoperative evaluation and
prevalence of postoperative complications.
Results: Statistically significant differences were found on the body mass index (32,152,13 vs 24,172,77, p=0,050), duration of surgery (361,25 54,52 min vs
266,6736,17 min; p=0,05), maximal ALT level (709,0416,5 vs 164,755,7; p=0,05), and time of ALAT level normalization (ALAT 7th postoperative day 197,570,8
vs 86,839,6; p=0,05). The prevalence of postoperative complications and the volume of intraoperative bleeding was not influenced by the presence of hepatic
steatosis.
Conclusions: Donor graft survival is not affected by macrovesicular minimal hepatic steatosis (less than 30%). Postoperative outcome does not depend on the
presence of minimal, macrovesicular hepatic steatosis.

Mituri printre pacieni n colecistectomia laparoscopic


Patients Myths in Laparoscopic Cholecystectomy
G. C. Duu (1), Andreea Gherghe (2), Andreea Rusu (2), Elena Stircu (1), F. Svulescu (1)
(1) Spitalul Universitar de Urgen Militar Central, Chirurgie II, Bucureti, Romnia
(2) Universitatea de Medicin i Farmacie Carol Davila, Chirurgie II, Bucureti, Romnia
Obiectivul studiului: Prezentarea abordeaz o problem frecvent ntlnit pe secia de chirurgie general, aceea a miturilor pacienilor legate de tratamentul
chirurgical al litiazei biliare. Enumernd principalele confuzii, obiectivul lucrrii este de a le identifica, de a nelege cauzele producerii lor i de a gsi soluii care
s permit evitarea lor n viitor.
Material i metode: Au fost studiate dou loturi de bolnavi cu litiaz biliar i complicaii ale acesteia: 50 de pacieni internai n Secia Chirurgie II din Spitalul
Universitar de Urgen Militar Central Dr. Carol Davila Bucureti i 50 de bolnavi care nu au urmat tratament chirurgical pentru aceast patologie. S-a aplicat un
chestionar de 9 ntrebri cu scopul de a evalua cunotinele bolnavilor n ceea ce privete tratamentul.
Rezultate: Au fost identificate, printre altele, situaii precum: asimilarea colecistectomiei laparoscopice cu operaia cu laser, nencrederea n tehnica
laparoscopic, reticena fa de intervenia chirurgical n sine, orientarea spre tratamente naturiste ineficiente sau periculoase, nenelegerea termenului de
colecistectomie i confundarea acesteia cu extragerea calculilor biliari (colecistolitotomie). Cei care au consultat direct sau online surse de chirurgie general i
au beneficiat de tratament prezint un risc mai sczut de complicaii n urma mijloacelor terapeutice instituite corespunztor pentru litiaza biliar, n timp ce acele
persoane care s-au informat din surse nonchirurgicale sunt mai predispuse complicaiilor, prin amnarea sau refuzarea interveniei chirurgicale.
Concluzii: Aflat de peste 20 de ani n arsenalul terapeutic i impus ca gold standard n tratamentul litiazei biliare colecistectomia laparocopic poate oferi
nc surprize n ceea ce privete nelegerea i acceptarea ei de ctre pacieni. O informare corect a pacienilor de la surse medicale autorizate poate reduce
rata prezentrilor tardive n stadii complicate i, n consecin, morbiditatea i mortalitatea.

Objective of the study: This presentation addresses a problem commonly encountered in the General Surgery ward, the one of patients myths related to the
surgical treatment of gallstones. By listing the main misconceptions, the purposes of the paper are to identify them, to understand the causes of their occurrence
and to find solutions in order to avoid their appearance in the future.
Material and methods: Two groups of patients with gallstones and their respective complications have been studied: 50 patients hospitalized at Dr. Carol Davila
Central Military Emergency University Hospital, in the department of surgery II and 50 patients who have not received surgical treatment for this pathology. The
patients were asked to answer a survey consisting of 9 questions to assess their knowledge regarding the treatment of their pathology.
Results: There have been identified, among others, situations such as: confusion of the laparoscopic cholecystectomy with the laser surgery, distrust of the
laparoscopic technique, aversion to surgery itself, a preference for dangerous and ineffective natural treatments, misunderstanding the term of cholecystectomy
and confusing it with gallstones removal procedure (cholecystolithotomy). The ones who have consulted direct or online sources of general surgery and have
received treatment present a lower risk of complications from therapeutic means set properly, while those who have sought information from nonsurgical sources
are more prone to complications by delaying or refusing surgery.
Conclusions: Being part of the therapeutic arsenal for over 20 years and imposed as a gold standard in the treatment of gallstones, the laparoscopic
cholecystectomy can still offer surprises in terms of its understanding and acceptance by patients. A correct information of the patients from authorized medical
sources can reduce the rate of late-stage presentations and, consequently, morbidity and mortality.

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89

Sesiune Medici Comunicri orale


Physicians Session Oral Communications

Fistule pancreatice interne n pancreatita cronic: modificarea algoritmului de tratament pe baza analizei unei
serii chirurgicale de bolnavi
Internal Pancreatic Fistulas in Chronic Pancreatitis: Proposal of a Modified Treatment Algorithm Based On a Surgical
Series Analysis
S. T. Barbu (1), D. Vlean (2), Alexandrina Murean (3), Narcisa Balea (3)
(1) Universitatea de Medicin i Farmacie Iuliu Haieganu, Clinica Chirurgie IV, Cluj-Napoca, Romnia
(2) Spitalul Clinic Ci Ferate, Clinica Chirurgie IV, Cluj-Napoca, Romnia
(3) Spitalul Clinic Ci Ferate, Anestezie i Terapie Intensiv, Cluj-Napoca, Romnia
Introducere: Fistulele pancreatice interne (FPI) sunt complicaii severe, rare, dar bine definite ale pancreatitei cronice (PC).
Obiectiv: Evaluarea rezultatelor tratamentului chirurgical al FPI i ameliorarea algoritmului de tratament.
Material i metode: Studiu retrospective al bolnavilor cu FPI operai ntre 1995-2014 n Clinica noastr. Am analizat caracteristicile clinice, intervalul de timp de la
debutul complicaiei la diagnostic, la tratamentul endoscopic i la cel chirurgical, starea bolnavilor operai, procedeele chirurgicale utilizate, morbiditatea i
evoluia postoperatorie (urmrire medie=58,1 luni).
Rezultate: Unsprezece din 235 bolnavi cu PC au prezentat FPI (4,7%): 8 ascit pancreatic (AP) i 3 fistul pancreaticopleural (FPP) (1FPP cu fistul
bronhopleural). Toi cei 11 au fost brbati, alcoolici (vrsta medie=43,7 ani, durata medie a PC=5,4ani). Intervalele de timp medii au fost: debut-diagnostic 49 zile,
diagnostic-tratament endoscopic 34 zile, endoscopie-tratament chirurgical= 45 zile. La internarea pentru operaie toi bolnavii prezentau anemie,
hipoproteinemie, BMI mediu=15,4 i sindrom inflamator sever. Un bolnav AP a decedat nainte de a putea fi operat. S-au practicat 2 pseudochito-jejunostomii, 6
pancreatico-jejunostomii L-L si 2 procedee duVal cu stentarea retrograd intraoperatorie a Wirsungului. Splenectomia a fost asociat la 5 bolnavi (3FPP, 2AP).
Durata medie de spitalizare=29,8 zile. Mortalitatea postoperatorie a fost nul. Nu s-au semnalat recidive.
Concluzii: FPI apar precoce n evoluia PC, la brbai alcoolici tineri. Algoritmul de tratament trebuie s fie agresiv: tratament conservativ scurt (stabilizarea
bolnavului), tratament endoscopic (de evitat la bolnavii cu PC avansat), urmat imediat (n caz de eec) de tratamentul chirurgical (procedeu ales n funcie de
morfologia Wirsungului), urmrind reducerea spitalizrii, a costurilor i a mortalitii.

Introduction: Internal pancreatic fistulas (IPF) are well-recognized complications of chronic pancreatitis (CP).
Purpose: To assess the outcome of IPF patients managed by surgery; to ameliorate the management algorithm.
Material and Methods: We retrospectively identified all IPF patients operated between 1995 and 2014 in our Department. We reviewed the clinical features, time
to diagnosis, to endoscopic and surgical treatment, patients status at the time of surgery, surgical procedures, outcomes, morbidity and hospital stay. All patients
were followed-up (mean=58.1 months).
Results: IPF was identified in 11 (4.7%) of 235 CP patients: 8 pancreatic ascites (PA) and 3 pancreaticopleural fistula (PPF) (one complicated with bronchopleural
fistula). All patients were alcoholic males (mean age=43.7 years, mean CP duration=5.4 years). Mean time to diagnosis was 49 days, from diagnosis to endoscopic
treatment 34 days, and from endoscopy to surgery 45 days. When admitted for surgery, all patients had anemia, high CRP, hypoproteinemia, and mean BMI=15.4.
One PA patient died before surgery could be performed. Surgery implied 2 pseudocystojejunostomies, 6 pancreaticojejunostomies, and 2 duVal procedures with
retrograde intraoperative Wirsungs stenting. In 5 patients, splenectomy was associated (3PPF, 2PA). Mean hospital stay was 29.8 days. There was 1 reoperation,
no postoperative mortality, and no IPF recurrence during follow-up.
Conclusion: IPF occurs in young alcoholic males, early in CP course. Efforts should be made for an early diagnosis, short conservative treatment (stabilize the
patient), endoscopic management (not in advanced CP), and if it fails, immediate surgery (procedure according to Wirsungs morphology), which reduces medical
expenses, hospital stay, and the risk of death.

Rolul rezeciilor hepatice n metastazele hepatice cu origine n neoplasmele ginecologice


The Role of Liver Resections for Liver Metastases from Gynecological Neoplasms
Irina Blescu (1), N. Bacalbaa (2)
(1) Spitalul Ponderas, Chirurgie General, Bucureti, Romnia
(2) Universitatea de Medicin i Farmacie Carol Davila, Obstetric i Ginecologie, Bucureti, Romnia
Obiectiv: De a demonstra beneficiul rezeciilor hepatice pentru metastazele cu origine n neoplasmele ginecologice.
Material i metod: n perioada 2012-2014, 16 pacieni au fost supui rezeciilor hepatice pentru metastaze de origine ginecologic; tumorile primare care au
condus la apariia metastazelor hepatice au fost ovariene n 8 cazuri, de corp uterin n 4 cazuri, col uterin n 3 cazuri i vulvar ntr-un caz.
Rezultate: Rezeciile majore, definite ca rezecii de mai mult de trei segmente Couinaud au fost efectuate n 3 cazuri, n timp ce n celelalte 13 cazuri s-au efectuat
rezecii minore. n 12 din cele 16 cazuri au fost necesare i alte rezecii pentru a obine rezecia complet a leziunilor. Morbiditatea postoperatorie a fost 12,5% (un
pacient a prezentat fistul biliar ce a fost tratat conservator n timp ce n cel de-al doilea caz reintervenia chirurgical a fost necesar pentru drenarea unui
abces hepatic). Dup un follow-up de un an niciun pacient nu a dezvoltat recuren hepatic sau sistemic.
Concluzii: Rezeciile hepatice pentru metastaze de origine ginecologic pot fi practicate n condiii sigure i pot asigura un bun control al bolii, crescnd astfel
supravieuirea la distan.

Objective: To demonstrate the benefit of liver resection for liver metastases from gynecological cancers.
90

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Sesiune Medici Comunicri orale


Physicians Session Oral Communications
Material and Methods: Between 2012-2014, 16 patients were submitted to liver resections for hepatic metastases from gynecological tumors; the main
gynecological cancers leading to the apparition of liver metastases were ovarian tumors (eight cases), uterine body (four cases), uterine cervix (three cases) and
vulvar cancer (one case).
Results: Major resections, defined as liver resections of more than three liver segments according to Couinauds classification were performed in three cases
while in the other 13 cases major resections were performed. In 12 of the 16 cases other visceral resections were associated in order to achieve a radical surgical
procedure. The postoperative morbidity was 12,5% (a patient developed a biliary fistula which was successfully treated in a conservative manner while in the
second case re-operation was needed for draining a liver abscess). After A one year follow-up there is no case of hepatic or systemic recurrence.
Conclusions: Liver resections for gynecological cancer liver metastases can be safely performed and can provide a good control of the disease increasing in this
way the long term survival.

Variantele anatomice ale arterei hepatice i duodenopancreatectomia cefalic: reconstrucia, evoluia


postoperatorie, prognosticul i calitatea vieii
Hepatic Artery Anatomic Variants and Pancreaticoduodenectomy: Tailoring, Perioperative Course and Quality of Life
Ana-Maria Trofin (1), Mihai Lucian Zabara (1), Delia Rusu-Andriei (1), F. Crumpei (2), Costel Bradea (3), Oana Apopei (4), Corina Ursulescu-Lupacu (5),
Dan Andronic (3), Alexandra Vornicu (1), C. Lupacu (1)
(1) Spitalul Clinic Judeean de Urgene Sf. Spiridon, Clinica II Chirurgie, Iai, Romnia
(2) Spitalul Clinic Judeean de Urgene Sf. Spiridon,, Clinica de Radiologie, Iai, Romnia
(3) Spitalul Clinic Judeean de Urgene Sf. Spiridon, Clinica I Chirurgie, Iasi, Romnia
(4) Spitalul Clinic Judeean de Urgene Sf. Spiridon, Clinica de Anestezie i Terapie Intensiv, Iai, Romnia
(5) Spitalul Clinic Judeean de Urgene Sf. Spiridon, Clinica de Radiologie, Iai, Romnia
Introducere: Rezecia duodenopancreatic (PD) este tratamentul de elecie la pacienii cu tumori ale regiunii periampulare. Variantele anatomice ale arterei
hepatice (HAav) sunt ntlnite frecvent n timpul PD. Prezervarea lor este fezabil fr a compromite supravieuirea. Acest studiu evalueaza incidena HAav ntr-o
serie de PD i evalund tehnicile chirurgicale i rezultatelor.
Material i metode: Patruzeci i nou de pacieni cu HAav au fost identificai ntr-o serie consecutiv de 140 de PD pentru tumorile periampulare i
cefalopancreatice ntre 1 ianuarie 2009 i 31 decembrie, 2015. Loturile cu sau fr HAav au fost comparate n ceea ce privete abordurile chirurgicale,
complicaiile i supravieuirea. Chestionarele EORTC QLQ-C30 i EORTC QLQ-PAN26 au fost completate de toi pacienii cu scopul de a evalua calitatea vieii
postoperator.
Rezultate: Toi pacienii au suferit proceduri Whipple, cu abord posterior drept pentru cei la care a fost identificat HAav. Arterele hepatice aberante au fost
disecate fr leziuni n 45 de cazuri. La patru pacieni HAav a fost fie sacrificat (2) sau deteriorat (2) i necisitnd reconstrucie arterial. Nu s-au identificat
diferene privind complicaiile chirurgicale i supravietuirea. Rezultatele studiului calitii vieii nu au artat diferene semnificativ statistice.
Concluzii: HAav este ntlnia frecvent n timpul PD i un abord posterior drept este adecvat. Prezervarea sa este obligatorie, dar n afeciunile maligne se poate
deteriora sau este necesar sacrificarea sa i prin urmare, este necesar reconstrucia arterial. Nu exista niciun impact negativ de HAav n ceea ce privete
morbiditatea chirurgical i prognosticul pacienilor. Calitatea vieii este relaionat cu rezultatele postoperatorii.

Aim: Pancreaticoduodenectomy (PD) is the procedure of choice in patients with tumors of periampullary region. Hepatic artery anatomic variants (HAav) are
frequently encountered during PD. Its sparing is feasible without compromising survival. This study evaluates the incidence of HAav in a series of PDs and
consequence on technical tailoring and outcome.
Methods: Forty-nine patients with HAav were identified in a consecutive series of 150 PDs for periampullary and pancreatic head tumors between January 1,
2009 and December 31, 2015. The groups with or without HAav were compared in terms of operative approach, complications and survival. EORTC QLQ- C30 and
EORTC QLQ- PAN26 questionnaires were completed by all patients in order to asses the postoperative quality of life.
Results: All patients underwent Whipple procedure, with right posterior approach for those having HAav. HAav was spared without damage in 45 cases. Four
patients to whom the HAav was either sacrificed (2) or damaged (2) required arterial reconstruction. There were no differences in surgical complications and
survival. The comparing results of the outcome assessment showed no statistical significance in the two subgroups of patients.
Conclusions: HAav is frequently encountered during PD and a right posterior approach is advocated. Its safeguardind is mandatory but in malignancy it can be
damaged or sacrificed, hence arterial reconstruction is required. There is no negative impact of HAav on the surgical morbidity and outcome. The quality of life is
related with the postoperative outcomes.

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91

Sesiune Medici Comunicri orale


Physicians Session Oral Communications

Conduita medico-chirurgical n abcesele hepatice


Medico-Surgical Approach to Liver Abscesses
V. Hotineanu (1), A. Iliadi (2), Valeriu Bogdan (3), O. Cunir (1), Gheorghe Trinca (1), S. Salaur (1), A. Cazac (4)
(1) Universitatea de Stat de Medicin i Farmacie Nicolae Testemianu, Chiinu, Republica Moldova
(2) Universitatea de Stat de Medicin i Farmacie Nicolae Testemianu, Catedra 2 Chirurgie, Chiinu, Republica Moldova
(3) Universitatea de Stat de Medicin i Farmacie Nicolae Testemianu, Spitalul Clinic Republican, Chiinu, Republica Moldova
(4) Universitatea de Stat de Medicin i Farmacie Nicolae Testemianu, Catedra 2 Chirurgie, LC Chirurgie Reconstructiv a Tractului Digestiv, Chiinu,
Republica Moldova
Lucrarea prezint experiena clinicii pe o perioad de 20 ani (1995-2015), asupra unui lot de 112 pacieni. Vrsta pacienilor: 19-72 ani, cu prevalarea sexului
feminin (68,75%). Diagnosticul s-a bazat pe datele investigaiilor de laborator i imagistice. Abcesele solitare, n majoritatea cazurilor (82,14%) au afectat lobul
drept al ficatului. Cauzele de apariie a abceselor hepatice: colangiogene (26), postraumatice (18), parazitare (34), metastatice portale (7), metastatice arteriale
(4), neidentificate (23). Cele mai frecvente manifestri clinice au fost febra, durerea abdominal i hepatomegalia. Germenii microbieni decelai ca responsabili de
producerea abceselor: E.coli, St. Aureus, Bac Piocianic, Proteus. Tratamentul chirurgical practicat a constat n asanarea focarului septic realizat preponderant n
ultimii ani prin puncia ecoghidat transcutanat i laparotomii. Tratamentul general i local practicat prin shimbarea de drenaje (fistulografie) a determinat
dinamica schimbrilor focarului septic i a contribuit la obinerea rezultatelor satisfctoare n cazuri clinice concrete. Mortalitatea postoperatorie - 6 pacienti
(5,3%).
Concluzii: Tabloul clinic a abceselor hepatice este polimorf i necesit metode contemporane de diagnostic: tomografia computerizat i rezonana magnetic
nuclear ne permit de a concretiza diagnosticul topic i diferenial; drenarea transcutanat ecoghidat computerizat sunt metode contemporane de perspectiv;
antibioticoterapia selectiv prin recanalizarea venei ombilicale i truchiului celiac prin puncia aortic n cazuri concrete sunt o component important.

The study presents the clinics experience of a period of 20 years (1995-2015) on a group of 112 patients. Patients age varied from 19 to 72 years old with the
prevalence of female subjects (68.75%). The diagnosis was based on laboratory indexes and imaging methods of investigation. Solitary abscesses in the majority
of cases (82.14%) affected the right lobe of the liver. Causes of abscess developing were: cholangiogenic (26), posttraumatic (18), parasitic (34), portal
metastasizes (7), arterial metastasizes (4), non-identified (23). The most common clinical manifestations were fever, abdominal pain and hepatomegaly. Microbial
germs identifiable as responsible for the abscesses developing were: E.coli, St. Aureus, Bac. Piocianic, Proteus. Surgical treatment consisted in drainage of septic
focus practiced predominantly by echo-guided percutaneous puncture especially in recent years and by laparotomy. Practiced general and local management via
changing of drains (fistulography) determined the dynamic changes and contributed to obtaining satisfactory results in concrete clinical cases. Postoperative
mortality rate was of 6 patients (5.3%).
Conclusions: The clinical picture of hepatic abscesses is polymorphic and requires contemporary methods of diagnosis such as computed tomography and
magnetic resonance which allowed us to concretize the topical and to perform the differential diagnosis. Echo-guided or computerized percutaneous drainage
are contemporary methods of abscesses management. Selective antibiotic therapy through recanalyzed umbilical vein and via celiac trunk by aortic puncture in
concrete cases is an important component.

Amputaia de rect versus rezecia rectal joas


Abdominoperineal Resection versus Low Anterior Resection
F. Graur
Universitatea de Medicin i Farmacie Iuliu Haieganu / Institutul Regional de Gastroenterologie i Hepatologie Prof. Dr. Octavian Fodor, Chirurgie III,
Cluj-Napoca, Romnia
Amputaia de rect i rezecia rectal joas sunt intervenii chirurgicale ce se realizeaz n cazul tumorilor rectale joase sau mijlocii.
Amputaia de rect este mai frecvent utilizat n cazul tumorilor avansate local sau a celor slab differentiate, precum i n cazurile cu tumori jos situate sau care
invadeaz sfincterul anal. n aceste cazuri sunt contraindicate interveniile chirurgicale care prezerv sfincterul anal. Exist studii care compar calitatea vieii
(QOL) dup aceste intervenii i care constat c QOL nu are de suferit pe termen lung n cazul amputaiei fa de rezecia joas (Campos-Lobato et al. 2011). n
plus calitatea vieii dup rezectiile joase are de suferit n perioada postoperatorie (uneori chiar mai ndelungat) de incontinen anal, dificil de ngrijit comparativ
cu anusul iliac. De asemenea, sindromul postrezecie joas este un alt inconvenient al acestor proceduri ce poate reduce calitatea vieii dup rezeciile joase.
n studiul prezent s-a realizat un review al literaturii cu privire la avantajele i dezavantajele comparative ale celor dou tehnici.
Cuvinte cheie: amputaie de rect, rezecie rectal joas

Abdominoperineal resection and low anterior resection are used in low or middle rectal tumours.
Abdominoperineal resection is more frequently used in locally advanced tumours or those poorly differentiated and in cases with low located tumours or invasive
in the anal sphincter. In these cases the procedures that preserve the anal sphincter are contraindicated. There are studies that compare the quality of life (QOL)
after these interventions and finds that QOL does not suffer on long term when compared amputation to low anterior resection (Campos-Lobato et al. 2011). In
addition the quality of life suffers after low resections in the postoperative period (sometimes longer) of anal incontinence, difficult to care compared with iliac
anus. Low anterior resection syndrome also is another drawback of the procedure that can reduce quality of life after low resections.
In present study a literature review was done on the comparative advantages and disadvantages of the two techniques.

92

Congresul Naional de Chirurgie 2016 01 - 04 iunie 2016 Centrul Internaional de Conferine Sinaia
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Sesiune Medici Comunicri orale


Physicians Session Oral Communications
Keywords: abdominoperineal resection, low anterior resection

Starea nodulilor limfatici din cancerul de rect cu radiochimioterapie preoperatorie


Status of Lymph Nodes after Preoperative Chemoradiotherapy for Rectal Cancer
L. Kiss (1), R. Kiss (1), Denisa Elena Milcioiu (1), S. Eremev (1), S. Zaharia (2)
(1) Spital Clinic Judeean de Urgen, Chirurgie I, Sibiu, Romnia
(2) Spital Clinic Judeean de Urgen, Anatomie Patologic, Sibiu, Romnia
Rezumat: Numrul i starea nodulilor limfatici examinai sunt cruciale pentru stadializarea tumoral. n cancerul de rect, impactul radiochimioterapiei
neoadjuvante asupra strii nodulilor limfatici i a supravieuirii este controversat. Scopul acestui studiu a fost s defineasc impactul radiochimioterapiei
neoadjuvante asupra numrului de noduli limfatici decelai i a nodulilor limfatici tumorali din piesa de rezecie rectal i evaluarea strii nodulilor limfatici post
radiochimioterapie preoperatorie. Rezultate: n intervalul 2002-2014, din 495 de pacieni rezecai cu cancer rectal, 332 au beneficiat de radioterapie
preoperatorie de lung durat. La pacienii care au beneficiat de radioterapie neoadjuvant, raportul dintre supravieuire i numrul de noduli limfatici gsii n
piesa de rezecie a fost determinat prin metoda Kaplan-Meyer i testul log-rank. n comparaie cu tratamentul chirurgical singular, radiochimioterapia
neoadjuvant scade numrul mediu de noduli limfatici (NL) gsii (17/13 p<0.001) ct i numrul de noduli limfatici netratai (23/12) p=0.002. Concluzia:
Radiochimioterapia neoadjuvant scade cu 24% numrul de NL gsii n piese i cu 48% numrul de NL pozitivi, iar supravieuirea nu este influenat de numrul
de NL identificai n piesa de rezecie iradiat.

Summary: The number and status of lymph nodes examined is critical for tumor staging.
In rectal carcinoma, the impact of neoadjuvant chemoradiotherapy of lymph nodes status and survival is still controversial.
The aim of this study was to define the impact of neoadjuvant radiochemotherapy on the number of lymph nodes retrieved and positive lymph nodes in rectal
cancer specimen, to evaluate the lymph status after neoadjuvant radiochemotherapy.
Results: From 2002-2014, 495 patients underwent rectal resection for cancer out of which 332 received long coarse preoperative radiotherapy. Kaplan-Meyer
method and log-rank test assessed the relation between survival and number of lymph nodes retrieved in patients treated by neoadjuvant radiotherapy.
Compared with surgery alone, neoadjuvant radiotherapy decreased both the mean number of lymph nodes (LN) retrieved (17 vs 13, p < 0.001) and the number of
positive LN (23 vs 12), p=0.002.
Conclusion: The neoadjuvant radiochemotherapy decreases by 24% the number of LN retrieved and by 48% the number of positive LN and survival was not
influenced by the number of LN retrieved in eradicated rectal specimen.

Complicaiile postoperatorii precoce dup chirurgia cancerului colorectal n urgen i cronic


Early Postoperative Complications Following Colorectal Cancer Surgery in Emergency and Elective Setting
C. M. Coarc (1), G. Cazacu (2), D. G. Popa (1), A. Murean (1), A. Cotovanu (1), V. O. Butiurca (1), G. A. Vizitiu (1), Mihaela Baziluc (1), Ioana Iulia Cojocaru (1),
C. Copotoiu (1)
(1) Spitalul Clinic Judeean de Urgen, Clinica Chirurgie 1, Trgu Mure, Romnia
(2) Spitalul Clinic Judeean de Urgen, Chirurgie Oral i Maxilo-Facial, Trgu Mure, Romnia
Introducere: Chirugia rmne principalul mijloc terapeutic al cancerului de colon cu riscuri crescute de apariie al complicaiilor postoperatorii, avnd n vedere
patologia abordat.
Obiectiv: Prezentm un studiu retrospectiv efectuat n Clinica Chirurgie I a Spitalului Clinic de Urgen Trgu Mure privind complicaiile post operatorii precoce
dup chirurgia, n urgen i electiv, a cancerului colorectal.
Material i metod: Sunt prezentate datele pacienilor tratai n clinic n perioada 2013-2015; att cazurile cronice care au beneficiat de o pregtire preoperatorie
corespunztoare ct i cazurile de urgen, a cror pregtire preoperatorie a fost de scurt durat sau nu s-a efectuat.
Material de lucru: Foile de observaie ale pacienilor cu neoplasme colorectale internai n Clinica Chirurgie I a Spitalului Clinic de Urgen Trgu Mure
Rezultate: Dei datele din literatur nu arat diferene semnificative ntre rata complicaiilor precoce aprute la pacienii operai n regim de urgen fa de cei
operai n regim cronic, datorit nepregtirii prealabile a colonului, rolul pregtirii mecanice i microbiologice a colonului trebuie reconsiderat avnd n vedere o
serie de aspecte cum ar fi: necesitatea explorrii digitale intraoperator a colonului, mai ales cnd exist posibilitatea existenei tumorilor de mici dimensiuni;
efectuarea colonoscopiei intraoperator; respectarea prevederilor ghidurilor terapeutice.
Concluzii: n cadrul terapiei complexe a cancerului colo-rectal, rezecia chirurgical rmne mijlocul cel mai eficient de tratament. Rezecia unei poriuni a
colonului este o intervenie ampl, agresiv, care implic riscuri crescute de apariie a complicaiilor precoce, locale i generale, ce pot avea un impact decisiv
asupra evoluiei ulterioare a bolnavilor tratai pentru aceast patologie.

Introduction: Surgery remains the main therapeutic means for colon cancer, presenting high risks of postoperative complications, considering the approached
pathology.
Objective: We are presenting a retrospective study that was performed at Surgical Clinic I, from the Trgu Mure County Clinical Hospital regarding early
postoperative complications from emergency and elective surgery.
Material and method: We present cases treated in this clinic in the period 2013-2015; both in an elective setting that received appropriate preoperative care and
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emergency cases, whose preoperative care lasted less or was not provided at all.
Material to work with: Medical observation chart of patients with colorectal cancer hospitalized at Surgical Clinic I, from the Trgu Mure County Clinical Hospital.
Results: Even if literature data does not show major differences between early postoperative complications of patients that had emergency surgery and those
who had elective surgery, the role of mechanical bowel preparation has to be reconsidered, taking into account a series of aspects such: the need of digital
intraoperative exploration of the colon, particularly when there are small tumors; performing intraoperative colonoscopy; following the treatment guidelines.
Conclusions: The surgical resection remains the most efficient means of treatment in the complex therapy of colorectal cancer. The resection of a part of the
colon is an intensive surgery that implies high risks of early postoperative complications, local and general, which could have a decisive impact on the patients
that are being treated of this pathology.

Managementul chirurgical al metastazelor hepatice din cancerul colorectal


Surgical Management of Liver Metastases in Colorectal Cancer
D. G. Popa (1), Gabriel Serac (2), Mihaela Baziluc (1), C. Russu (2), A. Strat (1), G. A. Vizitiu (1), C. M. Coarc (1), A. Simionescu (1), C. Copotoiu (2)
(1) Spitalul Clinic Judeean de Urgen, Clinica Chirurgie 1, Trgu Mure, Romnia
(2) Universitatea de Medicin i Farmacie, Clinica Chirurgie 1, Trgu Mure, Romnia
Introducere: Aproximativ 50% din pacienii cu cancer colorectal (CCR) au sau vor dezvolta metastaze. Metastazarea hematogen din tumorile colo-rectale se face
predominant n ficat. Aproximativ 25% din pacienii cu CCR prezint metastaze hepatice(MH) la diagnosticare.
Strategia optim de tratament a CCR metastatic necesit o abordare multidisciplinar.
Supravieuirea la 5 ani a pacienilor cu MH a crescut n ultima decad datorit dezvoltrii tratamentului adjuvant i neoadjuvant, a rezeciilor MH i a metodelor
noi de ablaie. Doar 20% din pacienii cu MH prezint leziuni rezecabile n totalitate.
Material i metod: Am efectuat un studiu retrospectiv pe un lot de 172 de pacieni cu CCR i MH tratai n Clinica de Chirurgie nr. 1 din Trgu Mure. Au fost
analizate: incidena, rata de rezecabilitate i modalitatea de tratament
Rezultate: Alternativele de tratament al MH au inclus: rezecia tumorii primare urmat de abordarea metastazelor hepatice, rezecie simultan colorectal i
hepatic sau abordul primar al MH, apoi abordul tumorii primare. Dezideratul n abordul MH a constat n realizarea unei rezecii hepatice R0 cu prezervarea de
esut hepatic restant capabil pentru susinerea funciei metabolice.
Concluzii: Momentan nu exist criterii uniforme privind tratamentul chirurgical la pacienii care iniial prezint MH considerate nerezecabile, la acestia fiind
dovedit rolul tratamentului neoadjuvant chimioterapic. Pacienii cu MH nerezecabile pot beneficia de terapie non-chirurgical chemoembolizare, chimioterapie
intraarterial, ablaie prin radiofrecven, ultrasunete, crioterapie, injectare intratumoral.

Introduction: About 50% of the patients with colorectal cancer (CRC) have or will develop metastases. Blood stream metastasis from CRC is predominantly in the
liver. Approximately 25% of patients with CRC have liver metastases (LM) at the time of diagnosis.
The optimal strategy for treating metastatic CRC requires a multidisciplinary approach.
The 5-year survival of patients with LM has increased in the last decades due to adjuvant and neoadjuvant therapy development, the LM surgery and new
methods of ablation. Only 20% of the patients with LM have completely resectable lesions.
Material and method: We conducted a retrospective study on a group of 172 patients treated with CCR and MH in Surgery Clinic No.1, Trgu Mure. We analyzed
incidence, rate of resectability and treatment modality.
Conclusion: LM treatment alternatives included: resection of the primary tumor followed by metastasis approach, simultaneously LM and colorectal resection or
primary approach of the LM, followed by approach of the primary tumor. The challenge in LM approach consists in achieving R0 liver resections with the
preservation of liver tissue remaining able to support metabolic function.
There are currently no uniform criteria on surgical treatment in patients with initially considered unresectable LM, in these cases the role of neoadjuvant
chemotherapy being well demonstrated. Patients with unresectable LM can benefit from non-surgical therapy: intraarterial chemoembolization, chemotherapy,
radiofrequency, ultrasound, cryosurgery, intratumoral injection.

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Pregtirea colonului n chirurgia colorectal


Bowel Preparation in Colorectal Surgery
C. Molnar (1), O. Budic (2), C. M. Coarc (3), M. Gherghinescu (2), A. Murean (2), Laura-Denisa Lata (2), R. Pisic (2), D. G. Popa (2)
(1) Universitatea de Medicin i Farmacie, Clinica Chirurgie 1, Trgu Mure, Romnia
(2) Spitalul Clinic Judeean de Urgen, Clinica Chirurgie 1, Trgu Mure, Romnia
(3) Universitatea de Medicin i Farmacie, Anatomie, Trgu Mure, Romnia
Introducere: Pregtirea mecanic (PM) a intestinului gros a reprezentat o etap indispensabil n chirurgia colonului i rectului. Iniial a fost postulat ideea c
numai o PM adecvat asigur o evoluie intra i postoperatorie favorabil prin diminuarea riscurilor de apariie a dehiscenei de anastomoz, a contaminrii
cmpului operator i a apariiei infeciilor postoperatorii. Asocierea cu pregtirea antimicrobian (PA) a colonului a reprezentat urmatorul pas n chirurgia
colo-rectal. Dac PM este pus n discuie n studiile recente, PA rmne n continuare o necesitate.
Material si metoda: Am efectuat un studiu retrospectiv pe un lot de 717 pacieni internai n Clinica Chirurgie I Trgu Mure pe o perioad de 16 ani (2000-2015),
privind rolul PM n chirurgia colo-rectal.
Rezultate: PM a fost regula la pacienii operai electiv. Incidena supuraiei de plag la cei cu PM a fost de 7,43% fa de doar 5,54% nregistrat la cei fr PM. Nu
am constatat diferene statistic semnificative ntre cei cu i fr PM (4,57% vs 5,54%, p=0,06)
Concluzii: Exist situaii n care PM devine ns o necesitate. Cu toate c exist numeroase trialuri care susin abandonarea PM, pe plan mondial s-a constatat c
60-95% din chirurgi prefer nc o PM preoperatorie.

Introduction: Mechanical preparation (MP) of the bowel is a mandatory step in colorectal surgery. Initially postulated as ensuring a favorable intra and
postoperative evolution by reducing the incidence of anastomotic leak, of operative field contamination and of postoperative infections, the mechanical bowel
preparation opened the door for the next step in colorectal surgery: its own association with antimicrobial preparation (AP). If several studies have questioned MP
as being obsolete, AP continues to remain a necessity.
Material and method: We performed a retrospective study about the role of PM in colorectal surgery, on 717 patients admitted between 2000-2015 in Surgical
Clinic I, Trgu Mure.
Results: PM was mandatory for the patients with elective colorectal surgery. The incidence of surgical site infection for the procedures with PM was 7.43 %
compared to 5.54 % for those without PM. We did not find statistically significant differences between those with or without PM (4.57 % vs. 5.54 %, p=0.06)
Conclusions: However, there are situations which require MP in the highest grade. And even if several trials advocate for abandoning it, 60 to 95 percent of the
worlds surgeons still argue for a preoperative MP.

Factori ce influeneaz rspunsul la tratamentul neoadjuvant n cancerul de rect jos situat


Elements that Influence the Response to Neoadjuvant Treatment in Rectal Cancer
D. V. Scripcariu (1), Maria-Gabriela Aniei (1), I. Huanu (1), B. Filip (1), adiye-Ioana Scripcariu (2), Ana-Maria Muin (1), Mihaela-Mdlina Gavrilescu (1),
Mihaela Buna-Arvinte (1), A. Pantazescu (1), V. Scripcariu (1)
(1) Institutul Regional de Oncologie, Clinica I Chirurgie Oncologic, Iai, Romnia
(2) Spitalul Clinic de Obstetric i Ginecologie Cuza Vod, Clinica I Obstetric i Ginecologie, Iai, Romnia
Introducere: Tratamentul modern al cancerului de rect jos situat este unul multidisciplinar, incluznd, pe lng chirurg, o echip format din imagistician,
gastroenterolog, oncolog medical i specialist n radioterapie. n ciuda cantitii mari de informaie adunate inclusiv din studiile moleculare, stadializarea TNM
este n continuare singurul instrument folosit pentru indicaia de tratament neoadjuvant, precum i pentru a descrie prognosticul n cancerul de rect i, implicit,
abordarea terapeutic a fiecrui pacient. Clasificarea pacienilor cu neoplasm rectal n responderi i non-responderi la tratamentul neoadjuvant este important
pentru clinician i pentru pacient n luarea deciziei terapeutice. Existena factorilor de predicie ai rspunsului la tratamentul neoadjuvant permite aplicarea de
strategii de tratament diferite, mai agresive pentru pacienii considerai mai puin probabil s rspund la tratamentele standard, evitnd astfel aplicarea unui
tratament care are beneficii reduse sau absente, dar efecte secundare importante.
Pacieni i metode: Au fost luai n studiu pacienii operai cu viz curativ pentru cancer de rect jos situat (mijlociu i inferior), radio-(chimio-)tratat neoadjuvat, n
perioada mai 2012 martie2016, n cadrul Clinicii I Chirurgie Oncologic a Institutului Regional de Oncologie Iai. S-au analizat datele imagistice i imunochimice
ale pacienilor, urmrindu-se corelaia cu rspunsul la tratamentul neoadjuvant.
Rezultate: S-au obinut corelaii ntre lungimea intervalului dintre finalizarea tratamentului neoadjuvant i secvena chirurgical, asocierea chimioterapiei n timpul
tratamentului neoadjuvant i stadializarea cT, pe de-o parte i scorul Dworak de regresie tumoral pe de alt parte.
Concluzie: Este important a evalua valoarea diferitelor elemente de predicie a rspunsului la tratament neoadjuvant, n vederea stabilirii unei strategii
terapeutice eficiente, adaptate fiecrui pacient.

Introduction: The modern treatment of low rectal cancer needs to be multidisciplinary, as it includes, alongside the surgeon, an entire team consisting of a
radiologist, gastroenterologist, medical oncologist and radiotherapist. Despite the large amount of information gathered including molecular studies,TNM staging
is still the only instrument used for the indication of neoadjuvant treatment, and to describe the prognosis in rectal cancer and hence the management of each
patient. Classification of patients with rectal cancer in responders and non-responders to neoadjuvant treatment is important both for the clinician and the patient
in making therapeutic decisions. The existence of predictive factors for the response to neoadjuvant treatment enables the application of different therapeutic
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strategies, more aggressive for patients considered less likely to respond to standard treatments, thus avoiding treatment with reduced or absent benefits, but
significant side effects.
Patients and methods: In this study we included patients operated with curative intent for distal rectal cancer (mid and low), that received
radio-(chemo-)neoadjuvant treatment between May 2012-March2016, in the Ist Surgical Oncology Clinic of the Regional Institute of Oncology Iai. Imaging and
immunochemistry data were analyzed, aiming to find correlations with response to neoadjuvant treatment.
Results: We obtained correlations between the length of stay from finishing neoadjuvant treatment and the surgical sequence, association of chemotherapy to
neoadjuvant treatment and cT staging, on the one hand and Dworak tumor regression score on the other hand.
Conclusion: It is important to assess the value of different predictive elements for the response to neoadjuvant treatment, as to establish an effective therapeutic
strategy that is appropriate for each patient.

Opiuni chirurgicale n cancerul de rect treime medie


Surgical Options for the Middle Rectal Cancer
. Neagu, R. V. Costea, C. Dumitrescu, M. Hasouna, M. Khalil, Octavia Cristina Rusu, G. Gangura, C. Popa, Eugenia Claudia Zrnescu, N. O. Zrnescu
Spitalul Universitar de Urgen, Chirurgie II, Bucureti, Romnia
Aproximativ 30% din cancerele rectale sunt localizate n treimea medie (CRM). Alegerea procedeului chirurgical care conserv sau nu sficterul anal trebuie fcut
n funcie de mai muli factori: nivelul leziunii, aspectul macroscopic, intinderea circumferenial, gradul de difereiere histologic, stadializarea TNM.
Operaiile princeps practicate n cazul CRM sunt rezecia anterioar cu anastomoz colo-rectal (anal) tip Dixon i amputaia de rect Miles. n cazurile cu risc
operator major (comorbiditi importante) poate fi indicat rezecia a la Hartmann sau rezecie transanal.
Au fost operate 200 de cazuri de CMR n perioada 2003-2015. Au fost 40 de cazuri amputaie de rect Miles (20%), 132 cazuri rezecii tip Dixon (66%), 14 operaii
Hartmann (7%), 14 colostome (7%). n funcie de stadializare, s-a aplicat tratament oncologic (radio- i chimioterapie) pre- i/sau post-operator. Rata recidivei
locale a fost de 5% att pentru rezecie ct i pentru amputaie de rect. Mortalitatea postoperatorie a fost de 2%.
Prioritatea n alegerea procedeului chirurgical n cazul CRM este securitatea bolnavului i ce este mai bine pentru el, i nu considerentele statistice.

About 30% of rectal cancers are located in the middle third (MTR). Choosing conserving surgical procedure or anal sphincter should be based on several factors:
macroscopic appearance, circumferential extent, tumor grading, TNM staging.
The most common operations are: Dixon anterior resection and Miles operation. In case of high risk patients (significant comorbidities) Hartmann operation or
transanal resection may be indicated.
In our clinic, there have been 200 cases of MTR cancer in the period 2003-2015. There were 40 cases of Miles amputation (20%), 132 cases with Dixon type
resection (66%), 14 cases with Hartmann operation (7%), 14 cases with colostomy (7%). According to the tumor stage, oncological treatment (radio- and
chemotherapy) pre- and/or post-operatively was applied. Local recurrence rate was 5% for both resection and amputation of the rectum. Postoperative mortality
was 2%.
Priority in choosing CRM surgical procedure should be the patients security and what is best for him and not statistical considerations.

Recuperarea postoperatorie rapid n chirurgia colorectal programat


Enhanced Recovery after Elective Colorectal Surgery
A. Bordea, G. Richiteanu, F. Grama, D. Cristian, Angela Blajin, T. Burco
Spitalul Clinic Colea, Chirurgie General, Bucureti, Romnia
Scop: Evaluarea stadiului implementrii n Clinica Chirurgie Colea a unui protocol pentru recuperarea rapid n chirurgia colo-rectal programat.
Material i metod: Dup analiza literaturii, n protocolul de recuperare rapid au fost incluse 35 de recomandri referitoare la 19 parametri care influeneaz cele
mai importante 6 consecine ale chirurgiei colo-rectale; aprecierea impactului acestor parametri s-a fcut pe baza a 2 criterii principale: durata de spitalizare i
rata de complicaii. Studiul i-a propus s analizeze dinamica implementrii acestor 35 de recomandri ntr-o perioad de 5 ani, n clinica Chirurgie Colea.
Rezultate: Analiza implementrii celor 35 de recomandri a condus la urmtoarele observaii: 1. recomandri care s-au dovedit utile; a) aplicate nc de la
nceputul perioadei; b) introduse pe parcurs; c) restrnse n aceast perioad; 2. recomandri ne/incomplet aplicate; 3. practici inutile, dei unele larg aplicate;
Concluzii: Dei unele recomandri sunt discutabile sau amendabile, protocolul pentru recuperarea rapid postoperatorie are o valoare cert n reducerea duratei
de spitalizare i a complicaiilor postoperatorii n chirurgia colo-rectal programat.

Objective: To evaluate the progress of an enhanced recovery protocol implementation after elective colo-rectal surgery in Coltea Surgical Department.
Methods: After a literature review, 35 recommendations on 19 parameters influencing the most important 6 consequences of colo-rectal surgery were included in
the protocol. The final outcomes analyzed were the post-op length of stay and the complications rate. The purpose of this study was to analyze the dynamic of
this 35 recommendations protocol over a 5 years period, in Coltea Surgical Department.
Results: The implementation analysis of the 35 recommendations led to the identification of 3 categories of recommendations: 1. recommendations proved to be
useful a) since the beginning; b) introduced on the way; c) confined to this period; 2. recommendations partially introduced/completely left out; 3.
recommendations proved to be useless, though frequently encountered.
Conclusion: Although some recommendations are controversial or in need of a review, the enhanced recovery protocol has a certain value in reducing the length
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of stay and the post-op complication rate in elective colo-rectal surgery.

Abordul minim invaziv n polipoza colonic familial multipl


Minimally Invasive Access for Familial Colonic Polyposis
N. Iordache, Rzvan Andrei Stoica, I. Bistriceanu, M. Gheorghe
Spitalul Clinic de Urgen Sfntul Ioan, Clinica de Chirurgie, Bucureti, Romnia
Polipoza familial multipl este o afeciune rar, dar n continu cretere. Are o transmitere autozomal dominant i se caracterizeaz prin apariia precoce a sute
sau chiar mii de polipi adenomatoi diseminai n ntreg colonul i rectul. n absena tratamentului, evolueaz invariabil spre cancer colonic. Incidena este
constant n ntreaga lume i variaz de la 1:6000 la 1:12000 nateri, ambele sexe fiind implicate n mod egal.
Tratamentul este reprezentat de colectomia total, polipectomia fiind imposibil datorit numrului foarte mare de polipi i n multe cazuri absena mucoasei de
aspect normal.
n Clinica de Chirurgie a Spitalului Clinic de Urgen Sf. Ioan s-au efectuat n ultimul an dou colectomii totale pentru aceast afeciune, ambele fiind rezolvate
pe cale laparoscopic.
Evoluia pacienilor a fost favorabil, far complicaii.
Abordul laparoscopic pentru colectomia total este fezabil i are avantajul recuperrii extrem de rapide a pacienilor, laparotomia xifopubian fiind nlocuit de 5
incizii, de maxim 1 cm.

Multiple familial polyposis is a rare but growing disease. It has an autosomal dominant transmission and is characterized by the appearance of early hundreds or
even thousands of adenomatous polyps disseminated throughout the colon and rectum. In the absence of treatment, colon cancer invariably develops. The
incidence worldwide is constant and varies from 1: 6000 to 1: 12,000 births, both sexes are involved equally.
Treatment is represented by total colectomy, polypectomy is impossible due to the number of polyps and in many cases the absence of normal mucosa.
Last year, in the Surgery Clinic of Sf. Ioan Emergency Hospital there were performed two total colectomies for this condition, both laparoscopically resolved.
Evolution was favorable in all patients, without complications.
Laparoscopic approach for total colectomy is feasible and has the advantage of extremely fast recovery of patients, xifopubiana laparotomy being replaced by 5
incisions of maximum 1 cm.

Suturi mecanice versus suturi manuale n patologia neoplazic colorectal


Mechanical Sutures Versus Manual Sutures in Colorectal Cancers
D. Ene (1), C. Turcule (1), T. F. Georgescu (1), E. Ciuc (1), A. Vldscu (1), M. Beuran (2)
(1) Spitalul Clinic de Urgen Floreasca, Clinica de Chirurgie I, Bucureti, Romnia
(2) Spitalul Clinic de Urgen Floreasca, Clinica de Chirurgie III, Bucureti, Romnia
Introducere: Aparitia stapler-lui n anii 80 a facut posibil restabilirea continuitii digestive n cazul neoplasmelor localizate la nivelul rectului mediu sau inferior,
i a fcut posibil scurtarea duratelor interveniilor chirurgicale practicate n cazul neoplasmelor colorectale. Rata complicaiilor pentru aceast patologie a rmas
neschimbat, descriindu-se chiar noi complicatii datorate staplerelor.
Scop: Scopul acestei lucrri este de a analiza experiena clinicii noastre n patologia neoplazic colorectala i de a prezenta avantajele i dezavantajele celor
dou tipuri de suturi.
Materiale i metode: Am efectuat un studiu retrospectiv pe un lot de 120 de pacieni cu neoplasme colo-rectale internati n perioada ianuarie 2013 - iulie 2015 n
secia Chirurgie I a Spitalului Clinic de Urgen Bucureti, utiliznd pentru obinerea datelor sistemul informatic Hypocrate.
Rezultate: Din totalul de 120 de pacieni studiai, mai mult de jumtate (63 pacieni), s-au prezentat n stadii avansate (stadiul III sau IV din clasificarea TNM). n 87
de cazuri s-a tentat tratamentul chirurgical curativ, n 84% (73 pacieni) din acestea practicndu-se suturi manuale. Doar la 14 pacieni din cei la care s-a practicat
tratamentul chirurgical curativ s-au utilizat staplere pentru efectuarea suturilor mecanice.
Concluzii: Importana diagnosticului precoce a neoplasmului colorectal i tratamentul chirurgucal precoce pentru a incerca curabilitatea. Complicaii postoperaorii
i evoluii similare pentru cele dou tipuri de suturi.

Introduction: The development of the stapler in the 80s made the reestablishment of the digestive tube possible in cases of inferior or middle rectal cancers and
contributed in reducing the duration of surgical procedures performed in colorectal neoplasms. On the other hand, reports reveal new complications in patients
on which mechanic sutures were accomplished.
Aim: The goal of this study is to analyze the advantages and disadvantages of the two types of sutures on colorectal neoplasia based on our clinics experience.
Materials and Methods: We performed a retrospective study on a lot of 120 patients suffering of colorectal neoplasia hospitalized in between January 2013 and
July 2015 in the surgical ward I of the Clinical Emergency Hospital of Bucharest, obtaining data by accessing the informatics system Hypocrate.
Results: From the total of 120 patients studied, more than half (63 patients) were in an advanced stage (stage III or IV according to TNM classification). In 87 cases
curative surgical treatment was attempted, of which 84% (73 patients) by using manual sutures. To only 14 patients, of the ones with curative surgical treatment,
mechanical sutures using staplers were performed.
Conclusions: The importance of an early diagnosis and treatment of colorectal cancer in pursuing curability. Same postoperative complications and similar
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evolutions were registered in both types of sutures.

Evaluarea factorilor de prognostic n cancerul de colon


Prognostic Factors Evaluation in Colon Cancer
Ana-Maria Muin, Mihaela Mdlina Gavrilescu, I. Radu, I. Huanu, B. Filip, Maria Gabriela Aniei, Mihaela Buna-Arvinte, D. V. Scripcariu, A. Panu, V. Scripcariu
Universitatea de Medicin i Farmacie Gr. T. Popa, Clinica I Chirurgie Oncologic, Institutul Regional de Oncologie, Iai, Romnia
Obiective: n prezent, tratamentul chirurgical rezecional reprezint prima opiune terapeutic n cancerul de colon. Pn n prezent au fost identificai numeroi
factori prognostici, dar cu excepia stadializrii TNM, niciunul dintre acetia nu are suficient valoare prognostic astfel nct s fie introdus n practic. Material i
metod: Am efectuat un studiu retrospectiv bazat pe o baz de date colectat prospectiv, ce a inclus pacienii diagnosticai cu neoplasm de colon, operai n
perioada 2012-2014. Pacienii au fost stadializai conform ultimei stadializri TNM, fiind analizai o serie de factori prognostici: stadiul tumoral, stadiul T i N,
numrul de ganglioni totali i pozitivi, tipul histopatologic i gradul de difereniere tumoral, vrsta pacienilor i localizarea tumorii, statusul imunitar i nutriional
al pacientului. Rezultate: Au fost inclui n studiu 312 pacieni stadiile II-IV, cu tumori localizate de la nivelul cecului pn la nivelul jonciunii recto-sigmoidiene, cu
o predominan a localizrilor pe colonul drept. Numrul mediu de ganglioni a fost 24, cu un numr semnificativ mai mare pentru tumorile localizate pe partea
dreapt (p<0.05). Adenocarcinomul a fost tipul histopatologic predominant n lotul de studiu. Au fost identificai ca i factori de prognostic negativ: stadiul tumoral
avansat, numrul de ganglioni pozitivi crescut i numrul de ganglioni totali sczut (p<0.05). Concluzii: Pentru o corect stadializare este necesar un numr de
minim 12 gangioni totali identificai. Pn n prezent stadializarea TNM este singura capabil s prezic supravieuirea pacienilor. Un factor pentru a putea fi
considerat factor prognostic trebuie s aib suficient putere astfel nct s prezic evoluia pacienilor.

Aim: At present resectional surgical treatment represents first the therapeutic option in colon cancer. Until now many prognostic factors were identified, but
except TNM staging, none of them has enough power in order to be introduced in clinical practice. Methods: We are hereby presenting a retrospective study,
based on o prospective data base, that included patients diagnosed with colon cancer, and operated between 2012-2014. Patients were staged according to the
last TNM staging classification, a series of prognostic factors being analyzed: tumor stage, T and N stage, number of total and positive lymph nodes, pathological
type, tumor grade, age and localization, immune and nutritional status. Results: We included 312 patients, stages II-IV, with tumor that were localized from the
caecum to the colo-rectal joint, with a high frequency of tumor localized on the right side of the colon. Medium number of lymph nodes was 24 with a higher
number of tumors localized on the right side p<0.05). Adenocarcinoma was the predominant pathological type in the study group. Negative prognostic factors
were identified like: advanced tumor stage, higher number for positive lymph nodes and lower number for total lymph nodes (p<0.05). Conclusions: For a correct
staging of the patients, a minimum number of 12 lymph nodes are needed to be identified. Until now, only TNM staging could predict the patients survival rate. A
factor in order to be considered prognostic factor should be strong enough to predict clinical evolution of the patients.

Cecostomia - soluie chirurgical provizorie n neoplasmul colonic distal ocluziv


Cecostomy - Temporary Surgical Approach in Bowel Obstruction Caused by Distal Colon Cancer
Violeta Elena Radu, I. S. Coman, Oana Ilona David, V. A. Porojan, A. R. Stoian, V. T. Grigorean
Spitalul Clinic de Urgen Prof. Dr. Bagdasar-Arseni, Chirurgie General, Bucureti, Romnia
Obiective: Scopul principal a fost rezolvarea ocluziei intestinale printr-un abord minim, cu riscuri ct mai mici anestezico-chirurgicale.
Material i metod: Am realizat un studiu retrospectiv din 2011 pn n prezent, pe 28 de pacieni internai i operai n Clinica de Chirurgie General a Spitalului
Bagdasar-Arseni, venii n camera de gard cu stare general extrem de grav (vrstei naintate, tarelor cardiologice asociate, precum i neoplaziilor asociate),
n ocluzie intestinal, la care s-a adoptat ca prim soluie terapeutic cecostomia n urgen.
Rezultate: Din cei 28 de pacieni internai i operai n clinica noastr, vrsta medie a acestora a fost de 67,4 ani, cu predominan a pacienilor de sex feminin din
mediul urban. Pacienii au prezentat simptomele clasice ale ocluziei intestinale, asociind dezechilibre hidroelectrolitice severe, tulburri de coagulare, sindrom
anemic, fiind operai n regim de urgen, incomplet investigai. Durata medie de spitalizare a fost de 11,9 zile. Din cei 28 de pacieni internai, doar 12 dintre ei au
beneficiat ca investigaie suplimentar de computer tomograf, ce a evideniat fie o neoplazie n stadiul terminal ovar, stomac, baza de mezenter, sau o
formaiune tumoral stenozant complet la nivelul colonului distal. Din totalul pacienilor am nregistrat 11 decese n primele 48-72 de ore de la intervenia
chirurgical.
Concluzii: Descoperirea tardiv a ocluziei intestinale prin diferite mecanisme, asociat cu alte leziuni neoplazice terminale ne-au determinat la efectuarea
cecostomei ca soluie terapeutic salvatoare, cu minim agresivitate chirurgical i cu scopul scoaterii pacientului din ocluzia intestinal neglijat.

Objective: Our purpose was to solve the bowl obstruction by a simple approach, with a minimum risk involving both the anesthesia and the surgical procedure.
Means and methods: We carried out a retrospective study from 2011 until 2016. We found 28 patients admitted and operated on at the Bagdasar Arseni
Emergency Hospital, General Surgery Clinic. The patients were in extremely poor general condition (elderly with cardiologic comorbidities, suffering from cancer),
having symptoms of bowel obstruction. Due to the clinical state at presentation, cecostomy performed in urgency was chosen as the first therapeutic measure.
Results: We studied 28 patients admitted and operated on in our clinic. The mean age was 67.4 years. The majority of our patients were females from the urban
environment. Patients presented with classical symptoms of bowel obstruction associating severe hydro-electrolytic imbalance, coagulopathy and anemia. They
suffered surgical interventions in emergency, sometimes even if they were not completely investigated. The mean hospitalization period was 11.9 days. From the
total of 28 patients, only 12 were investigated using computed tomography that showed an end stage neoplasia ovarian, stomach, mesentery or distal colonic
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cancer causing complete stenosis. 11 patients died in the first 48-72 hours after the surgical procedure.
Conclusions: Late discovery of bowel obstruction caused by different mechanisms and the association with terminal neoplastic disease were the factors that
determined limiting the surgical procedure to cecostomy as a lifesaving solution, implying a minimum surgical invasiveness, having as primordial purpose helping
the patient to overcome the occlusive shock.

Neoplazie primar multipl cu localizare rar - prezentare de caz


Multiple Primary Neoplasia with a Rare Localization - Case Report
C. Velicescu, D. C. Opinc, A. Grigorovici, Alexandra Mrginean, C. Burcoveanu
Spitalul Clinic Judeean de Urgene Sf. Spiridon, Secia Clinica IV Chirurgie, Iai, Romnia
Introducere: Acest prezentare de caz aduce n discuie diagnosticul i tratamentul tumorilor sincrone cu localizri rare (rectal inferior i tiroidian). La pacienii cu
neoplazie cunoscut de cele mai multe ori echipa se concentreaz asupra bolii de baz, astfel nct coexistena accidental a unei alte leziuni maligne primare
poate fi ratat.
Materiale i metode: Un brbat n vrst de 64 ani se interneaz n secia clinic IV Chirurgie, Spitalul Sf. Spiridon cu rectoragii i tulburri de tranzit intestinal.
La examenul clinic se deceleaz prezena unei formaiuni tumorale la nivelul rectului inferior, ulcerat cu stigmat de sngerare. De asemenea, la examenul clinic
se pune n eviden o formaiune nodular de aproximativ 5 cm la nivelul lobului tiroidian drept cu multiple adenopatii laterocervicale drepte. Examenul IRM
abdomino-pelvin deceleaz o ngroare parietal circumferenial, neregulat, la nivelul peretelui rectal inferior, pe o lungime de 48 mm, cu limita inferioar la 33
mm de ma. Se practic biopsie de la nivelul formaiunii rectale cu stabilirea diagnosticului de adenocarcinom moderat difereniat ulcerat. Deoarece valorile
calcitoninei (>2000) i examenul endocrinologic opiniaz pentru un neoplasm tiroidian medular std IV, se intervine chirurgical practicndu-se tiroidectomie total
cu disecie radical a gtului pe partea dreapt (rezecie de vena jugular int i limfadenectomie extins sector II, III, IV i V drept). Evoluia postoperatorie este
favorabil cu normalizarea calcitoninei, la o sptmn postoperator pacientul ncepe tratamentul oncologic radio-chimioterapic specific leziunii rectale joase n
serviciul de radioterapie IRO Iai. La 8 sptmni de la radioterapie se intervine chirurgical i se practic excizie abdominoperineal de rect cu evoluie
postoperatorie favorabil. Examenul anatomopatologic al tumorii tiroidiene arat prezena unui n. tiroidian medular cu metastaz extins la nivelul ggl
laterocervicali avnd, de asemenea, pe lobul tiroidian contralateral prezena unui microcarcinom tiroidian papilar.
Concluzii: Neoplasmele sincrone reprezint o entitate patologic rar, fiind justificat utilizarea ntregului arsenal de explorri pentru stabilirea corect a
diagnosticului.

Introduction: This case report brings to discussion the diagnosis and the treatment of the synchronous tumors with rare locations (lower rectal and thyroid). In
patients with known malignancy, the surgical team often focuses on the primary disease and that makes the accidental coexistence of another primary malignant
lesion sometimes to be missed.
Materials and Methods: A 64-year-old male is hospitalized in the 4th Department of Surgery, St. Spiridon Hospital with rectal bleeding and intestinal
dysfunctions. The clinical examination shows an ulcerated and bleeding tumor located on the lower rectum. A 5 cm nodule located on the right thyroid lobe, with
multiple right laterocervical lymph nodes is also detected at the clinical examination. The abdominal-pelvic MRI scan shows an irregular, circumferential parietal
thickening located on the lower rectal wall (48 mm length), with the lower limit at 33 mm from the anal verge. A rectal biopsy from the tumor is done in order to
establish the diagnosis: moderately differentiated adenocarcinoma. The increased values of calcitonin (>2000) and the endocrinological exam point out to stage
IV medullary thyroid cancer. The next step is the surgical treatment which consists in a total thyroidectomy with node dissection (resection of the internal jugular
vein and extended lymphadenectomy on the IInd, IIIrd, IVth and Vth right side regions). The postoperative evolution is favorable, with the normalization of the
calcitonin levels. A week after the surgery, the patient begins the specific oncological treatment for lower rectal cancer (radiation and chemotherapy) at IRO Iasi.
At 8 weeks after radiotherapy we practiced abdominoperineal excision of the rectum with favorable postoperative evolution. The pathological exam of the thyroid
tumor shows not only the presence of a medullary thyroid cancer with an extended metastasis on the laterocervical lymph nodes, but also the presence of a
papillary thyroid microcarcinoma on the controlateral thyroid lobe.
Conclusion: The synchronous neoplasms represent a rare pathological entity which justifies the use of an entire arsenal of paraclinical exploration in order to
establish the correct diagnosis.

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Calitatea vieii pe termen mediu i lung dup rezeciile colorectale laparoscopic versus open + eras
Medium and Long Term Quality of Life after Colorectal Resections. Laparoscopy versus Open + ERAS
M. Bica, M. Lazr, D. Marinescu, N. D. Mrgritescu, V. Vlcea, Mihaela Olteanu, I. Georgescu, V. urlin
Universitatea de Medicin i Farmacie, Clinica I Chirurgie, Craiova, Romnia
Scop: Studiul influenei aplicrii protocolului ERAS asupra calitii vieii pe termen mediu i lung la pacienii supui chirurgiei colorectale.
Material i metod: Aplicarea ERAS n chirurgia colorectal n studii comparative laparoscopic vs. open a demonstrat diminuarea avantajelor chirurgiei
laparoscopice fa de chirurgia deschis n ceea ce privete evoluia postoperatorie a pacienilor. Ce se ntampl ns pe termen mediu i lung? Exist diferene
n calitatea vieii pacienilor determinate de abordul utilizat (lap vs. open) n condiiile aplicrii ERAS? Am utilizat un chestionar de calitate a vieii adresat
pacienilor supui chirurgiei colorectale pe cale laparoscopic i deschis n ultimii 5 ani. ERAS a fost aplicat la toi pacienii. Chestionarul a fost completat de
pacieni la minim 6 luni postoperator.
Rezultate: 142 de pacieni au completat chestionarul de calitate a vieii. Nu s-au nregistrat diferene semnificative statistic n calitatea vieii pacienilor ntre cele
dou loturi (laparoscopic vs deschis).
Concluzii: n condiiile aplicrii ERAS, calitatea vieii pe termen mediu i lung a pacienilor supui chirurgiei colorectale este similar indiferent de abordul utilizat
(laparoscopic sau deschis).

Aim: To study the influence of ERAS on medium and long term quality of life for patients undergoing colorectal surgery.
Material and method: Applying ERAS in colorectal surgery in laparoscopy vs. open comparative studies led to decreasing the advantages of laparoscopy
regarding patients postoperative early outcome. What happens with medium and long term outcome? Is there a difference in quality of life determined by
laparoscopic vs. open approach when using ERAS? We used a quality of life questionnaire for patients that underwent both laparoscopic and open colorectal
surgery in the past 5 years. ERAS was applied for all patients. The patients were interviewed at a minimum of 6 months after surgery.
Results: 142 patients were interviewed. No statistically significant differences were registered in the patients quality of life between the 2 groups (laparoscopic vs.
open).
Conclusion: When ERAS is applied, medium and long term quality of life for colorectal surgery patients is similar, regardless of laparoscopic or open approach.

Neoplasm sincron rectal i de colon ascendent


Synchronous Cancer of Rectum and Ascending Colon
D. Sabu, D. G. Bratu, Anca Dumitra, H. Noor Mohammady Far, A. D. Sabu, Vanina Marcu Iordnescu
Spitalul Clinic Judeean de Urgen, Chirurgie II, Sibiu, Romnia
Introducere: Cancerul de colon este cel mai frecvent cancer al tubului digestiv. Se afl pe al doilea loc la femei dup cancerul mamar i pe locul trei la brbai
dup cancerul pulmonar i cel de prostat. Tumorile epiteliale de tipul adenocarcinoamelor, carcinoamelor i carcinoidelor, reprezint 98% dintre tumorile
colonului. Sincronismul neoplazic la nivelul rectului i la nivelul colonului ascendent este o patologie rar ce impune msuri speciale de tratament.
Material i metode: Prezint cazul unei paciente n vrsta de 74 ani, cunoscut cu epilepsie, ulcer duodenal, anemie moderat, dislipidemie mixt i steatoz
hepatic, ce se interneaz pentru rectoragii, dureri abdominale difuze, scdere ponderal, tulburri ale tranzitului intestinal constipaia alternnd cu diareea i
astenie marcat. Endoscopia digestiv inferioar descrie tumora rectal la 8 cm de orificiul anal extern, polipi cecali i hemoragie digestiv inferioar. Examenul
CT abdomino-pelvin evideniaz mase tisulare la nivelul rectului i colonului ascendent cu adenopatii adiacente i retroperitoneale. Dup o prealabil pregtire
se intervine chirurgical n anestezie general cu intubaie oro-traheal practicndu-se laparotomie exploratorie, hemicolectomie dreapt cu
ileo-transversoanastomoz latero-lateral, rezecie recto-sigmoidian joas tip Hartmann, anexectomie bilateral (ovare polichistice), tumorectomie uterin
(fibrom uterin).
Rezultate: Evoluia pacientei a fost favorabil cu reluarea tranzitului intestinal pe colostom la 2 zile postoperator. Tuburile de dren s-au suprimat la 4 zile
postoperator.
Concluzii: Avnd n vedere complexitatea cazului prin prezena sincron a cancerului att la nivelul rectului ct i la nivelul colonului ascendent, a fost necesar o
intervenie chirurgical laborioas cu atac asupra colonului, rectului, anexelor i uterului. Aceast procedur permite reintegrarea ulterioar a anusului.

Introduction: Colon cancer is the most common cancer of the digestive tract. It is ranked second in women after breast cancer and third in men after lung cancer
and prostate cancer. Epithelial tumors like Adenocarcinoma, carcinoma and characinoid represent 98% of colon tumors.
Synchronous neoplasia of rectum and ascending colon is a rare pathology that requires special treatment measures.
Material and methods: We present the case of a patient aged 74, known with epilepsy, duodenal ulcer, moderate anemia, mixed dyslipidaemia and hepatic
steatosis, who is hospitalized for rectal bleeding, diffuse abdominal pain, weight loss, bowel disorders - constipation alternating with diarrhea and marked
asthenia. Lower gastro-intestinal endoscopy describes a rectal tumor 8 cm above the anus, cecal polyp and lower gastrointestinal bleeding. Abdominal and pelvic
CT highlights tissue masses in the rectum and ascending colon with adjacent and retroperitoneal lymphadenopathy. After a good preparation of the patient we
performed exploratory laparotomy, right hemicolectomy with ileo-transversoanastomosis, recto-sigmoid resection Hartmann type, bilateral anexectomy,
tumorectomy of uterus (uterine fibroma).
Results: Postoperative, the evolution of the patient was favorable by resumption of bowel in colostoma in 2 days. Drainage tubes were suppressed in 4 days
postoperatively.
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Conclusions: Given the complexity of the case by the presence of both synchronous cancer of the rectum and ascending colon, a laborious surgery on right colon,
rectum, uterus and annexes was necessary. This procedure allows subsequent reintegration of the anus.

Factorii de risc din dehiscienele anastomotice n chirurgia cancerelor colorectale


Risk Factors for Anastomotic Leakage in Colorectal Cancer Surgery
L. Kiss, R. Kiss, S. Eremev, G. Balteanu, Bianca Olaru, L. Popescu
Spitalul Clinic Judeean de Urgen, Chirurgie I, Sibiu, Romnia
Introducere: Dehisciena anastomozei n chirurgia colo-rectal rmne o provocare major, datorit consecinelor precoce i tardive.
Scop: Acest studiu multicentric are ca obiectiv determinarea factorilor de risc pentru dehiscienele anastomotice manifeste clinic aprute dup interveniile
elective efectuate pentru cancerele colo-rectale.
Material i metod: Am efectuat un studiu prospectiv al rezeciilor colorectale elective practicate n intervalul octombrie 2000 i octombrie 2014. Au fost
examinate prin analiz simpl sau multipl 18 aspecte clinic independente. Fistula anastomotic clinic manifestat a fost elementul cel mai important. Toi
pacienii au fost urmrii 30 de zile postoperator, fiind analizat morbiditatea postoperatorie la pacienii cu cancer colorectal.
Rezultate: n studiu au fost cuprini 392 de pacieni cu intervenii elective efectuate pentru cancer colorectal i care au avut documentaia medical eligibil
pentru studiu. Analiza unic i multipl a artat c administrarea preoperatorie de steroizi, contaminarea plgii, durata mare a interveniei au fost factori predictivi,
independeni pentru dehisciena anastomotic manifestat clinic. Aceasta din urma a fost identificat la 22 (5,6%) din pacieni. S-a decelat o diferen statistic
semnificativ n incidena dehiscienei dintre bolnavii cu sau fr stoma de protecie. Astfel, toi pacienii (patru) care au necesitat reintervenie pentru dehiscien
au fost fr stoma de protecie.
Concluzii: Chirurgul trebuie s fie constient de categoriile de pacieni cu risc mare (consumul de steroizi, contaminarea cmpului operator, durata lung a
interveniei) ceea ce poate s-l ajute la decizia crerii stomei de protecie. n situaia n care exist o asociere ntre o slab pregtire colic, rezecie paliativ i
anastomoz rectal joas, trebuie luat n considerare stoma de protecie.

Background: Anastomotic leakage in colorectal surgery remains a major challenge of its early and late consequences.
Aim: The aim of this study was to determine the incidence and risk factors for clinical anastomotic leakage after elective surgery for colorectal cancer.
Methods: We conducted prospective surveillance of elective colorectal sections performed from October 2000 to October 2014. Eighteen independent clinical
variables were examined by univariate and multivariate analyses. The element of interest was the clinical anastomotic leakage. All patients were followed for at
least 30 days postoperatively. Postoperative morbidity was analyzed in patients with colorectal cancer.
Results: A total of 392 patients undergoing elective operations for colorectal cancer were admitted to the program. Univariate and multivariate analyses showed
that preoperative steroid as wound contamination and longer duration of operation were independently predictive of clinical anastomotic leakage. Clinical
anastomotic leakage was identified in 22 (5,6%) patients. Although there were statistical differences in leakage rates between patients with and without covering
stoma, all patients (four) requiring reoperation for leakage were without covering stoma.
Conclusions: Surgeons should be aware of high risk patients (steroid use, contamination of the operative field, longer duration of operation) which would help
them to decide whether to create a diversion stoma or not. When poor colic cleanliness is associated with palliative resection and low distal rectal anastomosis, a
protective stoma should be considered.

Dificulti diagnostice n tumorile apendiculare - prezentare de caz


Diagnostic Challenges in Appendicular Tumors - Case Report
D. C. Opinc (1), A. Popovici (1), Alexandra Mrginean (1), Alina Solonanu (1), Cristian Velicescu (1), Delia Ciobanu (2), C. Burcoveanu (1), C. Dogaru (1)
(1) Spitalul Clinic Judeean de Urgene Sf. Spiridon, Clinica IV Chirurgie, Iai, Romnia
(2) Spitalul Clinic Judeean de Urgene Sf. Spiridon, Serviciul de Anatomie Patologic, Iai, Romnia
Introducere: Tumorile neuroendocrine digestive reprezint un procent redus din tumorile tubului digestiv. Carcinoidul apendicular reprezint o descoperire de
multe ori fortuit, n urma unei apendicectomii efectuat n urgen.
Material i metod: Pacient de 26 ani internat n urgen, n Clinica IV Chirurgie Spitalul "Sf. Spiridon" Iai pentru dureri n fosa iliac dreapt. Examenul clinic i
imagistic (ecografie abdominal) susin diagnosticul de apendicit acut pentru care se practic apendicectomie clasic i epiploonectomie parial. Examenul
anatomopatologic completat cu cel imunohistochimic susin diagnosticul de carcinoid apendicular pT4Nx-G1 LV0pN0. Pentru completarea profilului oncologic se
extinde explorarea imagistic (CT) i se efectueaz dozarea markerilor imunologici, n vederea stabilirii atitudinii terapeutice ulterioare. Se completeaz
intervenia iniial cu o hemicolectomie dreapt (conform protocolului de tratament al carcinoidului apendicular), cu evoluie postoperatorie favorabil.
Negativarea markerilor imunologici nu impune tratament chimioterapeutic adjuvant.
Concluzii: n ciuda frecvenei sczute a tumorilor neuroendocrine apendiculare, acestea sunt frecvent diagnosticate pe baza examenului anatomopatologic.
Diagnosticul impune o sanciune chirurgical n limite oncologice, ct mai precoce, pentru a preveni evoluia loco-regional i la distan, urmat de
dispensarizarea oncologic conform ghidurilor actuale.
Cuvinte cheie: carcinoid apendicular, apendicit acut, markeri tumorali

Introduction: Neuroendocrine tumors represent a small percentage of the digestive tract tumors. The appendicular carcinoid represents a finding most of the time
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fortunate after an appendicectomy achieved in emergency.
Materials and Method: A 26-year-old patient admitted in emergency in the 4th Surgery Department at the Sf. Spiridon Hospital Iai for abdominal pain in the
right iliac fossa. The clinical and imagistic examinations (abdominal echography) sustain the diagnosis of acute appendicitis for witch classic appendicectomy and
partial epiplonectomy is performed. The anatomical pathology examination in addition to the immunohistochemical examination sustains the diagnosis of
appendicular carcinoid pT4Nx-G1 LV0pN0. To complete the oncologic profile, the imagistic exploration is added (Computer Tomography) and immunological
markers dosage in order to establish the following therapeutic attitude. The initial procedure is completed by a right hemicolectomy (according to the treatment
protocol of the appendicular carcinoid), with an encouraging postoperative evolution. The absence of the immunological markers does not justify the adjuvant
chemotherapeutic treatment.
Conclusion: Despite the low frequency of the appendicular neuroendocrine tumors, these are most frequently diagnosed based on the anatomical pathology
examination.
The diagnosis imposes a surgical intervention in oncological limits as early as possible to avoid the local, regional and overall dissemination followed by
oncological care according to the up-to-date guides.
Keywords: appendicular carcinoid, acute appendicitis, tumoral markers

Rezeciile multiorgan n cancerul colorectal local avansat


Multiorgan Resections in Locally Advanced Colorectal Cancer
Natalia Velenciuc, S. T. Makkai-Popa, C. Roat, V. Porumb, G. Dimofte, S. Lunc
Institutul Regional de Oncologie, Clinica II Chirurgie, Iai, Romnia
Obiectivul studiului: Datorit invaziei structurilor de vecintate cancerele colorectale local avansate ridic probleme din punct de vedere al tratamentului,
impunnd rezecii multiviscerale pentru a mbunti prognosticul pacienilor.
Material i metode: n cadrul studiului nostru am analizat un numr de 26 de pacieni selectai retrospectiv pe o perioad de 10 ani. n cazul fiecrui pacient au
fost efectuat rezecii multiorgan pentru cancer colorectal.
Rezultate: Topografia tumorilor a fost urmtoarea - 6 cancere de colon drept, 2 de colon transvers, 2 de unghi splenic, 11 de colon sigmoid i 5 cancere de rect. n
vederea obinerii unei rezecii R0, n afara rezeciei colice sau rectale au mai fost efectuate i ovarectomii (n=3), apendicectomii (n=1), cistectomii (n=5),
colpectomii pariale (n=2), splenectomii (n=2), pancreatomii (n=2), gastrectomii (n=3), rezecii duodenale (n=1), sigmoidectomii (n=3), enterectomii (n=8) i rezecii
de perete abdominal (n=7). La 50 % dintre pacieni a fost constatat prezena de noduli limfatici invadai i toi pacienii au urmat chimioterapie adjuvant.
Urmrirea postoperatorie medie a fost de 36 de luni cu un minim de 2 luni i un maxim de 120 de luni. Niciunul dintre pacieni nu a prezentat recidive locale i
durata medie de spitalizare nu a fost prelungit.
Concluzii: Rezeciile multiviscerale n cancerul colorectal local avansat pot mbunti prognosticul acestor pacieni.

Objective: Due to invasion into neighboring organs locally advanced colorectal cancer raises a major challenge in terms of treatment, multiorgan resections being
required in order to improve the long-term prognosis of such patients.
Material and methods: Our study analyzed a group of 26 patients retrospectively selected over a period of 10 years. Each of them suffered a multiorgan resection
for locally advanced colorectal cancers.
Results: The locations of the tumors were as follows - 6 right colon cancers, 2 transvers colon cancers, 2 splenic flexure cancers, 11 sigmoid colon cancers and 5
rectal cancers. In our study group, in order to achieve an R0 resection besides the colonic or rectal resection we also performed ovarectomies (n=3),
appendectomies (n=1), cystectomies (n=5), partial colpectomies (n=2), splenectomies (n=2), pancreatomies (n=2), gastrectomies (n=3), duodenal resections (n=1),
sigmoidectomies (n=3), enterectomies (n=8) and abdominal wall resections (n=7). Positive lymph nodes were present in 50% of the patients and all patients had
adjuvant chemotherapy. The mean follow-up was 36 months, with a minimum of 2 months and a maximum of 120 months. None of the patients presented local
recurrences and the mean length of hospital stay was not longer compared to other colorectal resections.
Conclusions: Multiorgan resections in locally advanced colorectal cancer can improve long-term prognosis.

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Factori de risc pentru fistulele anastomotice dup chirurgia colorectal


Risk Factors for Anastomotic Leakage in Colorectal Surgery
Eugenia Claudia Zrnescu, N. O. Zrnescu, R. V. Costea, . Neagu
Spitalul Universitar de Urgen, Chirurgie II, Bucureti, Romnia
Introducere: Fistula anastomotic dup chirurgia colorectal rmne una dintre cele mai de temut complicaii postoperatorii. Cunoaterea factorilor de risc
implicai n apariia fistulei anastomotice colorectale precum i depistarea precoce i corectarea acestora poate duce la prevenirea apariiei fistulei sau la
limitarea consecinelor acesteia. Material si metod: Studiul nostru cuprinde o analiz retrospectiv a 204 pacieni cu patologie colorectal la care s-a realizat o
rezecie cu anastomoz per primam. Pacienii au fost operai n Clinica Chirurgie II a Spitalului Universitar de Urgen Bucureti n perioada ianuarie 2010-iunie
2015. Rezultate: Lotul a cuprins 102 brbai (50%), vrsta medie a pacienilor fiind 65.28 + 11.28 ani. Fistula anastomotic a fost prezent la 29 pacieni (14.2%),
dintre acetia 65% prezentnd fistule de grad B i C. Nu au existat decese n randul pacienilor cu fistul postoperatorie. La analiza multivariat de regresie
logistic, factorii de risc independent asociai cu fistul anastomotic au fost: obezitatea (p=0.034), scorul ASA crescut (p=0.028), anastomoza colorectal
(p=0.005) i transfuziile de snge postoperator (p<0.001). Pacienii la care s-a realizat stoma de protecie nu au prezentat un risc mai mic de fistul anastomotic
fa de pacienii fr stoma de protecie. Diareea cu Clostridium difficile nu a crescut riscul de fistul. Concluzii: Factorii de risc independent asociai cu fistul
postoperatorie n lotul studiat au fost: obezitatea, scorul ASA crescut, anastomoza colorectal i transfuziile postoperatorii.

Background: Anastomotic leakage after colorectal surgery remains one of the most feared postoperative complications. Knowing the risk factors involved in the
occurrence of colorectal anastomotic dehiscence and early detection and correction can lead to prevention of anastomotic leak or to limit its consequences.
Material and method: Our study includes a retrospective analysis of 204 patients with colorectal pathology where anastomosis per primam was performed.
Patients were operated at the Second Department of Surgery of the Emergency University Hospital Bucharest between January 2010-June 2015.
Results: The study group included 102 men (50 %), average patient age being 65.28 + 11.28 years. Anastomotic leakage was present in 29 patients (14.2 %), 65%
of these presenting grades B and C of fistula. There were no deaths among patients with postoperative fistula. On multivariate analysis, risk factors
independently associated with anastomotic leakage were: obesity (p = 0.034), increased ASA score (p = 0.028), colorectal anastomosis (p = 0.005) and blood
transfusions after surgery (p < 0.001). Patients with protective stoma did not have a lower risk of anastomotic dehiscence than the patients without protective
stoma. Clostridium difficile diarrhea has not increased the risk of fistula.
Conclusions: Risk factors independently associated with anastomotic leakage in the study group were: obesity, increased ASA score, colorectal anastomosis and
postoperative transfusions.

Studiu comparativ ntre abordul laparoscopic versus abordul clasic al cancerului rectal privind fezabilitatea
oncologic
A Comparative Study of Laparoscopic Versus Open Approach for Rectal Cancer Regarding Oncological Feasibility
D. A. Brebu (1), C. Lazr (1), A. Dobrescu (1), Diana Al-Jobory (1), Alis Dema (2), Sorina Taban (2), C. Du (1), F. Lazr (1)
(1) Spitalul Clinic Judeean de Urgen Pius Brnzeu, Chirurgie II, Timioara, Romnia
(2) Spitalul Clinic Judeean de Urgen Pius Brnzeu, Anatomie Patologic, Timioara, Romnia
La nivel mondial, cancerul colorectal reprezint una dintre cele mai ntlnite neoplazii. Din motive de siguran oncologic, datele privind tratamentul chirurgical
laparoscopic al cancerului rectal sunt insuficiente. Principalul obiectiv al studiului nostru a fost s determinm caracterul adecvat, din punct de vedere oncologic,
al chirurgiei laparoscopice n tratarea cancerului rectal, comparnd fiabilitatea oncologic a acesteia cu rezultatele oncologice obinute dup tratamentul
chirurgical clasic al cancerului rectal. n cadrul acestui studiu retrospectiv au fost inclui 80 de pacieni operai de cancer rectal, internai n clinica noastr ntre 1
ianuarie 2014-31 noiembrie 2015. Grupul de studiu a fost mprit n funcie de abordarea aleas: chirurgie clasic (59 de cazuri), respectiv chirurgie laparoscopic
(21 de cazuri). Pe baza examinrii histopatologice am analizat gradul histologic al neoplasmelor rectale, stadializarea TNM, marginile de rezecie, invazia
limfovascular i perineural, precum i numrul de limfonoduli identificai n esutul adipos perirectal. Numrul mediu de limfonoduli izolai au demonstrat
diferene nesemnificative ntre cele dou tipuri de abordri: 20 de limfonoduli n abordarea clasic vs. 18 limfonoduli n abordarea laparoscopic (p=0,109).
Limfonodulii afectai de metastaze au fost asociai n majoritatea cazurilor cu cancere rectale de stadiul IIIB i stadiul IIIC (100%, respectiv 83,3%). Abordarea
laparoscopic s-a dovedit a fi eficient n ceea ce privete atingerea limitelor de rezecie onocologic. La specimenele de rezecie extrase prin chirurgie
laparoscopic, tumora rezidual (R1) a fost ntlnit n 5,0% din cazuri, versus 6,7% din cazurile cu abordare clasic. Abordarea laparoscopic este fezabil din
punct de vedere oncologic n tratamentul chirurgical al cancerului rectal.

Worldwide, colorectal cancer is one of the most prevalent malignancies. Due to oncological safety concerns, data regarding the laparoscopic surgical treatment
of rectal cancer is scarce. Our studys main aim was to investigate the oncologic adequacy of laparoscopic surgery in the treatment of rectal cancer by comparing
its oncological reliability with the oncological results obtained after open surgery for rectal cancer. Retrospective study, 80 patients who underwent surgery for
rectal cancer, admitted in our clinic between 1st of January 2014-31st of November 2015 were enrolled. The studied group was stratified according to the way of
approach chosen: classic surgery (59 cases) respectively laparoscopic surgery (21 cases). Based on the histopathological examination we analyzed the histologic
grading of rectal neoplasms, TNM staging, resection margins, lymphovascular and perineural invasion and the number of regional lymph nodes identified in the
perirectal adipose tissue. The average number of isolated lymph nodes demonstrated non-significant differences between the two types of approaches: 20
lymph nodes in the classical approach vs. 18 lymph nodes in the laparoscopic approach (p=0.109). Lymph nodes affected by metastases were associated in the
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majority of cases with stage IIIB and stage IIIC rectal cancers (100% respectively 83.3%). The laparoscopic approach proved to be efficient in terms of reaching
oncological resection limits. On the resection specimens extracted by laparoscopic surgery, the residual tumor (R1) was encountered in 5.0% of the cases versus
in 6.7% of the cases after classic surgery. The laparoscopic approach is oncologically feasible in the rectal cancer surgical treatment.

Tratamentul paliativ al pacienilor terminali cu cancer colorectal


Palliative Treatment of End Stage Colorectal Cancer Patients
Terezia Boruah
Spitalul Orenesc, Compartimentul Chirurgie, Cugir, Romnia
Noiunea de tratament paliativ al pacienilor oncologici a suferit importante schimbri n ultimele dou decenii. Dac iniial tratamentul paliativ se referea strict la
paliaia chirurgical a neoplaziei i la regimurile chimio-radioterapice cu scop paliativ, la ora actual tratamentul paliativ a devenit un concept mult mai elaborat,
centrat pe pacient i viznd mbuntirea calitii vieii. Cancerul colorectal este o patologie comun n Romnia, grevat de o morbiditate i mortalitate
considerabile. Fiecare al cincilea pacient diagnosticat cu cancer colorectal dezvolt boal metastatic ce nu beneficiaz de tratament curativ n peste 80% din
cazuri. Pacienii cu cancer colorectal aflai n afara resurselor terapeutice necesit paliaia simptomatologiei legat de evoluia bolii, precum i asisten
psihologic cu privire la acceptarea bolii i la evoluia inexorabil spre exitus. Prezentm analiza cazuisticii Spitalului Orenesc Cugir (iunie 2013-februarie 2016),
privind tratamentul paliativ a 37 pacieni cu cancer colorectal aflai n afara resurselor terapeutice. Schema terapeutic a inclus att paliaia simptomatologiei, ct
i componenta de consiliere psihologic a pacientului i a familiei. De asemenea, s-a efectuat analiza chestionarelor de satisfacie ale pacienilor i familiei.
Tratamentul paliativ al pacienilor cu cancer colorectal n stadii terminale nu nseamn doar tratament chirurgical i oncologic, ci presupune o abordare integrat
a problemelor fiecrui pacient, cu deosebit atenie la paliaia simptomatologiei clinice i la consilierea psihologic. Existena serviciilor organizate de ngrijire
paliativ a pacienilor oncologici terminali reprezint o necesitate a sistemului sanitar romnesc.
Cuvinte cheie: tratament paliativ, pacieni terminali, cancer colorectal

The term of palliative treatment of oncologic patients underwent major changes during the last two decades. If at the beginning palliative treatment referred only
to surgical palliation and palliative chemo-radio-therapy regimens, nowadays, palliative treatment became a more elaborated concept, more patient-oriented and
having as main purpose improving life quality. Colorectal cancer is a very common pathology in Romania, with considerable morbidity and mortality. Every fifth
patient with colorectal cancer presents metastatic disease, which is not curable with radical intend in roughly 80% of cases. Patients with end stage colorectal
cancer need palliation of cancer related symptoms and also psychological assistance regarding acceptance of the disease and its evolution towards death. We
present the analysis of 37 end stage colorectal cancer patients treated in Municipality Hospital of Cugir between June 2013 and February 2016. The therapeutic
program included palliation of disease related symptoms and also psychological counseling of the patient and family. We also analyzed the satisfaction
questionnaires of patient and family. Palliative treatment of end stage colorectal cancer patient does not mean only surgical and oncologic treatment and
consists of an integrated approach of each patient, with particular attention regarding palliation of disease related symptoms and psychological counselling.
Existence of organized palliative services for end stage oncologic patients represents a necessity of Romanian health system.
Key words: palliative treatment, end stage colorectal cancer patients

Morbiditate i mortalitate perioperatorie n cancerul de colon stng complicat


Perioperative Morbidity and Mortality in Left-Sided Complicated Colon Cancer
M. Beuran, I. Negoi, A. Runcanu, B. Stoica, I. Tnase, A. Cruceru, C. Ciubotaru, S. Pun
Spitalul Clinic de Urgen Floreasca, Chirurgie General, Bucureti, Romnia
Obiectivul acestui studiu este de a caracteriza morbiditatea i mortalitatea perioperatorie la pacienii cu cancer de colon stng complicat.
Metod: Studiu retrospectiv al pacienilor cu cancer de colon stng complicat, managerizai ntr-un centru de urgen teriar pe perioada a cinci ani (ianuarie
2011-ianuarie 2016).

The aim of the current study is to characterize the perioperative mortality and morbidity in patients with left-sided complicated colon cancer.
Method: Retrospective study of patients with complicated left-sided colon cancer, managed in e tertiary emergency center during five years (January
2011-January 2016).

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Influena administrrii perianastomotice i intraperitoneale de CSM asupra anastomozelor colonice din punct de
vedere al parametrilor histo-patologici
Stem Cells Transplantation Effect over Histo-Pathological Parameters of Colonic Healing
Alexandra Caziuc (1), G. C. Dindelegan (1), Emoke Pall (2), A. L. Nagy (3), I. A. Mironiuc (4)
(1) Spitalul Clinic Judeean de Urgen, Chirurgie I, Cluj-Napoca, Romnia
(2) Universitatea de tiine Agricole i Medicin Veterinar, Departamentul de Reproducere, Obstetric i Ginecologie Veterinar, Cluj-Napoca, Romnia
(3) Universitatea de tiine Agricole i Medicin Veterinar, Departamentul de Toxicologie Veterinar, Cluj-Napoca, Romnia
(4) Spitalul Clinic Judeean de Urgen, Chirurgie II, Cluj-Napoca, Romnia
Un parametru important al vindecrii anastomozelor colonice este aspectul histo-patologic. Efectele secundare administrrii perianastomotice sau
intraperitoneale de celule stem mezenchimale prezentate pn n prezent n literatur sunt contradictorii.
Obiectivul studiului a fost s stabilim dac exist diferene semnificative ntre lotul martor comparativ cu loturile la care s-au transplantat CSM (fie perianastomotic,
fie intraperitoneal) din punct de vedere al parametrilor histo-patologici prin urmrirea pacienilor timp de 7, 14, respectiv 30 zile postoperator.
Material i metod: n vederea atingerii obiectivului propus, am alctuit un model experimental pe obolani de tip Wistar, de sex masculin, cu vrsta de 10
sptmni. n ziua 7, 14, respectiv 30 postoperator subiecii au fost exclui din studiu prin sacrificare. Analiza lamelor a fost fcut de un singur cercettor acesta
realiznd o notare pe o scal de la 0 la 3 (0=absent, 1=sczut, 2=moderat, 3=crescut) a depozitelor de colagen, necrozei, epitelizrii i a inflamaiei.
Rezultate: Administrarea de CSM nu influeneaz calitatea epitelizrii i prezena necrozei la nivelul anastomozelor colonice. Att administrarea perianastomotic,
ct i cea intraperitoneal produc o scdere a reaciei inflamatorii la nivelul anastomozelor colonice la 7, 14, respectiv 30 zile postoperator. Administrarea
perianastomotic a CSM crete semnificativ numrul depozitelor de colagen de la nivelul anastomozelor colonice la 7, 14, respectiv 30 zile postoperator. Acest
efect, dei important pentru administrarea intraperitoneal, este inferior variantei de administrare perianastomotic.
Concluzii: Administrarea de CSM s-a dovedit a fi o metod sigur, fr a aduce complicaii suplimentare n vindecarea anastomozelor colonice.

Mesenchymal stem cells have recently been shown in vitro to facilitate digestive anastomoses healing due to plastic properties. Since the results remain
contradictory in vivo, we investigated whether perianastomotic and intraperitoneal administration influence the quality of colonic anastomoses healing from the
point of view of histopathological features.
To answer this question we used an experimental model of Wistar rats in which we performed a standard intervention with one layer colonic anastomoses. We
sacrificed 10 subjects from each group (control, perianastomotic and intraperitoneal) at 7, 14 and 30 days post-surgery. For each subject a researcher did a blind
macroscopic and microscopic analysis assessing on a scale from 0 to 3 the presence of necrosis, epithelization, inflammation and collagen deposits.
The results showed a significant decrease of inflammation after mesenchymal stem cells transplantation and increase of collagen deposits, with no significant
difference concerning epithelization and necrosis.
We concluded that mesenchymal stem cells transplantation proved to be a safe method in improving the healing process of colonic anastomoses. The effects
over inflammation and collagen deposits suggest that mesenchymal stem cells can increase the resistance of anastomoses, limiting the number of complications
such as leaks or stenosis.

Stadializarea neoplasmului rectal: acurateea rezonanei magnetice de nalt rezoluie i a ultrasonografiei


endorectale. Rezultate preliminare
Rectal Cancer Staging: The Accuracy of High Resolution Magnetic Resonance Imaging (HR-MRI) and Endorectal
Ultrasonography (ERUS). Preliminary Results
A. Coe (1), R. Elisei (2), E. I. Mois (1), F. Graur (1), A. Lebovici (3), N. Al Hajjar (1), F. Zaharie (1), M. Bodea (2), L. Mocan (1), C. Iancu (1)
(1) Universitatea de Medicin i Farmacie Iuliu Haieganu / Institutul Regional de Gastroenterologie i Hepatologie Prof. Dr. Octavian Fodor, Chirurgie
General, Cluj-Napoca, Romnia
(2) Institutul Regional de Gastroenterologie i Hepatologie Prof. Dr. Octavian Fodor, Chirurgie General, Cluj-Napoca, Romnia
(3) Universitatea de Medicin i Farmacie Iuliu Haieganu / Spitalul Clinic Judeean de Urgen, Radiologie, Cluj-Napoca, Romnia
Obiectivul studiului: Investigaiile imagistice au un rol vital n stadializarea cancerului rectal i n selectarea planului terapeutic optim. Imagistica prin Rezonan
Magnetic de nalt Rezoluie (HR-MRI) i Ultrasonografia Endorectal (ERUS) sunt cele mai utilizate metode pentru stadializarea cancerului rectal pre- i post
radio-chimioterapie neoadjuvant.
Material i metode: A fost efectuat un studiu prospectiv pentru a evalua acurateea HR-MRI i ERUS n stadializarea cancerului rectal n perioada
01.10.2013-01.01.2016. Au fost exclui din studiu pacienii care au efectuat investigaiile imagistice n alte servicii medicale i cei care au refuzat intervenia
chirurgical. S-a analizat stadiul T pre- i postradio-chimioterapie obinut prin HR-MRI i ERUS, i a fost comparat cu rezultatul anatomopatologic.
Rezultate: Folosind ERUS i HR-MRI, au fost stadializai un numr de 58 de pacieni cu diagnosticul de neoplasm rectal att pre- ct i post radio-chimioterapie
(RCT) neoadjuvant. 32 de pacieni au urmat tratament neoadjuvant iar acurateea ERUS i HR-MRI efectuate preoperator a fost de 40,7%, respectiv 67,8%.
Restul pacienilor au fost iniial stadializai n stadii T operabile i nu au facut RCT. n aceste cazuri, acurateea ERUS i HR-MRI a fost de 50%, respectiv 62,5%.
Concluzii: ERUS reprezint o metod de stadializare a cancerului rectal dependent de examinator. ERUS i HR-MRI folosite combinat pot mbunti acurateea
diagnostic a stadiul T i N. Fibroza indus prin RCT poate influena stadializarea corect a neoplasmului rectal. HR-MRI reprezint investigaia de ales pentru
stadializarea pre- i post radio-chimioterapie a neopasmului rectal.
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Objective: Imaging in rectal cancer has a vital role in staging disease, and in selecting and optimizing treatment planning. High-Resolution MRI (HR-MRI) and
Endorectal ultrasonography (ERUS) are the methods of choice for local staging of rectal cancer for both primary staging and for restaging after preoperative
radio-chemotherapy.
Material and method: A prospective study was performed to assess the accuracy of HR-MRI and ERUS in staging rectal cancer between 01.10.2013-01.01.2016.
Were excluded from the study patients who performed HR-MRI and ERUS in other clinics, and who refused surgery. We analyzed preoperative T stage obtained
by HR-MRI and ERUS and it was compared with the histopathology exam.
Results: A number of 58 patients with rectal cancer were staged using ERUS and HR-MRI pre- and post-radio-chemotherapy. 32 patients did radio-chemotherapy
(RCT) before surgery. The ERUS made after RCT was accurate in 40,7% of cases and HR-MRI in 67,8% of cases. The rest of the patients were initially diagnosed in
lower T stages and did not do RCT. In this cases the ERUS was accurate in 50% of cases and HR-MRI in 62,5%
Conclusion: ERUS is a method of staging rectal cancer human dependent. Associating ERUS with HR-MRI can bring improvement in diagnostic accuracy of T stage
(and N).
Fibrosis induced by RCT can influence the correct ERUS and MRI staging of rectal cancer.
High-resolution phased array external MRI is the investigation of choice for local issues in the primary staging of rectal cancer as well as for restaging after
radio-chemotherapy.

Markerii instabilitii microsatelitare: implicaii n abordarea multimodal a cancerului colorectal


Microsatellite Instability Markers: Implications for the Multimodal Approach of Colorectal Cancer
A. Tulin (1), Beatrice Linoiu Ursu (2), I. Slavu (1), V. Braga (1), A. Kraft (3), L. Alecu (2)
(1) Spitalul Clinic de Urgen Floreasca, Chirurgie General, Bucureti, Romnia
(2) Spitalul Clinic de Urgen Prof. Dr. Agrippa Ionescu, Chirurgie General, Bucureti, Romnia
(3) Spitalul Clinic Colea, Chirurgie General, Bucureti, Romnia
Cancerul ereditar non-polipozic a fost catalogat ca o form de cancer ce poate fi supus unor teste de diagnostic i tratament precoce. Testarea
imunohistochimic permite n prezent o evaluare mult mai sensibil a pacienilor cu risc crescut de apariie a cancerului colorectal.
Scop: Utilizarea criteriilor clinice BETHESDA pentru a identifica persoanele supuse la risc de a dezvolta cancer colorectal nonpolipozic i identificarea n cazul
acestora a markerilor instabilitii microsatelitare. Material i metod: A fost realizat un studiu prospectiv pe o perioad de doi ani ntre 01.01.2013-01.01.2015 n
cadrul Seciei Clinice de Chirurgie General a Spitalului Clinic de Urgen Prof. Dr. Agrippa Ionescu, Bucureti n care au fost analizai pacienii diagnosticai i
operai pentru cancer colorectal prin centralizarea rezultatelor histopatologice inclusiv imunohistochimie, a foilor de observaie i a protocoalelor operatorii.
Rezultate: Au fost identificai un numr de 120 pacieni iar n trei cazuri markeri imunohistochimici ai instabilitii microsatelitare au fost pozitivi. Rudele acestora
de gradul I au fost investigate suplimentar (colonoscopie) identificndu-se Sindromul Lynch la doi copii ai unuia dintre subieci.
Concluzii: Markerii de instabilitate microsatelitar ar putea fi folosii de rutin selectnd pacienii cu ajutorul criteriilor clinice BETHESDA n depistarea Sindromului
Lynch dar limitrile din punct de vedere financiar i al departamentelor de anatomopatologie ngrdesc aceste lucruri.

Hereditary non-polyposis cancer was classified as a form of cancer that can be subjected to diagnostic tests and early treatment. Genetic testing currently allows
a more sensitive assessment of patients with increased risk of developing colorectal cancer.
Purpose: To use the clinical criteria BETHESDA to identify persons that are at a high risk to developing non-polyposis colorectal cancer and the markers of
microsatellite instability in these patients.
Methods: A prospective study was conducted over a two-year period between 01.01.2013-01.01.2015 within the Department of General Surgery of the Clinical
Emergency Hospital Prof. Dr. Agrippa Ionescu, Bucharest. The patients included in the study were diagnosed and operated for colorectal cancer. The data
analyzed included: histopathological bulletins including immunohistochemistry, observational sheets and operative protocols.
Results: We identified a total of 120 patients, in three cases the immunohistochemistry markers were positive. First degree relatives of the patients were further
investigated (colonoscopy) for Lynch syndrome and the results were positive in two children of one of the subjects.
Conclusions: Microsatellite instability markers could be used routinely by applying the clinical BETHESDA criteria in detecting Lynch Syndrome but limitations in
terms of financial and competence in immunohistochemistry of the pathology departments limit these investigations.

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Tehnici moderne de radioterapie pentru tumorile de rect: dou prezentri de caz


Modern Radiotherapy for Rectal Cancer: Two Case Reports
Iuliana-Ramona Giurgiu, C. Barbu, G. Rcu, Cristina Duran, Ruxandra Mitulescu
Clinica de Oncologie i Radioterapie Amethyst, Radioterapie, Otopeni, Romnia
Introducere: Neoplasmul colo-rectal reprezint 10-15% din toate tipurile de cancer i este a doua cauz de deces prin cancer n rile din vest. Aproximativ
jumtate din pacieni dezvolt boal metastatic. Material i metode: Este prezentat planul de iradiere n cazul a doi pacieni diagnosticai cu tumor rectal,
tratai n Clinica Amethyst Bucureti. n unul din cazuri radioterapia a fost facut n scop preoperator, n cel de-al doilea caz a avut intenie definitiv. S-a utilizat
tehnica de radioterapie cu intensitate modulat, versiunea VMAT.
Rezultate: n ambele cazuri radioterapia a putut fi administrat n siguran pn la atingerea dozei optime, cu efecte adverse minime la nivelul organelor
sntoase din vecintate.
Concluzii: Experiena actual confirm progresele nregistrate n tratamentul cancerului rectal prin asocierea unor tehnici moderne de radioterapie asociat cu
chimioterapie preoperatorie, urmat de o chirurgie performant i chimioterapie adjuvant atunci cnd este necesar. Balana optim ntre eficacitate, siguran i
calitatea vieii rmne o provocare continu care evolueaz odat cu apariia noutilor n fiecare form de tratament.

Introduction: Colorectal cancer represents 10-15% of all cancers and it is the second cause of cancer death in western countries. About a half of patients will
develop metastatic disease.
Material and methods: We presented the radiotherapy technique for two patients with rectal tumor that were treated in Bucharest Amethyst Clinique. The first
case was treated with preoperative radiotherapy and the second with definitive intention. We used the VMAT radiotherapy technique.
Results: Both cases got an optimal dose of radiotherapy with minimal adverse effects on organs at risk. Conclusions: Present experience confirms better results in
rectal cancer treatment based on multimodal approach by association of preoperative modern chemoradiotherapy techniques with performing surgery and
adjuvant chemotherapy whenever is necessary. Optimal balance between efficacy, safety and quality of life remains a continuous challenge that evolves with
treatment development.

Dificulti tehnice ale mobilizrii flexurii splenice a colonului pe cale laparoscopic


Technical Challenges of Laparoscopic Splenic Flexure Mobilization
I. B. Diaconescu (1), M. R. Bratu (2), S. Vlcea (1), C. Tudor (1), M. Beuran (2)
(1) Spitalul Clinic de Urgen Floreasca, Clinica de Chirurgie General, Bucureti, Romnia
(2) Spitalul Clinic de Urgen Floreasca, Clinica Chirurgie III, Bucureti, Romnia
Abordul laparoscopic al tumorilor colonice este des folosit la scar mondial cu rezultate favorabile indiferent de poziionarea tumorii. Pentru rezeciile colonului
transvers sau stng, atunci cnd tensiunea n anastomoz trebuie s fie minim, mobilizarea unghiului splenic este obligatorie. Aceasta este dificil din punct de
vedere tehnic, n special la pacienii cu obezitate visceral crescut. Scopul acestei lucrri este prezentarea detaliat a anatomiei i tehnicii de mobilizare a
unghiului splenic pe cale laparoscopic. Reperele anatomice ale poziionarii trocarelor, abordul medial sau lateral al flexurii splenice i recomandri pentru
manipularea esuturilor sunt descrise n prezentarea video. De asemenea, vor fi prezentate i detalii ale anatomiei locale. Pe o perioad de 3 ani am efectuat 70
de rezecii colorectale pe cale laparoscopic, dintre care 37 au necesitat mobilizarea flexurii splenice. Cinci dintre acestea au fost rezecii de colon transvers, 20
de colon stng i 12 rezecii rectale. Au necesitat conversia ctre chirurgia clasic 4 cazuri dintre care unul singur din cauza unei efracii ale capsulei splenice n
timpul mobilizrii unghiului splenic. Din punct de vedere al incidentelor intraoperatorii au fost prezente: 3 sngerari splenice, 1 depolisare colonic, 3 leziuni
pancreatice dintre care niciuna nu a dezvoltat pancreatit acut postoperatorie. n concluzie, orice chirurg colorectal trebuie s fie familiarizat cu ligamentele
flexurii splenice a colonului, cu incidentele i accidentele intraoperatorii posibile i modalitile de reparare a acestora.

Laparoscopic approach of colic tumors is frequently used all over the world with good results whether it is a left or right colic tumor. For left or transverse colic
resections, when there should be no tension in anastomosis, splenic flexure mobilization is a must. This is the most challenging part of the operation, especially in
obese patients with high visceral fat. The aim of this paper is to present tips and tricks of laparoscopic splenic flexure mobilization. Anatomical landmarks of
trocar insertion, first approach of mobilization of the splenic flexure from transverse or from left colon, tips on tissue manipulation are described during the video
presentation. Also, anatomical details of splenic flexure will be showed in the video. In 3 years we performed 70 laparoscopic colorectal resections of which 37
needed splenic flexure mobilization. Five of these were transverse colon resections, 20 left colon resections and 12 rectal resections. We converted to open
surgery 4 of these patients but only 1 was during splenic flexure mobilization (splenic capsule effraction). As intraoperative incidents, from 37 splenic flexure
mobilizations we had 3 splenic bleedings, 1 colic lesion, 3 pancreatic lesions, none of which developed acute pancreatitis. In conclusion, every colorectal surgeon
must be familiarized with splenic flexure ligaments and intraoperative incidents that might appear.

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Impactul lavajului intraoperator cu citologie pozitiv asupra prognosticului dup chirurgia cancerului colorectal
(ccr)
Impact of Positive Intraabdominal Lavage Cytology on the Long-Term Prognosis of Colorectal Cancer Patients
L. Kiss (1), R. Kiss (1), S. Zaharia (2), Denisa Elena Milcioiu (1), Raluca Tantu (1)
(1) Spitalul Clinic Judeean de Urgen, Chirurgie I, Sibiu, Romnia
(2) Spitalul Clinic Judeean de Urgen, Anatomie Patologic, Sibiu, Romnia
Numeroase studii analizeaz semnificaia prezenei celulelor tumorale n lichidul peritoneal la pacienii cu cancer colorectal (CCR). Valoarea prognostic a
prezenei celulelor tumorale se bazeaz pe citologia convenional sau IHC. Scopul studiului de fa a fost evaluarea nsmnrii celulelor tumorale, cu ocazia
rezeciilor deschise din CCR i analiza corelaiei dintre citologia peritoneal intraoperatorie negativ i pozitiv asupra supravieuirii far boal. Material i
metod: ntre ianuarie 2004 i decembrie 2010 citologia intraoperatorie a fost evaluata la 145 de pacieni cu rezecii cu intenie curativ pentru CCR. Rezultate:
Celulele maligne n aspirat au fost raportate la 25 de pacieni. Coleraia dintre stadiul T i citologie a fost statistic semnificativ (x2 test=<0.001), fiind mai pozitiv
n T3-T4. Diferen mare n rezultatele pozitive s-a decelat ntre T3 i T4. n prezena citologiei pozitive, recidiva a fost de 56% n comparaie cu 23% la cei cu
citologie negativ. Impactul stadiului tumoral este statistic semnificativ numai n caz de citologie negativ. n studiul de fa, recidiva a fost semnificativ mai
comun n prezena celulelor tumorale libere n cavitatea peritoneal (16,7% fa de 6,3%). Concluzie: Influena stadiului T i N combinate cu citologia
intraoperatorie asupra recidivei canceroase i mortalitate este semnificativ. Rezultatele cercetrilor noastre, confirm faptul c, rezultatele citologiei peritoneale
convenionale reprezint un marker prognostic la pacienii cu rezecii cu intenie curativ pentru CCR. La pacienii cu stadiul T1+T3 i N0, citologia peritoneal
pozitiv indic necesitatea terapiei adjuvante.

Several studies analyze the significance of free intraperitoneal tumor cells in colorectal cancer (CRC). Their prognostic value is based on conventional cytology on
IHC. The aim of the present study was to study tumor cell seeding during open resection for CRC and to analyze the correlation between positive and negative
intraoperative peritoneal lavage cytology (IPLC) and disease-free survival. Methods: Between January 2004 and December 2010, IPLC was performed in 145
patients with curative CRC-resection. In the aspirates of 25 patients there were reported malignant cells. The correlation between T stage and cytology was
statistically significant (x2 test=<0.001) with more positive in T3, T4. The greatest difference in positive results is found between T3 and T4. In the presence of
positive cytology the recurrence was 56% in comparison with 23% in negative cytology. The impact of tumor stage is statistically significant only with N0 status. In
our study, nodal status is significantly more common in the presence of free tumor cells in the peritoneal cavity (16,7% compared to 6,3% in negative cytology).
Conclusions: The influence of T and N status combined with IOPL cytology on cancer recurrence and mortality is significant. The results from our research confirm
that conventional peritoneal cytology results comprise a prognostic marker in patients with curative CRC surgery. In the patients with T1-3 and N0 status, positive
cytology indicates the need for adjuvant therapy.

Ce se ntmpl cu fistulele anastomotice dup chirurgia colorectal n era reabilitrii ameliorate?


Anastomotic Leakage in the Era of Enhanced Recovery After Colorectal Surgery
A. Venara, J. Barbieux, P. A. Colas, M. F. Talbot, Emilie Lermite, A. Hamy
Centre Hospitalier Universitaire, Chirurgie Visceral, Angers, Frana
Scop: Reabilitarea ameliorat n chirurgia colorectal i-a demonstrat importana n termeni de cretere a calitii vieii i scderea duratei de spitalizare, dar
impactul asupra morbiditii rmne discutat. Scopul acestei prezentri a fost evaluarea influenei unui program de reabilitare ameliorat asupra ratei fistulelor
anastomotice i punerea n eviden a relaiei dintre nivelul proteinei C reactive n a patra zi post operatorie i apariia unei fistule anastomotice. Metod: O sut
aizeci i trei de pacieni operai consecutiv de chirurgie colo-rectal au fost iclui. Pacienii au fost ngrijiti conform unui program de reabilitare ameliorat.
Rezultate: Nivelul adeziunii globale la protocol a fost de 79% i rata fistulelor anastomotice de 8.1%. Adeziunea la protocol a fost corelat cu apariia unei fistule
anastomotice (p<0.007) i o adeziune de >75% la protocol a fost asociat cu o scdere a ratei fistulei anastomotice (p=0.006). n analiza multivariat, o adeziune
de >75%, a avut o tendin nesemnificativ din punct de vedere statistic, de diminuare a ratei fistulei (OR=0.23; p=0.08). n analiza univariat, nivelul mediu al
PCR a fost semnificativ diferit ntre grupurile cu sau fr fistul. Dup aplicarea unei regresii lineare, nivelul prag al PCR>102 a fost predictiv pentru apariia unei
fistule anastomotice. Un nivel de PCR<102 a fost un factor de risc de fistula n analiza multivariate (OR=23; p=0.003) Concluzie: O complian a protocolului de
<75% i un nivel al PCR-ului postoperator de >102 sunt factori de risc pentru apariia unei fistule anastomotice. Aceti 2 parametrii trebuie s fie controlai
naintea autorizrii iesirii pacientului din spital.

Introduction: Enhanced recovery after surgery has allowed a decrease in postoperative morbidity and length of hospital stay. However, anastomotic leakage
remains frequent (1-30%) and is associated with a non-rare lethality (16%). The aims of this work were (i) to assess the impact of an early rehabilitation protocol on
fistula rate and (ii) to assess the relation between C-reactive protein (CRP) levels on postoperative day 4 and the occurrence of fistula. Material and Methods: One
hundred-seventy-three consecutive patients undergoing colorectal surgery were included. Univariate and multivariate analyses explored the relation between
rehabilitation and fistula, while linear regression assessed the correlation between fistula and CRP levels. Results and Discussion: In univariate analysis, protocol
observance was correlated with the occurrence of fistula (p=0.007) and if observance was 75%, it was associated with a reduction of fistula rate (p=0.006). In
multivariate analysis, observance 75% had a tendency to be protective against fistula (p=0.08). In univariate analysis, the median CRP level was significantly
different between groups of patients with and without fistulas (p<0.001). Using linear regression, a cutoff of CRP >102mg/L was predictive of fistula occurrence
with a sensitivity of 92% and a specificity of 71%. A CRP level >102mg/L was a risk factor for fistula in multivariate analysis (OR=23; p=0.003). Enhanced recovery
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protocol decreases the rate of postoperative fistula. Observance of enhanced recovery protocol <75% and a postoperative day 4 CRP level >102 mg/L is a strong
indication of anastomotic leakage. Patients presenting this characteristic should be discharged carefully and a control imaging should be performed in case of
any doubts.

Relaia dintre pregtirea preoperatorie n patologia malign colorectal neobstructiv i infecia cu Clostridium
difficile
The Relationship Between Preoperative Preparation in Neobstructive Malignant Colorectal Pathology and
Clostridium difficile Infection
M. T. Angelescu (1), V. Calu (1), V. Florescu (2), A. Miron (1)
(1) Universitatea de Medicin i Farmacie Carol Davila / Spitalul Universitar de Urgen Elias, Chirurgie, Bucureti, Romnia
(2) Spitalul Universitar de Urgen Elias, Chirurgie, Bucureti, Romnia
Pregtirea prin administrarea de soluii de lavaj per os combinat cu antibioterapie n chirurgia colo-rectal electiv este n continuare un subiect intens discutat
cu multiple preri pro i contra.
Scopul studiului a fost reprezentat de legtura dintre pregtirea preoperatorie n patologia malign colo-rectal i apariia unor infecii cu Clostridium Difficile n
Clinica de Chirurgie a Spitalului Universitar de Urgen Elias.
Material i metod: S-a realizat un studiu retrospectiv n perioada 2012 - 2013 n care s-au analizat un numr de 360 de cazuri, dintre care 242 tumori de colon cu
diferite de localizri i 118 tumori rectale, care au beneficiat de intervenie chirurgical electiv.
Rezultate: Din totalul de cazuri, 28 de pacieni au prezentat infecie cu Clostridium Difficile. n 13 cazuri infecia a aprut n lipsa pregtirii, posibil datorit
medicaiei cu IPP. Pregtirea preoperatorie a fost efectuat n 15 cazuri cu administrarea de soluii de lavaj per os, dar i antibioterapie. Din cei 15 pacieni cu
Clostridium care au beneficiat de pregtire, 13 pacieni au fcut fistula, necesitnd o a doua intervenie, restul de 2 fiind tratai cu antibioterapie specific fr
complicaii chirurgicale. Alte 6 cazuri de fistul au fost nregistrate n lipsa infeciei cu Clostridium.
Concluzii:
1. Pregtirea preoperatorie poate duce la apariia de infecii cu Clostridium Difficile.
2. Antibioterapia pre i postoperatorie nu trebuie administrat excesiv, dect atunci cnd este imperios necesar.
3. Depistarea infeciei cu Clostridium Difficile la pacineii chirurgicali trebuie efectuat precoce, pentru a evita pe ct posibil apariia complicaiilor chirurgicale.

Preparation by administering orally lavage solutions combined with antibiotics in the colorectal elective surgery is still the subject of intensive discussion with
multiple pros and cons.
The purpose of the study was the relationship between preoperative preparation in malignant pathology of the colon and rectum and the emergence of
Clostridium Difficile infection in Surgery Clinic of Elias Emergency University Hospital.
Methods: We conducted a retrospective study between 2012-2013 in which were analyzed a total of 360 cases, of which 242 colon tumors with different
localizations and 118 rectal tumors that benefited from elective surgery.
Results: Of the total cases, 28 patients had infection with Clostridium difficile. In 13 cases the infection appeared to lack of preparation, possibly due to PPI
medication. Preoperative preparation was carried out in 15 patients with the administration of the lavage solutions per os, and antibiotics. Of the 15 patients with
Clostridium, 13 patients underwent fistula, requiring a second intervention, the remaining 2 being treated with specific antibiotics without surgical complications.
Another 6 cases of fistula were recorded in the absence of infection with Clostridium.
Conclusions:
1. Preoperative preparation can lead to infections with Clostridium difficile.
2. Antibiotics should not be used excessively for pre- and post-operatory period, only when absolutely necessary.
3. Detection of Clostridium difficile infection in surgical patients should be done early to avoid possible occurrence of surgical complications.

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Criterii de evaluare a riscului operator n chirurgia de urgen a cancerului colorectal


Surgical Risk Evaluation Criteria for Emergency Colorectal Cancer Surgery
A. Miron, M. T. Angelescu, V. Calu, C. Giulea, O. Enciu
Spitalul Universitar de Urgen Elias, Chirurgie, Bucureti, Romnia
Spre deosebire de interveniile elective, chirurgia de urgen a cancerului colorectal este asociat cu mortalitate i morbiditate seminifcativ mai mari. Obiectivul
studiului este de a evalua riscul chirurgical i calitatea rezeciei oncologice n cazurile de cancer colorectal operat n urgen.
Pentru realizarea obiectivului au fost studiate retrospectiv cazurile a 86 de pacieni operai n urgen n Clinica de Chirurgie a Spitalului Elias ntre ianuarie 2014
i septembrie 2015.
Vrsta medie a fost de 68,10 ani, cu limite ntre 39 i 88 de ani, cu raport F/B=37/49. Oprirea tranzitului intestinal a fost motivul prezentrii n 76% din cazuri,
tumorile fiind localizate n 87% din cazuri la nivelul colonului stng. 40,69% din cazuri au fost stadiul IV la prezentare. Comorbiditi cardiace au fost obsevate la
peste 71% din pacieni, iar 18% au avut criterii de sepsis la internare. Operaia Hartmann a fost cea mai frecvent intervenie (32% din cazuri) iar rezecii cu
anastomoz au fost realizate n 34% din cazuri. Au fost operai n urgen imediat 27,90% din cazuri. Marginile de rezecie axiale au fost invadate n 3 cazuri de
colon stng n timp ce marginile circumfereniale au fost invadate n 2 cazuri de colon drept. Riscul chirurgical a fost evaluat folosind scorul CR-Possum, care a
indicat mortalitate 23,55% cu limite ntre 3,28 i 71,52%. Morbiditatea observat a fost de 35% iar mortalitatea 19%.
Chirurgia de urgen a cancerului colorectal este fezabil iar riscul chirurgical poate fi evaluat fidel folosind scorul CR-Possum care poate avea valoare practic,
tiintific i medico-legal.

Unlike elective surgery, emergency colorectal cancer surgery carries higher mortality and morbidity. The aim of the study is to evaluate the surgical risk and the
quality of the oncologic resection in emergency colorectal cancer surgery.
The cases of 86 patients that underwent emergency surgery in the Surgical Clinic of Elias Hospital between January 2014 and September 2015 were
retrospectively studied.
The mean age was 68.10 years, with limits between 39 and 88, with a F/M ratio of 37/49. Obstipation was present in 76% of cases, 87% of tumors being located
at the level of the left colon. 40.69% of cases were stage IV at admission. Cardiac comorbidities were present in over 71% of patients while sepsis criteria were
present in 18% of cases at admission. The Hartmann procedure was the most frequent intervention (32% of cases) while resections with anastomoses were
realized in 34% of cases. Urgent interventions were realized in 27.90% of cases. Axial resection margins were positive in 3 cases of left colon cancer while the
circumferential margins were positive in 2 cases of right colon cancer. The surgical risk was evaluated using the CR-Possum score that indicated a mortality of
23.55% with limits between 3.28% and 71.52%. The observed morbidity was 35% and mortality 19%.
Emergency colorectal cancer surgery is feasible and the surgical risk may be evaluated with accuracy using the CR-Possum score that may have practical,
scientific and legal value.

Rezecia anterioar de rect pe cale laparoscopic - dificulti i provocri


Laparoscopic Anterior Resection - Difficulties and Challenges
R. C. Popescu, Cristina Dan, A. Doa, A. C. Ghioldi
Spitalul Clinic Sf. Apostol Andrei, Chirurgie General, Constana, Romnia
Obiectivul studiului: Chirurgia laparoscopic n cancerul rectal i-a dovedit rezultatele n ceea ce privete recuperarea postoperatorie mai rapid, complicaiile
mai reduse, avnd aceleai rezultate oncologice ca i chirurgia deschis.
Material i metode: Prezentm experiena personal pe ultimii doi ani n rezecia anterioar de rect pe cale laparoscopic n cancerul rectal, analiznd dificultile
tehnice intraoperatorii i eventualele complicaii. n mod uzual au fost folosite 5 porturi de acces, cu abord vascular primar, urmat de mobilizarea flexurii splenice
i rezecie total de mezorect. Anastomoza colo-rectal sau colo-anal termino-terminal a fost realizat utiliznd tehnica dublului staplaj. Ileostomia protectiv
s-a practicat de rutin pentru cancerele rectale cu localizare medie sau joas.
Rezultate: Hemoragiile intraoperatorii au fost controlate prin aplicare de clipuri la nivelul pediculilor vasculari sau realiznd hemostaz cu ajutorul plasma Argon
la nivelul pelvisului. Un caz de peritonit fecaloid prin fistul anastomotic a fost rezolvat laparoscopic cu prezervarea anastomozei primare.
Concluzii: Rezecia anterioar de rect pe cale laparoscopic este o provocare pentru chirurg, mai ales n condiiile coborrii nivelului de anastomoz i creterii
cererii pentru prezervarea sfincterului anal.

Objective: Laparoscopic surgery for rectal cancer is proven to result in faster recovery, fewer complications with equal oncologic result.
Material and methods: We present our personal experience in the last two years regarding laparoscopic anterior resection, analyzing technical intraoperative
difficulties and postoperative complications. It was used a 5-port technique with vascular approach first, followed by mobilization of splenic flexure and TME. A
colorectal or coloanal anastomosis was performed using a double stapling technique and end-to-end anastomosis. Protective loop ileostomy was routinely
performed for middle and low rectal tumors.
Results: Intraoperative hemorrhage was controlled by titan clips on vascular branches or plasma Argon into pelvic floor. A case of peritonitis due to anastomotic
leakage was managed laparoscopically preserving the primary anastomosis.
Conclusion: Laparoscopic anterior resection for rectal cancer is challenging for surgeons with the lowering level of anastomosis and increasing demands for anal
sphincter preservation.
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Amputaia de rect prin abord laparoscopic (prezentare video)
Rectum Amputation Through Laparoscopic Approach (Video Presentation)
S. Olariu (1), N. Pop (2), Andreea Tache (2), A. Parau (2), B. Magiar (2), Sonia Olariu (1)
(1) Universitatea de Medicin i Farmacie Victor Babe, Clinica Chirurgie I, Timioara, Romnia
(2) Spitalul Clinic Judeean de Urgen Pius Brinzeu, Clinica Chirurgie I, Timioara, Romnia
Scopul studiului: Demonstrarea eficienei abordului laparoscopic i al rezultatului postoperator pe termen scurt n tratamentul cancerului de rect.
Material i metod: Au fost luai n eviden 10 pacieni cu adenocarcinoame rectale stadiul I, II i III, situate pe segmentul inferior care au necesitat amputaie de
rect prin abord laparoscopic, n perioada 2015-2016. Accesul n abdomen a fost cel convenional, cu 5 trocare. S-a scheletizat segmentul rectosigmoidian, cu
aplicarea de clipuri pe artera mezenteric inferioar la origine, disecia cu Sonicision retro i lateorectal, pn sub arterele rectale medii, urmat de seciunea
proximal a segmentului cu sutur mecanic iDrive. Specimenul a fost extras pe cale perineal, iar printr-o incizie minim s-a exteriorizat colostoma
(prezentare video).
Rezultate, discuii: Nu am avut complicaii intra i postoperatorii, durata medie de spitalizare a fost 52 zile. Acest tip de abord reduce agresiunea actului
chirurgical asupra bolnavului, dar cu respectarea principiilor de radicalitate oncologic, dar cu o recuperare mai rapid i un confort postoperator superior.
Concluzii: 1. Amputaia rectal prin abord laparoscopic este superioar celei prin abord clasic abdominoperineal. 2. Durata de spitalizare este redus i
recuperarea postoperatorie rapid. 3. Pierderile sanguine sunt semnificativ mai mici comparativ cu abordul conventional, iar confortul postoperator superior. 4.
Am utilizat aceast tehnic pentru tumorile rectale jos situate i stadii incipiente. Cuvinte cheie: adenocarcinom rectal, amputaie de rect, chirurgie laparoscopic.

Aims: To demonstrate the efficiency of laparoscopic approach and the short term postoperative results in the treatment of rectal cancer.
Materials and Methods: There were 10 patients taken in to observation, suffering from rectal adenocarcinoma stages I, II and III, situated on the inferior segment,
that needed rectum amputation in the 2015-2016 period. Access in the abdomen was done conventionally using 5 trocars. The sigmoid segment was dissected
with application of clips on the inferior mesenteric artery at its origin, the rectum was dissected below the middle rectal arteries using Sonicision followed by the
sectioning of the proximal segment using iDrive. The specimen was extracted through the perineal wound and the colostomy was done through a small incision
(video presentation).
Results, Discussion: We had no intraoperative or postoperative complications, mean hospitalization time was 52 days. This type of approach reduces the
aggression of the surgical act on the patient, keeping oncological principles, with a faster recovery and a superior postoperative comfort.
Conclusion: 1. Amputation of the rectum through laparoscopic approach is superior to the classical abdomino-perineal approach. 2. Hospitalization time is
reduced and the postoperative recovery is swift. 3. Blood loss is significantly lower compared to the open surgery approach and there is a superior postoperative
comfort. 4. We used this technique for low situated rectal tumors in early stages. Key words: rectal adenocarcinoma, amputation of the rectum, laparoscopic
surgery.

Apendicita acut asociat neoplasmului de cec


Acute Appendicitis Associated with Cecum Neoplasm
T. C. Constantinescu (1), M. Toma (1), D. Olariu (1), R. Martoiu (1), Lorena Keil (2)
(1) Spitalul Judeean de Urgen, Secia de Chirurgie General, Piteti, Romnia
(2) Spitalul Clinic de Urgen Prof. Dr. Bagdasar-Arseni, Clinica de Chirurgie General, Bucureti, Romnia
Apendicita acut poate reprezenta, destul de rar, prima manifestare clinic a unui cancer de cec sau colon ascendent. Neoplasmul de cec poate determina
obstrucia lumenului apendicular i ulterior apendicita acut n special la pacienii vrstnici. Sunt 3 modaliti care pot declana apariia apendicitei acute: 1.
tumora n imediata vecinatate a apendicelui; 2. modificrile inflamatorii determinate de cancerul de cec; 3. hiperpresiunea secundar obstruciei din zona
cecoascendent. Coexistenta cancerului de colon cu apendicita acut trebuie suspectat la pacienii vrstnici, care prezint scdere ponderal, dureri n flancul
i fosa iliac dreapt, anemie, tumor palpabil la examenul obiectiv. De aceea, la acesti pacieni o tomografie computerizat preoperatorie poate stabili
diagnosticul. Intervenia chirurgical recomandat la pacienii care prezint un astfel de diagnostic este hemicolectomia dreapt cu ileo-transversoanastomoz.

Acute appendicitis can be quite rare first clinical manifestation of a cecum cancer or right colon cancer. Cecum neoplasia can cause appendix lumen obstruction
and subsequent acute appendicitis especially in elderly patients. There are 3 ways that might trigger acute appendicitis: 1. tumor near the appendix; 2.
inflammatory changes caused by Cecum cancer; 3. high pressure in colon caused by obstruction. Coexistence of colon cancer and acute appendicitis should be
suspected in elderly patients, who experienced weight loss, abdominal pain, anemia, palpable tumor. Therefore, in these patients a preoperative CT can
establish the diagnosis. Surgery recommended in patients who have this diagnosis is right hemicolectomy with anastomoses between ileum and transverse colon.

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Respitalizarea non-programat dup chirurgia oncologic colorectal - studiu retrospectiv, monocentric, al


factorilor de risc (2005 - 2014)
Unplanned Readmission After Colorectal Cancer Surgery - Monocentric Retrospective Analysis of the Risk Factors
M. Anastasiu, R. Dedu, Rdia Popescu, N. Micu, D. Vicol
Spitalul Judeean de Urgen, Secia de Chirurgie General, Buzu, Romnia
Respitalizarea non-programat dup chirurgia colorectal are implicaii financiare majore i constituie o variabil obiectiv ce reflect complicaiile secundare sau
tardive ale interveniei iniiale, evolutivitatea lezional sau acutizarea unei patologii asociate. Material i metode: Studiul analizeaz incidena, cauzele i factorii
de risc ai respitalizrii non-programate pe un eantion de 622 cancere colorectale operate ntr-un interval de 10 ani. Analiza uni- i multivariat a factorilor de risc
s-a efectuat, din considerente de efectiv, doar la pacienii aflai la prima reinternare post-operatorie. Intervalul de timp luat n calcul a fost 3 luni de la externarea
iniial. Rezultate: Au fost exclui 102 pacieni (16,4%) reinternai programat pentru desfiinarea stomei digestive sau chirurgie hepatic pentru metastaze
sincrone. Patruzeci i doi de pacieni (8%) au fost reinternai o singur dat (RS1), 16 (3%) de 2 ori i 12 (2,3%) de 3 ori. Respitalizrile RS1 au survenit la un interval
mediu de 35 zile. Au fost reoperai 26 pacieni (37,1% din cei reinternai i 5% din total eantion analizat): 3 cazuri cu eventraie strangulat, 1 caz cu strangulare
intern, 13 cazuri cu sepsis peritoneal, 2 adeziolize pentru procese adereniale ocluzive, un cancer sincron distal ignorat, 4 hemoragii digestive i 2 reintervenii
pentru patologie ostial. Durata medie a sejurului spitalicesc la RS1 a fost 18 zile i au fost consemnate 5 decese. Cinci factori de risc ai respitalizrii
non-planificate au fost obiectivai n analiza multivariat: vrsta >70 ani, Hb <12g%, durata spitalizrii index >20 zile, contaminarea septic per-operatorie i
prezena gesturilor operatorii asociate. Scorul ASA, sexul, BMI, diabetul i patologia cardiac nu constituie, n analiza multivariat, factori de risc ai respitalizrii.
n concluzie, analiznd mai muli factori ai reinternrii non-planificate, studiul propune spre validare respitalizarea ca un indicator al calitii gestului terapeutic.

The readmission after the surgery for colorectal cancer, beyond the financial implications, represents an indicator reflecting secondary complications or the
development of initial pathology. Materials and Methods: The study analyses the incidence, the causes and the risk factors of the unplanned readmissions on a
sample of 622 colorectal cancers operated in our service the last 10 years. The statistical design and multivariate analysis are reported only for the patients who
were on the first readmission in the 3 months following the initial surgery. Results: One hundred and two patients (16.4%) were excluded from the series because
they were readmitted for the suppression of colostomy or for a planned liver resection secondary to colorectal metastasis. Forty-two patients (8%) were
readmitted once (RH1), 16 (3%) twice and 12 (2.3%) three times. Readmissions RH1 were done within 35 days after the initial operation. Twenty-six patients (37.1%)
of group RH1 were re-operated: for a strangled incisional hernia (3 cases), one case internal strangled hernia, in 13 cases for intra-abdominal sepsis, one ignored
synchronous cancer, 4 upper gastrointestinal bleedings, small bowel obstructions caused by adhesions (2 cases) and in 2 cases for stenosis or retraction of the
colostomy. For the readmitted patients, the average length of the hospital stay was 18 days and 5 deaths were taken into account. Five factors of risk of the
unplanned readmission (RH1) appeared in univariate analysis: the age higher as 70 years, hemoglobin <12g, per-operative septic contamination, the presence of
the associated manoeuvres and the initial hospital stay >20 days. In our study, the score ASA, the diabetes, the BMI and the cardiorespiratory antecedents were
not preoperative predictive factors of RH1. In conclusion, by analyzing several predictive factors of the unplanned readmission, the study proposes to validate the
readmission like an indicator of the quality of care in colorectal cancer surgery.

Analiza factorilor prognostici ai recidivei n cancerul colorectal operat


Assessment of Prognostic Factors for Colorectal Cancer Recurrence after Surgery
B. V. Micu (1), Carmen Maria Micu (2), V. Dudric (1), T. R. Pop (1), N. Constanea (1)
(1) Universitatea de Medicin i Farmacie Iuliu Haieganu, Clinica Chirurgie V, Spitalul Clinic Municipal, Cluj-Napoca, Romnia
(2) Universitatea de Medicin i Farmacie Iuliu Haieganu, Departamentul de Anatomie i Embriologie, Clinica Chirurgie V, Cluj-Napoca, Romnia
Obiectivele studiului: S evalum i s analizm factorii prognostici implicai n recidiva local i la distan la pacienii cu cancer colorectal operat cu viz curativ.
Material i metod: Am efectuat un studiu retrospectiv observaional care a inclus un numr de 301 pacieni diagnosticai cu cancer colorectal stadiul I-III,
internai i operai cu viz radical n Clinica Chirurgie V a Spitalului Clinic Municipal Cluj-Napoca. A fost creat o baz de date, care a inclus date demografice,
date clinice i anamnestice, examene de laborator, examene paraclinice, examenul morfo patologic. S-a calculat indicele Petersen, criterii Klintrup i limph node
ratio (LNR).
Rezultate: 112 (37,2%) pacieni au dezvoltat recidive pe o perioad de urmrire de 5 ani i 189 (62,8%) pacieni care nu au dezvoltat recidive. Pacienii cu cancer
stadiul IIIC au dezvoltat mai frecvent recidive dect cei n stadiul I (HR - 9.75; 95% CI 1.23-77.35; p=0.03). Pacienii cu scor Kintrup >1 au avut un prognostic mai
bun dect cei cu Klintrup 1 (HR-0.10; 95%CI=0.04-0.25). Pacienii cu scor Petersen >1 au avut un prognostic infaust fa de cei fr invazie venoas (HR-1,92;
95% CI=1.17-3.61; p=0,01). Pacienii cu scor de necroz 2 au avut un prognostic mai sever dect cei cu scor 0 (HR-2,84; 95% CI=1.31-6.16; p=0,008). Pacienii cu
scor desmoplzic 3 au avut rate de recidiv mai mici dect cei cu scorul de 1 (HR-0,43, 95% CI=0.22-0.95; p=0,01).
Concluzie: Recidivele au fost mai frecvente la pacienii cu tumori colorectale aflai n stadiile IIIB sau IIIC. Scorurile Klintrup i Petersen reprezint factori
prognostici independenti n apariia recidivelor. Scorul desmoplazic poate fi folosit ca factor prognostic independent i pozitiv n apariia recidivei la 5 ani la
pacienii cu cancer colorectal operat cu intenie curativ.

Aim: To assess and analyses the prognostic factors for recurrence in patients who had been previously subjected to curative surgery for colorectal cancer.
Material and Methods: 301 patients diagnosed with stage I-III colorectal cancer, admitted and undergoing radical surgery within the Fifth Surgical Clinic of
Cluj-Napoca Municipal Hospital were included in the study. A database was created, including demographic data, clinical and anamnestic data, laboratory exams,
paraclinical examinations, intraoperative findings, morphopathological examination, Petersen index, Klintrup criteria and lymph node ratio (LNR) were calculated.
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Results: There were 112 (37.2%) patients in the study experiencing cancer recurrence during the 5-year follow-up, and 189 (62.8%) patients who did not develop
recurrence. Patients with stage IIIC cancer were more likely to develop recurrences than those with stage I cancer (HR - 9.75; 95% CI 1.23-77.35; p=0.03). Patients
with Kintrup score >1 had a better prognosis than those with Klintrup 1 (HR-0.10; 95%CI=0.04-0.25; patients with Petersen score >1 had a worse prognosis than
those without venous invasion (HR-1.92; 95%CI=1.17-3.61; p=0.01). Patients with necrosis score 2 had a poorer prognosis than those with score 0 (HR-2.84;
95%CI=1.31-6.16; p=0.008). Patients with desmoplasic score 3 had lower recurrence rates than those with score 1 (HR-0.43, 95%CI=0.22-0.95; p=0.01)
Conclusion: Cancer recurrences were more frequent in patients with tumor grade 4, stage IIIB or IIIC. The independent prognostic role of Klintrup and Petersen
scores in cancer recurrences was also demonstrated. Desmoplasia score was an independent and positive prognostic factor for 5-year recurrence in patients
with colorectal cancer who had curative surgery.

Test de snge versus test de esut pentru depistarea rapid a tumorilor


Rapid Blood Test Detection of Tumors versus IHC test of Tissue
Camelia Gvan (1), Raluca Ioana Van Staden (2), C. Savlovschi (1), . Neagu (3), Maria Sajin (4), I. urcan (1), N. Copca (5), S. M. Oprescu (1)
(1) Universitatea de Medicin i Farmacie Carol Davila / Spitalul Universitar de Urgen, Clinica Chirurgie IV, Bucureti, Romnia
(2) Institutul Naional de Cercetare-Dezvoltare pentru Electrochimie i Materie Condensat, Laboratorul de Electrochimie i PATLAB, Bucureti, Romnia
(3) Universitatea de Medicin i Farmacie Carol Davila / Spitalul Universitar de Urgen, Clinica Chirurgie II, Bucureti, Romnia
(4) Universitatea de Medicin i Farmacie Carol Davila / Spitalul Universitar de Urgen, Clinica de Anatomie Patologic, Bucureti, Romnia
(5) Spitalul Clinic Sf. Maria, Clinica Chirurgie II, Bucureti, Romnia
n ultima perioad s-a pus din ce n ce mai mult accentul pe depistarea rapid, n msura n care este posibil - precoce a tumorilor. Imediat ce exist o suspiciune
de cancer, pacienii sunt trimii pentru analiza unor biomarkeri tumorali comuni, sau n stadii mai avansate se efectueaz puncii utilizate pentru analize prin
imunohistochimie. Aceste metode sunt foarte costisitoare, n mare parte realizate n afara spitalelor/clinicilor de stat, ELISA fiind tehnica utilizat n laboratoarele
clinice dup prelucrri avansate ale probelor de snge i esut. La fel de important pentru medicul chirurg este existena posibilitii testrii imediat dup ce a fost
extras a unei mici pri de tesut tumoral prin tehnici de investigaie rapid, cum ar fi utilizarea senzorilor sau a spectrometriei de for atomic (AFM). Ca
exemple pentru aceast prezentare se vor folosi: metode bazate pe determinarea HER2 n snge versus rezultatele obinute pentru analiza esutului tumoral
utiliznd imunohistochimia pentru cancer de sn i rezultate preliminare ale determinrii de glycogen (AFM) i testare cu sensor din esutul tumoral extras de la
pacienii operai de cancer colorectal. Lucrarea a fost realizat n cadrul proiectelor din PNII: Idei 123/2011 i Parteneriate 22/2014.

Lately increasingly more emphasis has been put on early detection, to the extent possible - early tumors. As soon as there is a suspicion of cancer, patients are
sent for analysis of common tumor biomarkers, or in advanced stages puncture is performed for immunohistochemistry analysis. These methods are very
expensive, largely made outside state hospitals/clinics, ELISA technique being used in clinical laboratories by advanced processing of blood and tissue samples.
Equally important is the existence of the possibility of testing by surgeon, immediately after being drawn, of a small part of the tumor tissue through rapid
investigative techniques such as using sensors or atomic force spectroscopy (AFM). The next examples for this presentation will be used: HER2 determination
methods based on blood analysis results versus tumor tissue using immunohistochemistry for breast cancer and preliminary results of the determination of
glycogen (AFM) and using sensors in tumor tissue extracted from patients operated for colorectal cancer. The work was performed within projects in PNII Ideas
123/2011 and 22/2014 Partnerships.

Anatomia chirurgical a fasciei Denonvilliers - implicaii funcionale i oncologice n excizia total de mezorect
Surgical Anatomy of the Denonvilliers Fascia - Functional and Oncological Implications in Total Mesorectal Excision
F. Grama, D. Cristian, N. Jitea, G. Richiteanu, T. Burco
Spitalul Clinic Colea, Secia de Chirurgie General, Bucureti, Romnia
Obiectiv: Conceptul anatomico-chirurgical al fasciei Denonvilliers a fost intens studiat n ultimii ani, cu scopul de a defini structura i originea fasciei, precum i
planul anterior optim de disecie - att din punct de vedere oncologic, ct i funcional - n cancerul de rect.
Materiale i metode: Am realizat o revizuire amnunit a literaturii privind anatomia i considerentele chirurgicale ale fasciei Denonvilliers, de la momentul
primei descrieri a termenului pn n prezent. Cu aceleai obiective am evaluat 54 excizii totale de mezorect (11 laparoscopice i 43 clasice) pentru cancer de rect
mijlociu i inferior realizate n Clinica de Chirurgie Colea n intervalul 2011 - 2014.
Rezultate: n excizia total de mezorect am ilustrat, att n chirurgia clasic, ct i n cea laparoscopic, repere anatomice i chirurgicale privind rolul fasciei
Denonvilliers n optimizarea planului anterior de disecie precum i raporturile anterioare i laterale cu nervii autonomi pelvini. Din punct de vedere embryologic,
date recente confirm teoria biomecanic privindu-i originea, fiind o fascie indus de tensiune, mai degrab aderent la structurile vecine. Din punct de vedere
histologic este multilamelar. Este mai bine reprezentat i mai uor individualizat la sexul masculin dect la cel feminin.
Concluzii: Fascia Denonvilliers reprezint un reper anatomo-chirurgical esenial pentru disecia oncologic joas a rectului. Disecia realizat anterior de fascie
este recomandat din punct de vedere oncologic doar pentru tumorile localizate pe poriunea anterioar a rectului inferior sau mijlociu, cea realizat posterior
protejeaz nervii autonomi pelvini de a fi lezai.

Objective: The anatomic-surgical concept of the Denonvilliers fascia was closely revised in the last years. The goal was to define the fascias structure and origin
and to establish the optimal plane for anterior dissection in rectal cancer surgery in order to maximize the functional and oncological results.
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Material and Methods: A thorough literature review on the anatomy and surgical considerations on Denonvilliers fascia was undertaken, from the first mention
until present. In addition, 54 cases of rectal resections with total mesorectal excision (11 laparoscopic and 43 open) performed in the Coltea Surgical Department
between 2011 and 2014 were reviewed.
Results: Performing the total mesorectal excision, we identified anatomical and surgical landmarks regarding the Denonvilliers fascia in the quest of finding the
optimal anterior dissection plane. Furthermore we took in consideration the anterior and lateral relation of the fascia with the autonomic pelvic nerves.
Embryological new data is available, confirming the biomechanical theory of its origin. This fascia is a tension induced fascia and it is rather adherent to the
nearby structures. From a histological stand point it has a multiple layer structure. It is better represented and individualized in males than in females.
Conclusion: The Denonvilliers fascia represents an important landmark, essential for the low oncologic dissection of the rectum. Dissection in an anterior plane of
the fascia is recommended for anterior localized tumors of the inferior and middle rectum, while dissection in the posterior plan of the fascia keeps the autonomic
pelvic nerves safe from injuries.

Locul chirurgiei n cancerul colorectal cu metastaze hepatice


The Place Held by Surgery in Colorectal Cancer with Hepatic Metastases
Snziana Octavia Ionescu, A. M. Marinca, E. Brtucu, N. D. Straja, V. M. Prunoiu
Institutul Oncologic Prof. Dr. Alexandru Trestioreanu, Clinica de Chirurgie I, Bucureti, Romnia
Obiectiv: Studiul are drept scop determinarea locului chirurgiei n cazul pacienilor diagnosticai cu neoplasme colorectale cu metastaze hepatice.
Materiale i metode: Din totalul 69 de pacieni avnd cancer colorectal cu determinri secundare la nivelul ficatului, operai de-a lungul a trei ani (01 ianuarie
2012-31 decembrie 2014) n Clinica de Chirurgie General i Oncologic I a Institutului Oncologic Bucureti Prof. Dr. Alexandru Trestioreanu, au fost grupai n
funcie de intervenia chirurgical efectuat.
Rezultate: La 27% din pacieni s-a efectuat operaia Hartmann, la 13% s-au efectuat intervenii la nivelul ficatului de tipul ablaie cu radiofrecven, hepatectomie
atipic, excizia formaiunii de la nivelul ficatului, la 10% s-a efectuat colostoma, iar restul din pacieni au avut una din urmtoarele proceduri efectuate:
hemicolectomie dreapt, operaia Dixon, biopsie formaiune tumoral, amputaie de rect.
Concluzii: Urmrirea n dinamic a evoluiei pacientului i evaluarea prognosticului se poate face n funcie de intervenia chirurgical efectuat. Procedurile
efectuate la nivelul ficatului, fie de tipul ablaiei cu radiofrecven, fie hepatectomia atipic sau asocierea celor dou au mbuntit semnificativ supravieuirea i
intervalul liber de boal.

Objective: The purpose of the study is to determine the place held by surgery in colorectal cancer patients with hepatic metastases.
Material and Methods: Out of a total of 69 patients diagnosed with colorectal cancer and hepatic metastases, operated on during a three-year period (01
January 2012-31 December 2014) at the Ist Clinic of General Surgery and Surgical Oncology of the Prof. Dr. Alexandru Trestioreanu Bucharest Oncology Institute,
were grouped according to the surgical procedure performed.
Results: In 27% of the patients Hartmann procedure was done, in 13% there were interventions at the level of the liver such as radio-frequency ablation, atypical
hepatectomy, the excision of the lesion at the level of the liver, in 10% a colostoma was performed and in the rest of the patients one of the following procedures
was performed: right hemicolectomy, Dixons procedure, biopsy of the tumor formation, abdomino-perineal recto-sigmoid resection.
Conclusions: The dynamic follow-up of the evolution of the patient and the evaluation of the prognostic can be made according to the type of procedure
performed. The procedures made at the level of the liver such as radio-frequency ablation or atypical hepatectomy or the association between the two have
significantly increased the survival and the disease free interval.

Importana infiltratului inflamator din vecintatea tumorii n cancerele colorectale recidivate


The Importance of the Cellular Inflammatory Response in the Vicinity of the Tumor in Recurrent Colorectal Cancer
S. T. Makkai-Popa, G. Dimofte, V. Porumb, Natalia Velenciuc, C. Roat, S. Lunc
Institutul Regional de Oncologie, Clinica II Chirurgie, Iai, Romnia
Obiectivul studiului: Stadializarea TNM n cancerul colorectal este n mod continuu mbuntit prin utilizarea de noi markeri de predicie i prognostic derivai n
special din studiul anatomiei patologice a tumorii. Scopul studiului nostru este de a descrie infiltratul inflamator de la nivelul tumorilor primare ale pacienilor care
au prezentat recidiv local sau la distan, dup rezecii colonice i rectale cu viz curativ.
Material i metode: Studiul de fa este unul retrospectiv desfurat pe o perioad de 2 ani, n care au fost inclui un numr de 23 de pacieni. Au fost analizate
densitatea i procentul de celule cd3, cd4, cd8, cd45ro i cd68 pozitive la nivelul esutului normal peritumoral, frontului de invazie i regiunii intratumorale,
utiliznd o metod de analiz digital a imaginii.
Rezultate: Am constatat n lotul nostru de studiu prezena unei corelaii semnificative statistic (p < 0,05) ntre o densitate mic de celule T citotoxice peritumoral i
durata de supravieuire fr recidiv. De asemenea, importana infiltratului cu celule T citotoxice evaluat prin procentajul acestor celule n esutul din vecintatea
tumorii a stratificat pacienii inclui n studiu din punct de vedere al riscului recidivei.
Concluzii: n cadrul lotului nostru de studiu putem concluziona c prezena celulelor T citotoxice n esutul normal peritumoral a fost corelat cu un risc crescut de
recidiv. Totui, aceste rezultate trebuie verificate pe loturi de studiu mai mari nainte de a fi validate.

Objective: The TNM staging in colorectal cancer is continuously improved by using new prognostic and predictive markers derived especially from more in-depth
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pathology studies. The aim of our study is to characterize inflammatory infiltrates found in the primary tumors of patients with a local or systemic recurrence after
colonic and rectal resections performed with the intent to cure.
Materials and methods: Our study is a 2-year retrospective study including 23 patients. We analyzed the cd3, cd4, cd8, cd45ro and cd68 infiltrates using digital
solid tumor cytometry by assessing the density and percentage of positively stained cells in 3 different regions - the peritumoral tissue, the invasive margin and
the center of the tumor.
Results: Our results show an inverse statistical correlation (p < 0,05) between the disease-free survival and the density of cytotoxic T-cells in the morphologically
normal peritumoral tissue. The magnitude of the cytotoxic T-cell infiltrate in the vicinity of the tumor assessed by their percentage also stratified the patients in
our study in terms of relapse risk.
Conclusions: In our study an abundance of cytotoxic T-cells in the normal peritumoral tissue was correlated with the risk of recurrence. However, these findings
need to be verified on larger groups of patients before validation.

Protejarea anastomozelor n chirurgia colorectal: tub transanal sau ileostomie?


Anastomosys Protection in Colorectal Surgery: Transanal Drainage Tube or Ileostomy?
T. Ptracu, H. Doran, O. Mihalache
Spitalul Clinic Dr. Ioan Cantacuzino / Universitatea de Medicin i Farmacie Carol Davila, Departamentul 10 - Chirurgie I, Bucureti, Romnia
Fistula de anastomoz rmne principala problem a chirurgiei colo-rectale. Incidena acesteia a rmas neschimbat n ultimele 3 decade, cu valori cuprinse ntre
4 i 20%. Ileostomia de protecie s-a impus ca metod de scdere a incidenei i complicaiilor fistulelor dup rezeciile rectale joase, totui aceasta atrage dup
sine o serie de complicaii care nu sunt de neglijat. O alternativ la ileostomia de protecie poate fi drenajul transanal cu un tub, trecut sau nu, transanastomotic.
n ultimii 5 ani am folosit aceast metod la aproape toate rezeciile colo-rectale extinznd-o i la celelalte tipuri de rezecii colice. Analiza cazurilor operate n
perioada ianuarie 2011-decembrie 2015 a relevat un numr de 154 de cazuri la care a fost folosit drenajul cu tub transanal. Dintre acestea, 2 treimi au fost
colectomii stngi, inclusiv rezecii rectale, iar o treime a fost reprezentat de colectomiile drepte. Fistula de anastomoz a survenit n 8 cazuri (5,1%), toate dup
colectomii stngi, 4 fiind tratate conservator. Nu au fost nregistrate decese.
n concluzie, putem afirma c, protejarea anastomozelor cu tub transanal este o alternativ fezabil comparativ cu ileostomia att datorit rezultatelor bune
obinute ct i avantajelor conferite de facilitatea tehnic si de faptul c nu este nevoie de o nou intervenie chirurgical pentru desfiinare.

Anastomotic fistula remains the main problem of colorectal surgery. The incidence is still unchanged in the last 3 decades, and it ranges between 4 and 20%.
Protective ileostomy proved to be an efficient method to decrease the incidence and complications of low anterior rectal resections, but it is accompanied by a
series of complications which are not to be neglected. An alternative to diverting loop ileostomy may be a transanal drainage tube, which is passed or not,
through anastomosis.
In the past five years we used this method to almost all colorectal resections, and we extended it to the other types of colon resections. We analyzed the cases
operated between January 2011 and December 2015, and we found 154 cases in which trasanal drainage tube was used. From those, two thirds were resections
of the left colon, including rectal resections, and the other third, resections of the right colon. Anastomotic fistula occurred in 8 cases (5.1%), 4 of them were
managed conservatively. There were no deaths.
In conclusion, we can state that the protection of anastomosis, in colo-rectal resections, with a transanal drainage tube is a feasible alternative comparing to
ileostomy, both due to good results and, also by the advantages granted by the technical simplicity and the fact that a new surgical intervention for closure is not
needed.

Rezecia joas de rect pe cale laparoscopic efectuat fr utilizarea dispozitivelor de sutur mecanic
The Laparoscopic Low Rectal Resection Performed Without Stapling Devices
D. Cristian, F. Grama, G. Richiteanu, A. Ionic, T. Burco
Spitalul Clinic Colea, Secia de Chirurgie General, Bucureti, Romnia
Obiectivul studiului: Am evaluat fezabilitatea efecturii laparoscopice a rezeciilor rectale joase fr utilizarea dispozitivelor de sutur mecanic precum i
eficacitatea extragerii transanale a specimenului rectal.
Material i metode: Au fost evaluate 8 rezecii rectale inferioare laparoscopice pentru tumori localizate n intervalul 2.5-5 cm fa de orificiul anal, cu specimen
extras transanal i anastomoz coloanal manual. 5 cazuri au fost T1-2N0, fr tratament neoadjuvant, iar 3 cazuri au fost T2N1 ori T3N0 i au beneficiat de
chimioradioterapie neoadjuvant (cur lung). Toate anastomozele coloanale au fost protejate de ileostom de protecie n continuitate. Au fost evaluate
descriptiv: marginea de rezecie circumferenial, marginea distal, calitatea mezorectului (Quirke), riscul de implantare a celulelor tumorale (recurena local la 1
an) i continena anal. Am ilustrat elementele tehnice particulare specifice interveniei.
Rezultate: Indicele de mas corporal a fost 25.91 +/- 3.61 (20-28.2). Mezorectul a fost complet n 6 cazuri (75%) i sub-complet n 2 cazuri (25%). Marginea
circumferenial a fost neinfiltrat n toate cazurile (> 0.1 cm). Margina distal medie a fost 1.1 cm (0.7-2.5). Nu am ntlnit recuren local la 1 an. Morbiditatea i
mortalitatea asociate procedurii au fost 0%. Scorul de continen anal a fost 8 (0-20).
Concluzii: Secionarea la vedere a rectului pe cale transanal asigur controlul macroscopic al unei margini distale neinfiltrate i permite realizarea unei
anastomoze manuale, fr a fi necesar sutura mecanic pentru seciune sau anastomoz. Extracia transanal a piesei, n cazuri selecionate, este fezabil i
sigur din punct de vedere oncologic, prezervnd peretele abdominal, fr implicaii funcionale semnificative.
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Objective: We evaluated the fesability of laparoscopic low rectal resections without using the stapling devices together with the efficiency of the transanal
specimen extraction.
Material and Methods: We analyzed 8 laparoscopic low rectal resections performed for tumors located between 2.5 and 5 cm from the anal ring, followed by
transanal specimen extraction and coloanal anastomosis. There were 5 cases T1-2N0, without neoadjuvant therapy, and 3 cases T2N1/T3N0 treated by
neoadjuvant chemoradiotherapy (long course). All anastomosis were protected through a loop ileostomy. We descriptively evaluated: the circumferential
resection margin, the distal margin, the quality of the mesorectum (Quirke), the risk of tumor spillage (local recurrence at 1 year) and the anal continence. We
illustrated specific technical details of the surgery.
Results: The body mass index was 25.91 +/- 3.61 (20-28.2). The mesorectum was complete in 6 cases (75%) and sub-complete in 2 cases (25%). The
circumferential margin was free in all cases (> 0.1 cm). The median distal margin was 1.1 cm (0.7-2.5). No recurrence was noted at 1 year follow-up. The morbidity
and mortality associated with the procedure was 0%. The anal continence score was 8 (0-20).
Conclusions: By sectioning the rectum transanally, in open sight, the distal margin is macroscopically free and a manual coloanal anastomosis is possible, with no
need for using stapling devices for section or suturing. The transanal specimen extraction performed in selected cases is feasible and oncologically safe and
preserves the abdominal wall without any functional consequences.

Tratament neoadjuvant radioterapic i Oxaliplatin n cancerul colorectal local avansat cu instabilitate microsatelit
Neoadjuvant Oxaliplatin and Radiotherapy in Locally Advanced Rectal Cancer with Microsatellite Instability
Dana Lucia Stnculeanu (1), Daniela Zob (2), M. Alecu (3), L. Simion (3), N. D. Straja (3)
(1) Universitatea de Medicin i Farmacie Carol Davila / Institutul Oncologic Prof. Dr. Al. Trestioreanu, Clinica de Oncologie Medical I, Bucureti, Romnia
(2) Institutul Oncologic Prof. Dr. Al. Trestioreanu, Clinica de Oncologie Medical I, Bucureti, Romnia
(3) Universitatea de Medicin i Farmacie Carol Davila / Institutul Oncologic Prof. Dr. Al. Trestioreanu, Clinica de Chirurgie I, Bucureti, Romnia
Aproape 15 % din cancerele colo-rectale sunt caracterizate de deficiena ADN mismatch repair (MMR), ducnd la instabilitate microsatelit (MSI) precum i la
apariia de mutaii la nivelul genelor implicate n carcinogenez, transformnd receptorul pentru factorul de cretere tip beta II.
Tumorile MSI-high (MSI-H) sunt din punct de vedere patologic diferite de tumorile colo-rectale obinuite care iau natere n urma instabilitii cromozomiale. Ele
au o localizare predominant la nivelul colonului drept, au o slab difereniere, histologie tipic mucinoas i prezint infiltrat limfocitar peritumoral (avnd
imunogenitate crescut).
Pacienii cu tumori MSI-H au un prognostic uor mai bun dect cei cu cancere microsatellite-stable (MSS) sau MSI-low (MSI-L), i totui nu pare c acetia prezint
beneficiu n urma chemoterapiei adjuvante cu fluorouracil (FU). Aceast rezisten la FU se presupune c este datorat incorporrii metaboliilor FU la nivelul ADN
i nu inhibiiei thymidylate sintazei.
S-a urmarit stabilirea eficacitii terapiei neoadjuvante (NA) bazate pe oxaliplatin i radioterapie i determinarea toxicitii i ratei de rspuns a pacienilor cu
cancer colo-rectal cu instabilitate microsatelit.
Au fost introdui n studiu pacienii cu cancer colo-rectal cu instabilitate microsatelit, tratai ntre ianuarie 2015 i decembrie 2015. Au fost inclui n studiu 25 de
pacieni cu cancer colo-rectal local avansat: T3N0, orice T N1-2, T4, tratai n Secia Oncologie Medical I din cadrul Institutului Oncologic Bucureti Prof. Dr. Al.
Trestioreanu. Niciun pacient nu a prezentat metastaze i toti pacienii au beneficiat de examinare MRI a abdomenului i pelvisului, respectiv examen CT toracic.
Pacienii au primit 2 cicluri de Oxaliplatin 130 mg/m2 la 21 de zile, urmate de radioterapie (IMRT) cu administrare de Oxaliplatin ca agent de sensibilizare. Nu a
fost folosit radioterapia short course din cauza introducerii n studiu a pacienilor cu T4, stadiu pentru care acest tip de radioterapie nu este indicat. Rspunsul
clinic al tumorilor a fost estimat la sfritul terapiei prin MRI, specimenele operatorii i examenul anatomopatologic al acestora. n urma tratamentului
neoadjuvant, toi pacienii au devenit operabili i au beneficiat de intervenie chirurgical. Au fost introdui n studiu doar pacienii examinai imunohistochimic i
MSI.
Au fost introdusi n studiu 25 de pacieni. Toi pacienii au urmat 2 cicluri de Oxaliplatin i radioterapie. La sfrsitul terapiei aplicate toi pacienii au beneficiat de
intervenie chirurgical. Dintre acetia, 19 pacieni au prezentat remisiune complet, 5 pacieni au avut remisiune parial a bolii i doar un pacient a prezentat
evoluie staionar. S-a administrat GM-CSF de cte ori a fost nevoie i s-a facut profilaxia mucozitei. Reaciile adverse cele mai frecvente au fost reprezentate de:
toxicitate hematologic (neutropenie, anemie, trombocitopenie), toxicitate hepatic (mai frecvent de grad 1-2 i rar 3-4), neuropatie (mai frecvent de grad 1-2,
grad 3-4 doar la pacienii cu factori de risc precum diabetul sau etilismul cronic).
Tratamentul neoadjuvant cu Oxaliplatin ofer o mbuntire substanial pentru un subgrup de pacieni ce prezint un rspuns deficitar la 5FU din cauza MSI.
Oxaliplatin-ul este relativ bine tolerat fa de alte chimioterapice descrise n literatur pentru tratamentul neoadjuvant al cancerului colo-rectal local avansat.
Radioterapia neoadjuvant a fost administrat pacienilor conform ghidurilor internaionale, folosind Oxaliplatin ca agent de sensibilizare. Toxicitatea nregistrat
a fost mai mic n comparaie cu raportrile pentru tratamentul neoadjuvant cu 5FU.

Almost 15% of colorectal cancers are characterized by deficient DNA mismatch repair (MMR), leading to microsatellite instability (MSI) and mutations in genes
involved in carcinogenesis: transforming growth factor-beta type II receptor.
MSI-high (MSI-H) tumors are pathologically distinct from colorectal tumors that arise from the traditional chromosomal instability pathway. They have a
predominantly proximal location in the right colon have poorer differentiation, have mucinous histology and have peritumoral lymphocytic infiltration (being more
immunogenic).
Patients with MSI-H tumors had a modestly better prognosis than those with microsatellite-stable (MSS) or MSI-low (MSI-L) cancers, yet also did not seem to
benefit from adjuvant fluorouracil (FU)-based chemotherapy. This resistance to FU is presumably due to incorporation of FU metabolites into DNA rather than
inhibition of its effective target, thymidylate synthase.
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The purpose was to establish the efficacy of neoadjuvant (NA) oxaliplatin-based therapy and radiotherapy and determine the toxicity and response rate in
patients with rectal cancer with microsatellite instability.
Patients with rectal cancer with microsatellite instability treated between January 2015 and December 2015 were taken into account for this study. There were
included into the study 25 rectal cancer patients locally advanced: T3N0, any T N1-2, T4 treated in the Department of Medical Oncology I - IOB. None of the
patients was M1 disease; all patients were assessed with MRI of abdomen and pelvis and CT scan of thorax. There were administered 2 cycles of Oxaliplatin 130
mg/m2 at 21 days followed by radiotherapy (IMRT) with oxaliplatin as sensitizer. We did not use short course radiotherapy due to inclusion of T4 for witch short
course is not recommended. Clinical tumor response was assessed at the end of therapy by MRI and surgical intervention and pathological report. After
treatment all patients become operable and gone through surgical intervention. There were included only patients with immunohistochemistry tests and MSI test.
25 patients were enrolled. All patients completed 2 cycles of Oxaliplatin and radiotherapy treatment. At the end of therapy all patients suffered surgical
interventions. 19 patients had pathological complete response, 5 had partial remission of the disease and only 1 patient had stable disease. GM-CSF were
administered where needed, there were made prophylaxis of mucositis. Adverse reactions more common observed were: hematologic toxicity (neutropeniae,
anemia, trombocitopeniae), hepatic toxicity, digestive toxicity - more grade 1 or 2, less 3-4, neuropathy more grade 1-2, grade 3-4 were observed only in patients
with risk factors such as diabetes or chronic alcohol abuse.
Oxaliplatin neoadjuvant treatment offers a substantial improvement in a subset of patients who have a lower response to 5FU treatment due to MSI. Oxaliplatin is
relatively well tolerated with RR superior to other neoadjuvant chemotherapy regimens-from literature, in locally advanced rectal cancer cases. Neoadjuvant
Radiotherapy was administered to patients according to international guidelines using as sensitizer Oxaliplatin regimen. Toxicity was low comparing with one that
was reported to 5FU regimens administered in neoadjuvant setting.

Valoarea alternrii dispozitivelor mecanice de sutur n tumorile de rect jos situate


The Value of Alternating Mechanical Stapling Devices Rectal Tumors Located Below
T. D. Potec (1), A. E. Iacobescu (1), Anca Gabriela Potec (2), Irina Nicoleta Penciuc (1)
(1) Spitalul Clinic Colentina, Chirurgie, Bucureti, Romnia
(2) Universitatea de Medicin i Farmacie Carol Davila, Catedra de Anatomie Patologic, Bucureti, Romnia
Tratamentul optim chirurgical al tumorilor de rect jos situate este de excizie a formaiunii tumorale i refacerea continuitii tractului digestiv atunci. n studiul
prezentat, am pus n eviden valoarea folosirii dispozitivelor de sutur mecanic.
Metod: n perioada 2012-2016, n cadrul Clinicii de chirurgie din cadrul Spitalului Clinic Colentina au fost tratate un numr de 30 cazuri de tumori de rect jos
situate, care au beneficiat de tratament de refacere a tractului digestiv. Pacienii cu aceast patologie au fost mprii in dou loturi: pacieni cu sutur manual a
anastomozei (lotul A - 12 pacieni) i pacieni cu sutur mecanic a anastomozei - stapplere liniare i circulare (lotul B - 18 pacieni).
Rezultate: S-a constatat c timpul operator pentru pacienii din lotul B a fost mai mic, complicaiile postoperatorii puine; spitalizarea i reintegrarea n societate
au fost de o mai lung durat n cazul pacienilor din lotul A. Costurile interveniilor chirurgicale au fost mai mari pentru pacienii din lotul B. Reinternrile pentru
lotul B nu au existat, pentru lotul A numrul lor a fost de 4.
Concluzii: Costurile interveniei sunt mai mari n cazul pacienilor ce beneficiaz de anastomoz fcut cu sutur mecanic; apariia fistulelor anastomotice este
mai mic n cazul suturii mecanice. Durata interveniilor este mai mic n cazul suturii mecanice.

Optimal surgical treatment of tumors of the rectum located below is the excision of tumor formation and restoring continuity of the alimentary tract. In the present
study we emphasized the value of using mechanical stapling devices.
Method: In the 2012-2016 period, in Surgery Clinic of the Clinical Hospital were treated a total of 30 cases of rectal tumors located below who have received
treatment for recovery of the digestive tract. Patients with this pathology were divided into two groups: patients with anastomotic suture manually (group A - 12
patients) and patients with mechanical anastomosis suture - stapplere linear and circular (group B - 18 patients).
Results: We found that operative time for patients in group B was lower, fewer postoperative complications; hospital and reintegration into society were of longer
duration in patients in group A. The costs of surgery were greater for patients in group B. Readmissions for group B did not exist, for group A were 4.
Conclusions: The intervention costs are higher in patients receiving mechanical anastomosis suture made; anastomotic fistula occurrence is lower in mechanical
suture. Duration of the interventions is lower in mechanical suture.

Rezecia abdominoperineal extralevatorie versus standard n cancerul de rect: review sistematic i meta-analiz
Extralevatory versus Standard Abdominoperineal Resection for Rectal Cancer: A Systematic Review and
Meta-Analysis
M. Beuran (1), I. Negoi (1), A. Runcanu (1), Mihaela Vartic (2), S. Pun (1)
(1) Spitalul Clinic de Urgen Floreasca, Chirurgie General, Bucureti, Romnia
(2) Spitalul Clinic de Urgen Floreasca, Anestezie i Terapie Intensiv, Bucureti, Romnia
Scopul acestui studiu este de a compara rezultatele perioperatorii i oncoloagice ale rezeciei abdominoperineale extralevatorii cu rezecia abdominoperineale
standard la pacienii cu cancer de rect.
Metod: Review sistematic al literaturii i meta-analiz.

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The aim of the current study is to compare the perioperative and oncological outcomes after extralevator abdominoperineale resection with conventional
abdominoperineal resection in patients with rectal cancer.
Method: Systematic review and meta-analysis.

Scoruri de noduli limfatici ca i instrumente de prognostic ai recidivei cancerului colorectal


Lymph Node Ratios as Prognostic Tools of Colorectal Cancer Relapse
S. Lunc, S. T. Makkai-Popa, V. Porumb, Natalia Velenciuc, C. Roat, G. Dimofte
Institutul Regional de Oncologie, Clinica II Chirurgie, Iai, Romnia
Obiectivul studiului: Capacitatea de a estima mai bine evoluia cancerului colorectal pentru a putea mbunti luarea deciziilor terapeutice a determinat
focalizarea cercetrilor att spre factori moleculari, dar i spre factori clinico-patologici. Scopul studiului de fa este de a evalua 2 scoruri de noduli limfatici ca i
posibili markeri de predicie ai agresivitii tumorale.
Material i metode: Grupul nostru de studiu a inclus 25 de pacieni cu recidiv local sau la distan, selectai retrospectiv pe o perioad de 2 ani. Pentru fiecare
pacient a fost calculat raportul de noduli limfatici, raportul log odds i au fost colectate datele clinico-patologice uzual analizate n cancerul colorectal.
Rezultate: Comparnd pN, raportul de noduli limfatici i raportul log odds am observat c ultimul este singurul care se coreleaz att cu numrul total de noduli
excizai ct i cu numrul de noduli pozitivi. De asemenea, el s-a corelat i cu riscul de apariie a metastazelor i a difereniat pacienii cu risc crescut de recidiv
de cei cu risc sczut.
Concluzii: Raportul log odds ar putea fi o alternativ atractiv de completare a stadializrii TNM pentru sporirea capacitii de predicie a evoluiei pacienilor, dar
sunt necesare studii multicentrice, pe grupuri mai mari de pacieni pentru a verifica rezultatele obinute n studiul nostru.

Objective: The ability to better predict outcomes in colorectal cancer in order to improve therapeutic decisions is a goal that has lead researchers to look into
both molecular and clinico-pathological markers. The aim of our study is to assess the capacity of two lymph node scores to predict tumor aggressiveness.
Material and methods: Our study group included 25 patients with a local or systemic colorectal cancer recurrence, retrospectively selected over a period of 2
years. In each case we assessed the lymph node ratio, the log odds ratio and we collected all the common clinico-pathological characteristics evaluated in
colorectal cancer.
Results: Comparing the pN, the lymph node ratio and the log odds ratio we found that only the last one correlated with both the total number of resected nodes
and the number of positive nodes. The same score correlated well with the risk of developing a distant metastasis and discriminated between patients with a
high risk of relapse and those with a low risk.
Conclusions: The log odds ratio could be an interesting option to complete the TNM staging in order to improve outcome prediction but larger multicenter studies
are needed to verify our finding.

TaTME pentru cancerul de rect: experiena iniial i repere anatomice ale diseciei
Initial Experience with TaTME Dissection for Low Rectal Cancer and Anatomical Landmarks
I. B. Diaconescu (1), M. R. Bratu (2), S. Vlcea (1), G. L. Varsa (1), M. Beuran (2)
(1) Spitalul Clinic de Urgen Floreasca, Clinica de Chirurgie General, Bucureti, Romnia
(2) Spitalul Clinic de Urgen Floreasca, Clinica Chirurgie III, Bucureti, Romnia
Managementul chirurgical al cancerului de rect inferior ridic problema conservrii sfincterului anal i creterea calitii vieii pacientului n perioada
postoperatorie. n ultima perioad, rezecia total de mezorect pe cale transanal (TaTME) poate reprezenta o soluie mai agreabil pentru pacient dect rezecia
anterioar joas sau amputaiile de rect indiferent de abord, clasic sau laparoscopic. Vom prezenta experiena Spitalului Clinic de Urgen Bucureti cu rezeciile
TaTME. Initial, abordul a fost laparoscopic, cu ligatur la origine a arterei mezenterice inferioare, mobilizarea colonului stng apoi abordul transanal cu ajutorul
unui trocar dedicat. Crearea bursei endorectale, endocolotomia i disecia mezorectului sunt descrise n prezentarea video odat cu detaliile anatomice.
Recuperarea postoperatorie a fost comparabil cu cea a abordului laparoscopic. n concluzie, rezecia TaTME este fezabil, respect principiile oncologice i
prezint o recuperare postoperatorie cel putin la fel ca abordul laparoscopic. Standardizarea reperelor anatomice n cursul rezeciei duce la o identificare mai
uoar a planurilor de disecie cu mai puine incidente i accidente peroperatorii, avantaje ce trebuie evideniate n studii prospective.

Surgical management of low rectal cancer poses a challenging problem in conserving the sphincter and providing the patient a comfortable life. Recently,
transanal total mesorectal excision (TaTME) might represent a better solution for low rectal tumors than low abdominal resection, whether this is done by classic
or laparoscopic approach. We present initial experience of the Emergency Clinical Hospital of Bucharest with TaTME. Our approach was first laparoscopic, with
inferior mesenteric artery ligation and left colic mobilization and then transanal approach with a gelfoam trocar. The pursestring, endorectal incision and
mesorectal dissection are presented in the video along with anatomical details of the procedure. Initial postoperative recovery was comparable with the one for
standard approach except minus one abdominal incision because the organ is extracted through anal opening. In conclusion, TaTME technique is feasible, has
the same oncological principles and postoperative recovery as previous approaches and with standardized anatomical landmarks provides a better exposure of
the mesorectum with possible less intraoperative complications which need to be analyzed in future studies.

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Rezecia radical pentru cancer rectal, folosind robotul da Vinci XI: andocare unic, tehnic cu o singur etap
Radical Resection for Rectal Cancer Using Robotic Da Vinci XI System: Single Docking, Single Phase Technique
C. Du (1), S. Pantea (1), C. Tara (1), D. A. Brebu (2), C. Lazr (1), A. Dobrescu (1), F. Lazr (1)
(1) Universitatea de Medicin i Farmacie Victor Babe, Clinica Chirurgie II, Timioara, Romnia
(2) Universitatea de Medicin i Farmacie Victor Babe, Clinica Chirurgie I, Timioara, Romnia
Obiectiv: Scopul acestui studiu este de a evalua avantajele sistemului robotic Da Vinci Xi n chirurgia cancerului rectal. Acest studiu evalueaz, de asemenea,
rezultatele iniiale oncologice dup rezecia rectal cu acest sistem n Clinica Chirurgie 2, Timioara.
Introducere: Chirurgia robotic rectal are avantaje distincte fa de abordul laparoscopic. Rezecia total robotic este n cretere ca urmare a evoluiei
tehnologiei hibride. Cel mai recent sistem robotic Da Vinci Xi (Intuitive Surgical, Sunnyvale, USA) are o serie de caracteristici noi pentru a face rezecia total
robotic posibil, cu o singur andocare i o singur etap.
Metode i rezultate: Douzeci i unu de pacieni au suferit o rezecie total robotic ntr-o singur faz i cu o singur andocare. Am folosit poziiile de port n linie
dreapt. Distana medie de la orificiul anal a fost de 6,5 cm. Valoarea medie a timpului de andocare a robotului i timpul de procedur robotic au fost de 15 i
180 min, respectiv. Pierderea de snge medie a fost de 180 ml. Un pacient a avut nevoie de conversie la o abordare deschis din cauza bolii avansate. Marginea
de rezecie circumferenial i marginile de rezecie au fost curate la toi pacienii. Numrul mediu al ganglionilor limfatici excizai a fost de 17. Valoarea medie a
spitalizrii postoperatorii a fost de 7 zile. A fost un singur incident intraoperator, o leziune a arterei epigastrice.
Concluzie: Cu ajutorul celui mai recent sistem robotic Da Vinci Xi este posibil efectuarea unei rezecii rectale printr-o singur andocare. Cu noul sistem cu patru
brae, intervenia chirurgical rectal robotic poate nlocui tehnica hibrid chirurgie laparoscopic i robotic pentru afeciuni maligne rectale. Curba de nvare
pentru noul sistem pare s fie mai scurt dect cea anticipat. Rezultatele imediate perioperatorii sunt promitoare.

Objective: This study aims to assess the advantages of Da Vinci Xi system in rectal cancer surgery. It also assesses the initial oncological outcomes after rectal
resection with this system from Surgical Clinic 2, Timisoara.
Introduction: Robotic rectal surgery has distinct advantages over laparoscopy. Total robotic resection is increasing following the evolution of hybrid technology.
The latest Da Vinci Xi system (Intuitive Surgical, Sunnyvale, USA) is enabled with newer features to make possible total robotic resection with single docking and
single phase.
Methods and results: Twenty-one patients underwent total robotic resection in a single phase and single docking. We used port positions in a straight line.
Median distance from the anal verge was 6.5 cm. Median robotic docking time and robotic procedure time were 15 and 180 min, respectively. Median blood loss
was 180 ml. One patient needed conversion to an open approach due to advanced disease. Circumferential resection margin and longitudinal resection margins
were uninvolved in all other patients. Median lymph node yield was 17. Median post-operative stay was 7 days. There was one intra-operative adverse event,
epigastric artery lesion.
Conclusion: The latest Da Vinci Xi system has made total robotic rectal surgery feasible in single docking and single phase. With the new system, four arm total
robotic rectal surgeries may replace the hybrid technique of laparoscopic and robotic surgery for rectal malignancies. The learning curve for the new system
appears to be shorter than anticipated. Early perioperative and oncological outcomes of total robotic rectal surgery with the new system are promising.

Tratamentul minim invaziv n tumorile stromale gastrointestinale


Minimally Invasive Management of Gastrointestinal Stromal Tumors
M. L. Zabara (1), Ana-Maria Trofin (1), Alexandra Vornicu (1), Felicia Crumpei (2), C. Bradea (3), Oana Apopei (4), Corina Ursulescu Lupacu (2), D. Andronic (3),
C. Lupacu (1)
(1) Spitalul Clinic Judeean de Urgen Sf. Spiridon, Clinica II Chirurgie, Iai, Romnia
(2) Spitalul Clinic Judeean de Urgen Sf. Spiridon, Clinica de Radiologie, Iai, Romnia
(3) Spitalul Clinic Judeean de Urgen Sf. Spiridon, Clinica I Chirurgie, Iai, Romnia
(4) Spitalul Clinic Judeean de Urgen Sf. Spiridon, Clinica de Anestezie i Terapie Intensiv, Iai, Romnia
Introducere: Tumorile gastro-intestinale stromale reprezint o entitate distinct clinic i anatomopatologic de tumori mezenchimale putnd fi ntlnite la nivelul
oricrui segment al tractului digestiv.
Material i metode: Am realizat un studiu retrospectiv, pe parcursul a 10 ani n Clinica I-II Chirurgie General a Spitalulul Clinic Judeean de Urgen Sf. Spiridon,
n perioada 2006-2015, pe un lot de 50 de cazuri de tumori stromale gastrointestinal cu diferite localizari (28 localizate gastric, 3 la nivel duodenal, 11 afectnd
intestinul subire, 3 colon i 2 la nivel rectal).
Rezultate: n 40% din cazuri, tratamentul chirurgical s-a realizat prin abord laparoscopic. Cea mai frecvent localizare care a beneficiat de tratament minim invaziv
a fost reprezentat de tumorile stromale gastrice localizate pe mica sau marea curbur, acestea fiind urmate de intestinul subire. n 3 cazuri a fost necesar
conversia datorit dimensiunilor tumorale ct i datorit rapoartelor cu structurile adiacente. Evoluia postoperatorie a fost lipsit de complicaii, pacienii fiind
externai la interval de 3 pn la 5 zile postoperator. Examenul anatomopatologic a confirmat diagnosticul de tumor stromal.
Concluzii: Tumorile stromale gastrointestinale au fost i vor rmne o mare provocare pentru chirurgie datorit caracterului imprevizibil. Rezecia chirurgical
reprezint singurul tratament potenial curativ adresndu-se bolii localizate sau eventualelor metastaze. Tratamentul cu inhibitori de tirozin-chinaz reprezint o
opiune terapeutic n cazul bolii metastatice.

Aim: Gastrointestinal stromal tumors represent a distinctive clinical and pathological entity of mesenchymal tumors and can be discovered in each segment of the
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digestive tract.
Methods: We conducted a retrospective study, over 10 years in I-II Surgery Clinic of "Sf. Spiridon" Hospital, in the period from 2006 to 2015, on a sample of 50
cases of gastrointestinal stromal tumors with different locations (28 with gastric location, 3 duodenal, 11 small intestine, 3 colon and 2 rectum).
Results: In 40% of cases, surgical treatment was performed by laparoscopic approach. The most common location that benefited from minimally invasive
treatment was the stomach, with tumors affecting on the small or big gastric curvature, followed by the small intestine. In 3 cases the conversion was necessary
due to the size of tumor and close adherence to the adjacent structures. Postoperative course was without complications, patients being discharged in 3 to 5
postoperatively days. Pathological examination confirmed the diagnosis of stromal tumor.
Conclusions: Gastrointestinal stromal tumors have been and will remain a great challenge for surgery due to the unpredictable behavior. Surgical resection is the
only potentially curative treatment addressing possible localized or metastatic disease. Treatment with tyrosine kinase inhibitors represents a therapeutic options
in metastatic disease.

Cura laparoscopic a herniei inghinale


Laparoscopic Treatment of Inguinal Hernia
Teodor Dan Potec (1), A. E. Iacobescu (1), Anca Gabriela Potec (2), Irina Nicoleta Penciuc (1)
(1) Spitalul Clinic Colentina, Chirurgie, Bucureti, Romnia
(2) Universitatea de Medicin i Farmacie Carol Davila, Catedra de Anatomie Patologic, Bucureti, Romnia
Hernia inghinal se poate trata chirurgical att prin metoda clasic, ct i prin cea laparoscopic. n studiul prezentat am ncercat s evalum care este metoda
optim de tratament a herniei inghinale din perspectiva reintegrrii socio-profesionale.
Metod: n perioada 2014-2016, n cadrul Clinicii de Chirurgie a Spitalului Colentina au fost tratai un numr de 47 pacieni cu diagnosticul de hernie inghinal.
Acetia au fost mprii n dou loturi n funcie de metoda de abord chirurgical: lotul A - pacienii tratai prin metoda laparoscopic (procedeu TAP 19 pacieni) i
lotul B - pacienii tratai prin metoda clasic (28 pacieni).
Rezultate: Pentru pacienii din lotul A perioada de internare medie a fost de 2 zile, complicaiile intraoperatorii i postoperatorii au fost minime, pe cnd pentru
pacienii din lotul B perioada de spitalizare medie a fost de 7-8 zile, concediile medicale pentru lotul A au fost n medie de 14 zile, perioada recomandat de
evitare a eforturilor fizice a fost de 1 lun de zile. Pentru pacienii din lotul B s-a cerut o prelungire a concediilor medicale la aproximativ 30 de zile, perioada
recomandat de evitare a eforturilor fizice fiind de 3-6 luni.
Concluzii: innd cont de indicaiile i contraindicaiile anesteziei generale, modalitatea eficient de tratament a herniei inghinale din punct de vedere al
reintegrrii socio-profesionale este cura laparoscopic.

Inguinal hernia surgically treatable by both the classical and by laparoscopic. In the present study we tried to assess which is the best method of treatment of
inguinal hernia in terms of socio-professional reintegration.
Method: In the years 2014-2016 in the Surgery Clinic Colentina Hospital were treated a total of 47 patients with a diagnosis of inguinal hernia. They were divided
into two groups depending on the method of surgical approach: group A - patients treated by laparoscopic method (TAP process 19 patients) and group B patients treated by the classical method (28 patients).
Results: For patients in group A average hospitalization period was 2 days, intraoperative and postoperative complications were minimal, while patients in group
B average hospital stay was 7-8 days, sick leave for group A was an average of 14 days, the recommended period to avoid the physical effort was one month. For
patients in group B it was requested an extension of sick leave from 30 days period recommended to avoid physical exertion is 3-6 months.
Conclusions: Given the indications and contraindications for general anesthesia, how effective treatment of inguinal hernia in terms of socio-professional
reintegration is laparoscopic cure.

Abordul laparoscopic al ulcerului gastroduodenal perforat


Laparoscopic Approach for Perforated Gastroduodenal Ulcer
. O. Georgescu, D. Vintil, C. Bradea, C. Lupacu, C. Vasilu, B. M. Ciuntu
Spitalul Clinic Judeean de Urgene Sf. Spiridon, Chirurgie II, Iai, Romnia
De la apariia antagonitilor H2, inhibitorilor pompei de protoni i stabilirea rolului Helicobacter pylori, utilitatea suturii simple a unui ulcer gastroduodenal
perforat este n cretere. Repararea laparoscopic a ulcerului perforat permite efectuarea aceleai tehnici ca i n interveniile chirurgicale deschise, dar cu
beneficiile chirurgiei minim invazive.
Scop: Evaluarea aplicabilitii de reparare laparoscopic a ulcerului gastroduodenal perforat, riscurile i beneficiile acestei proceduri.
Metoda: Studiu retrospectiv pe 98 de pacieni cu abord laparoscopic pentru ulcerul gastroduodenal perforat ntre martie 1997 i martie 2016.
Rezultate: Grupul nostru de studiu reprezint 0,57% din 17193 proceduri laparoscopice efectuate n perioada menionat n Clinica Chirurgie I-II Iai, Romnia.
Cinci pacieni au necesitat conversie. Dup intervenia laparoscopic am avut dou cazuri cu complicaii: o fistul soluionat prin excizie i sutura i o stenoz
trzie (dup cinci luni) gestionata prin rezecie gastric cu anastomoza Billroth I.
Concluzii: Repararea laparoscopic a ulcerului gastroduodenal perforat este eficient, simplu i cu un real beneficiu pentru pacieni, datorit absenei unei incizii
mediene cu o reinserie social foarte bun.

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Background: Since the advent of H2-antagonists, proton pump inhibitors and the establishment of the role of Helicobacter pylori eradication, the usefulness of
simple suture of a perforated gastroduodenal ulcer is increasing. Laparoscopic repair of perforated ulcer allows to perform the same technique as open surgery
but with the benefits of the minimum invasion.
Aim: To asses the practicability of laparoscopic repair of perforated gastroduodenal ulcer, the risks and the benefits of this procedure.
Methods: Retrospective study on 98 patients with laparoscopic approach for perforated gastroduodenal ulcer between March 1997 and March 2016.
Results: Our study group represents 0.57% from 17193 laparoscopic procedures performed during the mentioned period in 1st Surgical Clinic Iai, Romania. Five
patients required conversion to open surgery. After laparoscopic repair we had two cases with complications: one leak resolved by open excision and suture and
one late stenosis (after five months) managed by gastric resection with Billroth I anastomosis.
Conclusions: The laparoscopic repair of perforated gastroduodenal ulcer is effective, simple and with a real benefit for patients thanks to absence of a great
median incision with a very good social reinsertion.

ERCP versus investigaiile imagistice - acurateea n diagnosticul etiologic al sindroamelor de colestaz


ERCP versus Imaging Techniques - The Accuracy in Etiology Diagnosis of Cholestasis Syndromes
M. Grigoriu, D. Vasile, C. Lutic, C. Budin, . Pan, C. Oprea, I. Scurtu, V. Bleanu
Spitalul Universitar de Urgen, Chirurgie I, Bucureti, Romnia
Lucrarea se bazeaz pe un studiu retrospectiv efectuat pe 530 de pacieni la care s-a practicat ERCP pentru sindrom de colestaz de diverse etiologii: litiazic,
tumoral, parazitar, etc. A fost urmrit concordana datelor oferite de investigaiile imagistice preoperatorii cu cele obinute prin colangiopancreatografie
endoscopic retrograd. Sunt incluse n analiz i cazurile la care de necesitate, s-a practicat iniial ERCP cu protezare biliar iar tomografia computerizat i/sau
rezonana magnetic nuclear au fost efectuate ulterior, dup remiterea sindromului icteric. Colangiografia endoscopic retrograd ramne cea mai fidel
metod de diagnostic etiologic al sindroamelor de colestaz. Ea ns nu trebuie sa se substitue investigaiilor imagistice care constituie pai obligatorii n
evaluarea acestor pacieni.

The paper is based on a retrospective study on 530 patients in whom ERCP was practiced for various etiologies cholestasis syndrome: lythiasis, tumoral, parasite
infections, etc. We followed the data provided by preoperative imaging investigations and those obtained during endoscopic retrograde
cholangiopancreatography. We included in the analysis also the cases in which ERCP was initially performed (with biliary prosthesis) and in which computed
tomography and/or magnetic resonance imaging were performed after remission of the jaundice syndrome. Endoscopic retrograde cholangiography remains the
fairest method of etiology diagnosis of syndromes of cholestasis, but it should not replace imaging investigations which are mandatory steps in the evaluation of
these patients.

Programul special dup gastrectomia longitudinal mbuntete pierderea n greutate


Special Program after Sleeve Gastrectomy Improves Weight Loss
C. Lazr (1), A. Dobrescu (1), G. Verde (2), G. Noditi (1), C. Du (1), Daniela Barjica (1)
(1) Universitatea de Medicin i Farmacie Victor Babe, Clinica Chirurgie II, Timioara, Romnia
(2) Universitatea de Medicin i Farmacie Victor Babe, Clinica Chirurgie I, Timioara, Romnia
Scopul studiului nostru este de a determina dac un program special direcionat mbuntete scderea n greutate dup gastrectomia longitudinal. Programul
nostru special de urmrire postoperatorie a fost introdus din 2012 i implic stabilirea unor obiective de control exhaustive la intervale fixe dup gastrectomie
longitudinal. Am comparat pacienii ntre 2012 i 2015 cu pacienii din 2009 pn n 2012, cnd programul de monitorizare a devenit standard. Un total de 387
de pacieni au fost inclui, cu 215 pacieni n programul special de urmrire post-gastrectomie longitudinal. Cele 2 grupuri au fost similare n ceea ce privete
distribuia pe sexe, distribuia etnic, vrst i greutatea preoperatorie, indicele de mas corporal preoperator i tehnica chirurgical. Procentul de urmrire a
pacienilor a fost la 3, 6, 9 i 12 luni pentru pacienii din programul special de 84,5%, 85,2%, 69,7%, i 87,2%, comparativ cu 65,9%, 58,3%, 61,2% i 48,3 % pentru
programul standard. Valoarea medie a pierderii excesului de greutate la 3, 6, 9 i 12 luni a fost de 40%, 54%, 62% i 72%, respectiv, pentru grupul program
special, iar 36%, 48%, 54% i 62% , respectiv, pentru programul standard, iar diferena semnificativ statistic ntre cele dou grupuri a fost atins la 12 luni
(p<0.005). n concluzie, rezultatele noastre sugereaz c un protocol special, bine conceput poate mbunti rezultatele n ceea ce privete scderea n greutate
dup gastrectomia longitudinal laparoscopic.

Background: The aim of our study is to determine if a special directed program improves weight loss after sleeve gastrectomy. Methods: Our special directed
program was introduced since 2012 and involves setting exhaustive control targets at fixed intervals after sleeve gastrectomy. We compared the patients
between 2012 and 2015 with the patients from 2009 to 2012 when the follow-up program was standard. Results: A total of 387 patients were included, with 215
patients in the special weight loss program. The 2 groups were similar in terms of gender distribution, ethnicity distribution, age, and preoperative weight,
preoperative body mass index, and surgical technique. The follow-up rates at 3, 6, 9, and 12 months for patients in the special program was 84.5%, 85.2%, 69.7%,
and 87.2%, respectively, compared with 65.9%, 58.3%, 61.2%, and 48.3% for the standard program. The mean excess weight loss at 3, 6, 9, and 12 months was
40%, 54%, 62%, and 72%, respectively, for the special program group, and 36%, 48%, 54%, and 62%, respectively, for the standard program, where statistical
significance (P<.005) was achieved at 12 months. Conclusion: Our results suggest that a special, well designed protocol may improve weight loss outcomes after
laparoscopic sleeve gastrectomy.
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Cura laparoscopic intraperitoneal (ipom) a eventraiilor postoperatorii cu utilizarea substanei anti-adezive
mezogel
Laparoscopic Intraperitoneal On-Lay Mesh Repair (IPOM) for the Ventral Hernia Using Anti-Adhesive Gel
A. Dima
Spitalul Clinic Militar Central / Universitatea de Stat de Medicin i Farmacie Nicolae Testemianu, Catedra Chirurgie Nr. 5, Chiinu, Republica Moldova
Obiectivul studiului: Poziionarea intraperitoneal a plasei chirurgicale impune selectarea materialului sintetic.
Material i metode: n clinica noastr de chirurgie (SCMC), n anii 2013-2016 au fost supui curei laparoscopice pentru eventraie postoperatorie 21 pacieni, 16
femei i 5 barbai. Vrsta medie 30-65 ani. Pentru protezare s-a folosit plasa din polivinilidenftorid (PVDF) de tip UNIFLEX (Rusia), mai mare cu 5 cm dect
defectul herniar pe toate dimensiunile. Pentru prevenirea aderenelor parieto-viscerale a fost utilizat suplimentar, compozitul antiadeziv MEZOGEL, Rusia.
Fixarea plasei s-a asigurat prin aplicarea a 5-8 suturi tip ancore transfasciale i agrafe helicoidale nerezorbabile de 4 mm, plasate la 1 cm de marginea
protezei. Algometria s-a efectuat cu utilizarea scalei analog vizuale (VAS).
Rezultate: Defectul herniar a avut un diametrul median de 7,9 cm. La 16 pacieni a fost suturat defectul herniar prin aplicarea suturii intracorporale. Dintre
particulariti intraoperatorii se menioneaz: reducerea coninutului sacului herniar, adezioliz, controlul hemoragiei din adeziuni. Durata medie a interveniilor a
fost de 55 min. (45-65 min). n perioada postoperatorie complicaii nu au fost semnalate. Sindromul dolor postoperator a fost minim (VAS 1-3), complicaii
parietale absente. Durata mediana de spitalizre 3,2 zile. n perioada postoperatorie la distan nu s-au constatat dureri i neuropatii, dereglri de tranzit
intestinal, recidive herniare.
Concluzii: Cura laparoscopic a eventraiilor postoperatorii cu aplicarea protezei. IPOM este o metod fezabil, sigur i miniminvaziv. Plasa i gelul cu
proprieti antiadezive reduce semnificativ riscul aderenelor parieto-viscerale i complicaiilor parietale, asigurnd reintegrarea socio-profesional rapid.
Avantajele expuse argumenteaz perspectivele utilizrii tehnicii IPOM n cura eventraiilor postoperatorii.

Introduction: IPOM positioning of a surgical mesh requires the selection of a synthetic material with anti-adhesive properties.
Materials and Methods: Within the period of 2013-2016, 21 IPOM hernia repairs have been performed on a group of 21 patients diagnosed with ventral hernia, 5
male and 16 female. The overall age was 48,2 years (range 30-65). The PVDF monofilament macroporous mesh has been utilized for repair. The mesh overlapped
the defect with 5 cm. The combined fixation technique was ensured by applying the anchor type sutures and 4 mm non-resorbable spiral tacks plaid up to 1
cm from the edge of the prosthetic mesh. The non-adhesive composite MEZOGEL has been used to ensure the prevention of the adhesions. Algometry was
performed using visual analog scale (VAS).
Results: The mean diameter of the hernia defect was 7.9 cm. In 16 cases the hernia defect has been closed by applying intracorporeal suture. The intraoperative
features were: reduction of the hernia sac content, removal of adhesions, control of the bleeding. The mean time of operations was 55 min. In the postoperative
period there were no reported complications. In the distance postoperative period pain and local neuropathy, bowel disorders, hernia recurrences were not
found.
Conclusions: Laparoscopic IPOM ventral hernia repair is a feasible, safe and minimally-invasive procedure. Prosthesis and gel with anti-adhesive properties
significantly reduce the risk of the parietovisceral adhesions and complications ensuring quick social and professional reintegration. The exposed advantages
argument the use of the IPOM procedure in the ventral hernia repair.

Double octree - o manier modern de a mbunti realismul din realitatea virtual


Double Octree - A Modern Way to Improve the Realism in Virtual Reality
D. Cochior, D. Custur-Crciun, L. Pripisi, Z. J. Kover, D. Toma, G. Dinc
Spitalul Clinic Ci Ferate Nr. 2, Chirurgie General, Bucureti, Romnia
Calitatea unei simulri ine de calitatea imaginii, de gradul de realism al simulrii. O cretere a calitii impune o cretere a rezoluiei, o cretere a vitezei de
reprezentare dar mai ales un set mai extins de calcule. Un simulator de realitate virtual execut cel mai complex set de calcule de fiecare dat cnd detecteaz
un contact ntre corpuri virtuale, astfel optimizarea deteciei coliziunilor este critic n viteza de lucru a unui simulator i implicit n calitatea lui.

The simulations quality is strongly related to the image quality as well as the degree of realism of the simulation. Increased quality requires increased resolution,
increased representation speed but more important, a larger amount of mathematical equations. A virtual reality simulator executes one of the most complex sets
of calculations each time it detects a contact between the virtual objects, therefore optimization of collision detection is fatal in the work-speed of a simulator and
hence in its quality.

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Programul de chirurgie bariatric al spitalului Sf. Constantin Braov


The Bariatric Program of St. Constantin Hospital Braov
B. Moldovan (1), D. Pocrea (1), Luminia Cmpeanu (2), Andreea Moldovan (3), C. C. Rad (1), Svetlana Enache (4)
(1) Spitalul Sf. Constantin, Chirurgie General, Braov, Romnia
(2) Spitalul Sf. Constantin, Anestezie i Terapie Intensiv, Braov, Romnia
(3) Spitalul Sf. Constantin, Boli Infecioase, Braov, Romnia
(4) Spitalul Sf. Constantin, Chirurgie Vascular, Braov, Romnia
Scop: Lucrarea i propune prezentarea experienei noastre de peste 4 ani n chirurgia bariatric.
Metod : Programul bariatric al Spitalului Sf. Constantin din Braov a nceput n anul 2011. Pn n februarie 2016 au fost efectuate un numr de 329 de
intervenii bariatrice: 321 de operaii de sleeve gastric longitudinal laparoscopic, 69 dintre acestea au fost realizate prin abord unic LESS-SILS. Prin manier
deschis au fost efectuate 8 cazuri, 6 dup gastroplastie vertical deschis, 1 dup ablaie de inel pe cale clasic i un caz de eventraie gigant cu pierderea
dreptului la domiciliu, ca prim timp nainte de cura eventraiei. Menionm i un caz de gastric sleeve laparoscopic dup Diversie Bilio-Pancreatic Scopinaro i 2
gastoplicaturi longitudinale. BMI-ul mediu preoperator este de 43, cu limite ntre 32,6 i 78,7; 7 cazuri depind grania a 200 kg.
Rezultate: S-a nregistrat o singur fistul la nivelul liniei de agrafare, rezolvat prin drenaj laparoscopic i tratament conservator, n rest s-au nregistrat
complicaii postoperatorii clasele Clavien-Dindo I i II, nenregistrndu-se decese. Din totalul de 73 cazuri cu diabet tip II preoperator, 67 sunt sevrate n prezent
de terapia cu Anti Diabetice Orale sau Insulin. Scderea ponderal medie este de 36 kg iar durata medie de spitalizare postoperatorie a fost de 2,3 zile.
Concluzie: Programul nostru bariatric se axeaz pe GSL n variantele standard i LESS, cu rezultate bariatrice i chirurgicale foarte bune.

Purpose: The paper aims to present our over 4 years of experience in bariatric surgery.
Method: St. Constantin Hospitals Bariatric Program began in 2011. Until February 2016 there were performed a total of 329 gastric sleeves, 321 laparoscopic
with 69 LESS-SILS approach and 8 cases through open method, 6 after vertical open gastroplasty, 1 after ring ablation and 1 case in a patient with giant ventral
hernia. We mention as well a case of laparoscopic gastric sleeve after Scopinaro Biliopancreatic diversion and 2 cases of gastric plication (1 laparoscopic, 1 open).
Apart from the previously mentioned surgeries there was also performed 2 laparoscopic gastric ring ablation as prime time of a redo surgery. The pre-surgery
mean BMI was 43, with ranges between 32,6 and 78,7. 7 cases exceeded the 200 kg limit.
Results: There was registered only one fistula at the stapling lines level, solved through laparoscopic drainage and conservatory treatment. 67 from 73 type 2
diabetes patients are currently without oral anti diabetic drugs or insulin. The average weight loss was 36 kg and the average hospitalization after the surgery
was 2,3 days.
Conclusion: Our bariatric program is based on laparoscopic sleeve gastrectomy in both standard and LESS variants, with excellent surgical and bariatric results.

Duodenopancreatectomie total laparoscopic pentru neoplasm pancreatic intraductal


Total Laparoscopic Duodenopancreatectomy for Intraductal Papillary Mucinous Pancreatic Neoplasia
A. Barto (1), C. Iancu (2), C. Breazu (3), Raluca Marcela Stoian (1), Dana Monica Barto (4)
(1) Institutul Regional de Gastroenterologie i Hepatologie Prof. Dr. Octavian Fodor, Clinica Chirurgie III, Cluj-Napoca, Romnia
(2) Universitatea de Medicin i Farmacie Iuliu Haieganu, Secia Chirurgie III, Cluj-Napoca, Romnia
(3) Universitatea de Medicin i Farmacie Iuliu Haieganu, Secia ATI I, Cluj-Napoca, Romnia
(4) Universitatea de Medicin i Farmacie Iuliu Haieganu'', Disciplina de Anatomie i Embriologie, Chirurgie III, Cluj-Napoca, Romnia
Obiective: Pancreatectomia efectuat exclusiv pe cale laparoscopic reprezint cea mai avansat tehnic laparoscopic din arsenalul terapeutic al chirurgiei
pancreasului. Dei literatura de specialitate indic faptul c aceast intervenie este fezabil i poate fi la fel de sigur ca i duodenopancreatectomia prin
laparotomie, complexitatea tehnic i riscul de apariie al complicaiilor fac ca puini chirurgi s opteze pentru aceast abord.
Prezentare caz: V prezentm cazul unui pacient n vrst de 40 ani, diagnosticat cu neoplazie pancreatic intraductal (IPMN), la care am practicat
duodenopancreatectomie total laparoscopic cu anastomoz hepatico-jejunal pe ans ascensionat ''in situ'' i gastro-jejunoanastomoz precolic. Evoluia
postoperatorie a fost grevat de apariia unei fistule biliare tardive (ziua 13 postoperator) drenat extern, rezolvat prin tratament specific.
Concluzii: Considerm c abordul total laparoscopic este fezabil n chirurgia radical a pancreasului, foarte important fiind selecia atent a pacienilor,
particularitile anatomopatologice ale acestora, mpreun cu tehnica i experiena echipei chirurgicale, toate acestea putnd influena evoluia postoperatorie.

Objectives: Pancreatectomy, performed exclusively by laparoscopic technique is the most advanced laparoscopic procedure from the pancreatic surgery arsenal.
Although the literature indicates that this surgery is feasible and can be as safe as classic duodenopancreatectomy, because of the technical complexity and the
risk of complications, few surgeons chose this approach.
Case presentation: We present the case of a 40-year old patient, diagnosed with pancreatic intraductal neoplasia (IPMN) for which I performed a laparoscopic
total duodenopancreatectomy with hepatico-jejunal anastomosis by ''in situ'' ascended loop and precolic gastrojejunal anastomosis. The postoperative outcome
was marked by a late biliary fistula (day 13 post surgery), externally drained, that was solved by specific treatment.
Conclusions: We believe that total laparoscopic approach is feasible for radical surgery of the pancreas, a very important aspect being the careful selection of
patients, their anatomopathological particularities, surgical technique and the experience of the surgical team in advanced laparoscopic procedures. All this can
influence the outcome of the surgery.
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Perspectivele utilizrii abordului laparoscopic transabdominal preperitoneal (TAPP) n tratamentul herniilor
inghinale
Prospects for the Use of the Laparoscopic Transabdominal Pre-Peritoneal Approach (TAPP) in Groin Hernia Repair
A. Dima, R. Targon, F. Potlog
Spitalul Clinic Militar Central / Universitatea de Stat de Medicin i Farmacie Nicolae Testemianu, Catedra Chirurgie Nr. 5, Chiinu, Republica Moldova
Introducere: Abordul laparoscopic n cura herniilor inghinale devine intervenie de elecie pe plan mondial. Rmne actual problema standardizrii tehnicii
chirurgicale i optimizarii rezultatelor acestui procedeu.
Materiale i metode: n perioada anilor 2008-2014 n clinic a fost efectuat cura laparoscopic a herniei inghinale la 271 pacieni (16 bilateral). Repartiia herniilor
conform clasificrii L.M.Nyhus: tip II (n=188), tip IIIa (n=64), tip IIIb (n=18), tip IIIc (n=9), typ IV (n=12). A fost utilizat tehnica transabdominal preperitoneal (TAPP).
Rezultate: Durata interveniei a constituit in medie 47.8 25.07 minute, fiind mai lung pentru hernii recidivante 9548.99 min. (60-180) i bilaterale 92.7823.47
min (65-140). Mediana spitalizrii 3 zile, rentoarcerea n cmpul muncii - sub 10 zile. Incidentele intraoperatorii au fost corectate laparoscopic. Conversia efectuat
la un pacient. Nu au fost constatate cazuri de infecie n plaga postoperatorie. Aprecierea rezultatelor tratamentului chirurgical la distan a fost realizat la 223
pacieni. Pentru evaluarea durerii la pacienii cu diagnosticul hernie inghinal a fost utilizat scala de evaluare numeric NRS-11. n perioada postoperatorie au
prevalat pacieni cu sindrom algic redus (NRS 1-3). Algoparestezia postoperatorie persistent a fost diagnosticat la 4 pacieni. Recidiva herniei a fost nregistrat
la 2 pacieni, n ambele cazuri recidiva a fost corectat laparoscopic.
Concluzii: Experiena noastr confirm posibilitatea utilizrii procedeului TAPP la diferite tipuri de hernie inghinal. Acumularea experienei permite de a lrgi
indicaiile pentru abordul laparoscopic la pacienii cu hernii bilaterale, glisante i recurente. Avantajele hernioplastiei laparoscopice sunt: micorarea sindromului
algic postoperator, reintegrarea socioprofesional rapid i numrul redus de complicaii parietale.

Background: The transabdominal pre-peritoneal procedure (TAPP) represents one of the most popular techniques used for inguinal hernia repair. The analysis of
the reported cases helps to standardize the relatively new laparoscopic technique and to improve the overall results.
Materials and Methods: The group of 271 patients underwent laparoscopic hernia repair (16 bilateral) for the period 2008-2014. According to L.M.Nyhus
classification, the groin hernias were classified as type II (n=188), type IIIa (n=64), type IIIb (n=18), type IIIc (n=9), type IV (n=12). The TAPP procedure was utilized.
Results: The mean operating time was 47.8 25.07 minutes, being statistically longer for recurrent hernias 9548,99 min. (range, 60-180) and bilateral hernias
92,7823,47 min. (range, 65-140). The average length of hospital stay was 3 days. Patients returned to work in an average of 10 days. The postoperative
morbidity rate was 2,2%. The majority of intraoperative incidents (intraoperative hemorrhage, n=4) were solved laparoscopically without sequelae. One case was
converted to Lichtenstein repair. Patients were evaluated at a median follow-up of 24 month (range, 12-36 month). A total of 223 patients were assessed for
long-term outcomes. Pain was assessed with Numerical Rating Scale (NRS -11). The vast majority of post-operative patients had minor pain manifestation of pain
(NRS 1-3). We observed 4 cases of persistent inguinal pain. The hernia recurrence was developed in 2 patients and has been corrected via laparoscopic approach.
Conclusions: While laparoscopic hernia repair requires a lengthy learning curve, it represents a safe and valid alternative to open hernia repairs and could be
effectively used for bilateral, recurrent and sliding hernias. The advantages of laparoscopic repair include less postoperative pain, faster return to normal
activities and low wound infection rate.

Dispozitive originale utilizate n chirurgia chistului hidatic hepatic


Original Devices Used in Hydatid Hepatic Cyst Surgery
D. Sabu (1), D. G. Bratu (1), H. Noor Mohammady Far (2), Vanina Marcu Iordnescu (2), A. Popeniu (3), . u (4), A. D. Sabu (1)
(1) Universitatea Lucian Blaga, Chirurgie II, Sibiu, Romnia
(2) Spitalul Clinic Judeean de Urgen, Chirurgie II, Sibiu, Romnia
(3) Spitalul Militar de Urgen, Chirurgie, Sibiu, Romnia
(4) Universitatea de Medicin i Farmacie Iuliu Haieganu, Cluj-Napoca, Romnia
Introducere: Chistul hidatic hepatic reprezint una din afeciunile nc frecvent ntlnite n Romnia i n lume. Chistulunic sau multiplu, cu localizri diverse, uor
sau dificil accesibile, constituie din ce n ce mai frecvent subiect i obiect de studiu i tratament al chirurgiei laparoscopice.
Experiena, curba de nvaare, cunoaterea aprofundat a anatomiei hepatice i perihepatice, precum i apariia unor dispozitive novatoare brevetate sau n curs
de brevetare ne-au permis accesul din ce n ce mai securizat pentru pacient n condiiile abordului miniinvaziv.
Material i metod: Pacienii de la 4 la 80 ani cu localizri corticale sau profunde ale chistului hidatic hepatic, n segmente anterioare sau posterioare, au fost
operai laparoscopic ca prim intervenie sau intervenie secundar pentru recidiva la 4-18 ani dup chirurgie deschis.
Metoda a uzat de dispozitive chirurgicale laparoscopice originale brevetate sau n curs de brevetare ce vizau abordul securizat al chistului, fluidizarea structurilor
semisolide i colectarea acestora cu evitarea ferm a contaminrii.
Rezultate: Confortul intraoperator, posibilitatea de a filma ntreaga intervenie i de a demonstra securitatea antiparazitar alturi de evoluie simpl
postoperatorie, durat de spitalizare redus i convalescent anodin, ne fac s recomandam chirurgia laparoscopic de prim intenie, aa-zisa selectare a
cazurilor pentru conversia n chirurgia deschis rmnnd s fie fcuta mai degraba intraoperator dect preoperator.
Concluzii: Considerm chirurgia miniinvaziv (laparoscopic) soluia de prim ordin n chirurgia chistului hidatic hepatic, motivate de sigurana pacientului,
fermitatea soluiilor antiparazitare a dispozitivelor, reducerea efortului financiar i n final, indicele de satisfacie a pacientului.

Introduction: The hepatic hydatid cyst represents one of the diseases that are still commonly found in Romania and worldwide. Single or multiple cysts with
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diverse, easily or difficult accessible locations, become increasingly more frequently the subject and object of study ant treatment in laparoscopic surgery.
The experience, learning level, thorough knowledge of hepatic and perihepatic anatomy, as well as the emergence of some innovative, patented or patent
pending devices, allowed us increasingly more secured access for the patient, in the conditions of miniinvasive approach.
Material and method: Patients between the ages of 4 and 80 years with peripheral or deep locations of hepatic cysts, in anterior or posterior segments, were
operated laparoscopically as the first intervention or secondary intervention for relapse after 4-18 years after open surgery.
The method used original, patented or patent pending, laparoscopic surgical devices, which aimed secure approach of the cyst, streamlining of semisolid
structures, and collecting them with a firm avoidance of contamination.
Results: Intraoperative comfort, possibility of filming the intervention, and the opportunity to demonstrate the antiparasitic safety, together with postoperative
simple passage, shorter hospitalization and harmless convalescence, make us recommend laparoscopic surgery as the first intent; the case selection for convert
to open surgery remains to be done rather intraoperative than preoperative.
Conclusions: We consider the miniinvasive (laparoscopic) surgery as the first intent solution in the surgery of hepatic hydatid cyst, being motivated by the patient
safety, firmness of antiparasitic solutions and devices, decreased financial effort, and finally, the index of patient satisfaction.

Endoscopia i chirurgia general - pri ale unui ntreg


Endoscopy and General Surgery - Parts of the Same Activity
H. Doran, E. L. Catrina, P. Mustea, T. Ptracu
Spitalul Clinic Dr. Ioan Cantacuzino, Departamentul 10 - Chirurgie General, Bucureti, Romnia
Obiectiv: n serviciile de chirurgie general i digestiv, diagnosticul i tratamentul adecvate necesit accesul pe scar larg i practic continuu la metodele
endoscopice. n condiiile n care numeroase clinici de chirurgie dispun deja de propriile uniti de endoscopie diagnostic i, eventual, intervenional,
considerm oportun luarea n discuie a includerii unui modul de endoscopie n programul de pregtire a medicilor rezideni de chirurgie general.
Materiale i metode: Am analizat retrospectiv activitatea unitii de endoscopie digestiv din Clinica de chirurgie a Spitalului Dr.I.Cantacuzino din 2007, cnd a
fost nfiinat, ncercnd s identificm beneficiiile pe care le-a adus att pentru accesibilitatea pacienilor, ct i ca suport pentru activitatea medicilor din clinic.
Rezultate: Numrul de proceduri a crescut continuu, de la 486, efectuate de 2 chirurgi n 2008, la aproape 1500, n 2015, cnd exist 7 chirurgi cu competen n
endoscopie, capabili s abordeze n mod practic continuu cazurile aprute. Endoscopia i-a dovedit avantajele pentru diagnosticul etiologic al hemoragiilor
digestive superioare i inferioare, depistarea precoce a tumorilor gastrice, colonice i ale rectului superior, monitorizarea post-operatorie a pacienilor oncologici.
n plus, chirurgii au pregtirea efectiv i competena legal necesare pentru rezolvarea complicaiilor metodei, cum ar fi perforaiile iatrogene ale colonului.
Discuii: Dei activitatea unei singure clinici nu poate fi relevant, putem considera, innd seama de experiena multor alte servicii i de reglementrile din alte
ri, c o cretere a numrului de chirurgi cu competen n endoscopie nu poate fi dect benefic.

Aim: In general and digestive surgical departments, an accurate diagnosis and appropriate treatment of our patients requires a wide and continuous access to
endoscopy. As many surgical clinics have already developed their own endoscopy units, we plead for the future inclusion of basic endoscopic skills in the training
of residents in general surgery.
Materials and Methods: We retrospectively analysed the activity of the endoscopic unit as a part of the Surgical Clinic of Dr. I. Cantacuzino Clinical Hospital
since 2007, when it was settled, and its benefits, regarding a higher accessibility for our patients and a reliable support for all the doctors.
Results: The number of procedures has increased constantly, from 486, performed by 2 surgeons in 2008 to almost 1500, in 2015, when 7 surgeons were able to
involve themselves in endoscopic procedures, on a 24/7 schedule. Etiological diagnosis of gastrointestinal haemorrhages, early detection of gastric, colonic and
upper rectal tumours, follow-up of oncologic patients are only a few of the fields in which endoscopy proved its benefits. Furthermore, surgeons are trained and
have the legal board certification for the approach and treatment of complications, such as colonic iatrogenic perforations.
Discussion: The experience of only one department cannot be very relevant. Nevertheless, in accordance with other countries practice, we think that surgeons
should be encouraged to learn basic skills of diagnostic endoscopy.

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Colecistectomia laparoscopic versus colecistectomia clasic la pacientul peste 60 de ani cu colecistit acut
Laparoscopic Cholecystectomy versus Classical Cholecystectomy Patient Over 60 with Acute Cholecystitis
C. Savlovschi, D. erban, C. Brnescu, B. Sandolache, C. Tudor, Simona Andreea Blescu
Spitalul Universitar de Urgen, Clinica Chirurgie IV, Bucureti, Romnia
Obiective: Lucrarea i propune s evalueze particularitile colecistectomiei laparoscopice la pacienii cu vrst peste 60 de ani. Material i metod: S-a efectuat
un studiu retrospectiv n perioada 2008-2015 pe pacienii internai n clinica noastr pentru colecistit acut. S-au definit 2 grupuri: grup A pacieni >60 de ani
i grup B pacieni <60 de ani. S-au analizat comparativ datele cu privire la: tarele organice asociate, tipul interveniei chirurgicale (clasic vs laparoscopic), rata
conversiei, incidena complicaiilor i durata medie de spitalizare pentru cele 2 grupuri. Rezultate: Din totalul de 497 pacieni, 149 au avut vrst peste 60 ani
(grup A). Tehnica laparoscopic a fost practicat n 38,25% cazuri pentru grupul A i n 83,62% cazuri pentru grupul B. Decizia de alegere a tehnicii clasice a fost
influenat n ambele grupuri de prezena tarelor cardio-vasculare i respiratorii, antecedente chirurgicale abdominale i forma anatomoclinic (plastron, litiaz
CBP asociat). Rata conversiei a fost de 17,54% (10 cazuri) n grupul A versus 6,61% (23 cazuri) n grupul B. Nu au existat diferene semnificative n ceea ce
privete durata de spitalizare i complicaiile pacienilor operai laparoscopic din grupul A fa de grupul B. Recuperarea postoperatorie a fost mai rapid pentru
pacienii peste 60 de ani operai laparoscopic versus cei operai clasic. Concluzii: Considerm c la pacientul cu vrst peste 60 de ani colecistectomia
laparoscopic poate fi practicat n siguran fr o cretere suplimentar a riscului chirurgical, cu condiia seleciei corecte a indicaiei de laparoscopie i
utilizarea unei echipe chirurgicale cu experien.

Objectives: This paper aims to evaluate the peculiarities of laparoscopic cholecystectomy in patients over 60 years of age. Methods: We conducted a
retrospective study on patients admitted during 2008-2015 in our clinic for acute cholecystitis. We defined two groups: group A patients >60 years and group B
- patients <60 years. Comparative data were analyzed with respect to: associated pathology, type of surgery (laparoscopic vs classic), conversion rate, incidence
of complications and average length of stay for the 2 groups. Results: Out of the 497 patients, 149 were older than 60 years (group A). Laparoscopic technique
has been practiced in 38.25% cases in group A and in 83.62% for group B. The decision to choose classical cholecystectomy was influenced in both groups by
the presence of cardiovascular and respiratory severe disorders, previous abdominal surgical history and anatomoclinical form (associated pericholecystitis,
choledocholithiasis). The conversion rate was of 17.54% (10 cases) in group A versus 6.61% (23 cases) in group B. There were no significant differences in terms of
length of stay and complications rate between patients who underwent laparoscopic surgery in group A compared to group B. Postoperative recovery was faster
for patients over 60 years who underwent laparoscopic surgery versus those who underwent classical cholecystectomy. Conclusions: We believe that in patients
older than 60 years, laparoscopic cholecystectomy can be performed safely without further increasing the surgical risks, but an experienced surgical team and
careful patient selection are necessary.

Drenri postERCP n colangite purulente


AfterERCP Drainages in Suppurative Cholangitis
D. Munteanu, A. Pnzescu
Spital Clinic Municipal, Secia Chirurgie I, Bli, Republica Moldova
Introducere: Colangita supurativ acut (CSA) este fatal dac o drenare biliar adecvat nu se obine n timp util. Cauze majore de CSA sunt coledocolitiaza i
dereglarea de pasaj biliar, dar nu se tie care pacieni sunt susceptibili de a dezvolta aceast patologie.
Obiectivul studiului: Evaluarea eficacitii tratamentului la pacieni cu CSA, folosind diferite tipuri de drenri endoscopice ale cii biliare principale (CBP).
Material i metode: S-a analizat un lot de 47 bolnavi cu CSA, tratai n SCM Bli pe parcursul anilor 2008 - 2015. S-a practicat: drenaj nazobiliar la 13 bolnavi,
biliodigestiv (stent7Fr) la 20 bolnavi i combinarea acestor metode la 14 bolnavi. S-a monitorizat evoluia dup criteriile de febr, hemogram, bilirubin, zile/pat.
Rezultate: S-a constatat o ameliorare vdit a pacienilor cu drenaj combinat prin scderea febrei i bilirubinei din prima zi i scurtarea spitalizrii cu 2 zile/pat (8
vz 10).
Concluzii: Drenarea endoscopic combinat a cilor biliare cu stent i dren nazobiliar n CSA are o eficacitate mai bun n comparaie cu folosirea acestor metode
de drenare separat.

Introduction: Acute suppurative cholangitis (ASC) is fatal if adequate biliary drainage is not obtained in a timely manner. ASC major causes are coledocholithiasis
and bile passage disturbance, but it is not known which patients are likely to have set up this pathology.
Objectives: The objective of this study is to analyses the therapeutic success in patients with a ASC, using different types of endoscopic drainage of the bile duct.
Materials and Methods: We analyzed a group of 47 patients with ASC, treated over the years 2008 - 2015 in MCH Bli. It was practised: drainage nazobiliar 13
patients, biliodigestive (stent 7 Fr) on 20 patients and on 14 patients a combination of these methods. Monitoring the evolution of the cases was made using the
following criteria: fever, blood count, bilirubin, day/bed.
Results: We found an obvious improvement of patients with drainage combined with lowering of the fever and bilirubin from day one and shortening
hospitalization 2 day/bed.
Conclusions: Combined endoscopic biliary drainage, stent and drainage nazobiliar, in ASC have better efficacy compared to the use of these methods separate.

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Esofagectomia minim invaziv prin triplu abord McKeown modificat pentru cancerul esofagian toracic
Minimally Invasive Esophagectomy Using Modified McKeown Triple Approach for Thoracic Esophageal Cancer
S. Constantinoiu (1), Rodica-Daniela Brl (1), D. Predescu (1), A. Constantin (1), P. Hoar (1), I. F. Achim (1), M. Gheorghe (1), M. Boeriu (1), Elena-Roxana Timofte (2),
A. Caragui (1)
(1) Universitatea de Medicin i Farmacie Carol Davila, Centrul de Excelen Chirurgie General i Esofagian, Bucureti, Romnia
(2) Spitalul Clinic Sf. Maria, Centrul de Excelen Chirurgie General i Esofagian, Bucureti, Romnia
Prezentm n sesiunea video experiena primelor cazuri de esofagectomie minim invaziv prin triplu abord McKeown modificat.
Pentru abordul toracoscopic am folosit poziia de decubit lateral stng iar pentru abordul laparoscopic i cervical poziia francez de decubit dorsal.
n timpul toracoscopic s-a practicat seciunea crosei venei azygos cu un stapler vascular, disecia esofagului toracic i limfadenectomia mediastinal s-au facut cu
ajutorul electrodului monopolar Hook i pensa Ligasure.
Mobilizare gastric laparoscopic cu secionarea pedicului coronar cu un stapler vascular i limfadenectomie la nivelul plexului celiac este urmat de incizia
latero-cervical stng cu secionarea esofagului cervical i extragerea piesei de esofagectomie printr-o minilaparotomie epigastric.
Prepararea grefonului se poate face dup tehnica Akiyama cu tubulizarea stomacului i rezecia micii curburi sau tehnica Nakayama cu seciunea grefonului
gastric la nivelul cardiei cu un stapler linear precum i practicarea unei piloroplastii extramucoase i montarea unei jejunostomii de alimentaie.
S-a practicat gastric pull-up prin mediastinul posterior i anastomoza eso-gastric cervical. Evoluiile postoperatorii au fost marcate la unele cazuri de apariia
unei fistule cervicale tratate conservator.
Pentru a avea anse de rezecabilitate i fr conversie i pentru a evita accidentele n timpul toracic (leziunea membranei traheale, bronhiilor, trunchiuri
vasculare importante) este important selecia preoperatorie a cazului.
Indicaia pentru abordul minim invaziv este reprezentat de tumorile incipiente sau cele cu rspuns la tratamentul neoadjuvant.

We present in the video session the initial experience of the first minimally invasive esophagectomy cases using modified McKeown triple approach.
For the thoracoscopic approach we used the left lateral decubitus position while for the laparoscopic and cervical approach the French supine position.
During the thoracoscopic interval, the section of the azygos vein was performed using a vascular stapler and the dissection of the thoracic esophagus and the
mediastinal lymphadenectomy were done using monopolar electrode and Ligasure forceps.
Laparoscopic gastric mobilization, with sectioning of the left gastric pedicle (using a vascular stapler) and celiac plexus lymphadenectomy is followed by a left
lateral cervical incision and by the cutting of the esophagus and extraction of the esophagectomy specimen by an epigastric minilaparotomy.
Preparation of the graft can be done using the Akiyama technique with gastric tubing and resection of the lesser gastric curvature or the Nakayama technique
that implies the resection of the cardia with a linear stapler and practicing an extra mucosal pyloroplasty and mounting a feeding jejunostomy.
Gastric pull-up through the posterior mediastinum followed by a cervical esogastric anastomosis were performed. Postoperative evolution was marked in some
cases by the appearance of a cervical fistula that was treated conservatively.
Preoperative selection of the cases is important in order to improve resectability chances without converting and avoid accidents during thoracic time (tracheal
membrane, bronchial or major vascular trunks lesions). The indication for minimally invasive approach is represented by early tumors or those with good
response to neoadjuvant treatment.

Tehnica rendez-vous n tratamentul litiazei colecisto-coledociene


Rendez-vous Technique in the Treatment of Biliary Jaundice
M. T. Angelescu, M. C. Ardelean, V. Florescu, A. Miron
Spitalul Universitar de Urgen Elias, Secia de Chirurgie, Bucureti, Romnia
Litiaza colecisto-coledocian este o patologie frecvent ntlnit. Abordul modern minim invaziv este reprezentat de colecistectomia laparoscopic i
papilosfincterotomia endoscopic retrograd (ERCP) efectuate simultan - tehnica rendez-vous.
Obiectivul studiului a fost reprezentat de analiza experienei Clinicii de Chirurgie General a Spitalului Universitar de Urgen Elias n ceea ce privete aceast
patologie.
Materiale i metode: S-a efectuat un studiu retrospectiv pe 2 ani (2014-2015) n care s-au analizat 54 de cazuri care au avut nevoie de diferite proceduri de
endoscopie intervenional. Din totalul de cazuri aproximativ 35 au fost reprezentate de: litiaz restant CBP (27 cazuri), papilooddit stenozant (3 cazuri) i 5
cazuri de proteze CBP pentru icter mecanic de cauz neoplazic.
Restul de 19 cazuri au fost pentru litiaz colecisto-coledocian pentru care s-au practicat sub aceeai anestezie ambele intervenii: colecistectomie laparoscopic
i ERCP.
Rezultate: S-a reuit eliberarea CBP n 17 cazuri, iar 2 cazuri au necesitat conversie la chirurgia deschis.
Concluzii:
1. Cel mai bun i mai sigur tratament al litiazei colecisto-coledociane este intervenia de tip rendez-vous atunci cnd exist aceast posibilitate de a se efectua
n acelai timp operator.
2. Timpul interveniei chirurgicale este redus n comparaie cu un abord laparoscopic al litiazei CBP.
3. Prezena echipamentului i personalului de endoscopie la blocul operator faciliteaz rezolvarea litiazei colecisto-coledociene prin tehnica rendez-vous.
4. Durata de spitalizare a pacienilor la care s-a efectuat aceast tehnic este scazut fa de chirurgia clasic.

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Cholecisto-choledocal lithiazis is a frequent pathology. Modern minimally invasive approach is laparoscopic cholecystectomy in association with endoscopic
retrograde papilo-sfincterotomy (ERCP) known as the rendez-vous technique.
The purpose of the study was the analysis of the experience of General Surgery Clinic of the University Hospital Emergency Elias regarding this pathology.
Material and Methods: We conducted a retrospective study for two years (2014-2015) in which we analyzed 54 cases that needed various interventional
endoscopy procedures. There were 35 cases which were represented by: CBP stones (27 cases), Oddi sphincter stenosis (3 cases) and 5 cases of CBP prosthesis
for tumoral jaundice.
The remaining 19 cases were for cholecisto-choledocal lithiazis which were performed under the same anesthesia: laparoscopic cholecystectomy and ERCP.
Discussion: CBP release was managed in 17 cases and two cases required conversion to open surgery.
Conclusions:
1. The best and safest treatment of cholecysto-choledocal lithiazis is rendez-vous when there is the possibility to be performed in the same operation.
2. Surgery time is less regarding endoscopic clearance of CBP compared with laparoscopic approach.
3. The presence of endoscopy equipment and personnel facilitate the management of cholecysto-choledocal lithiazis by rendez-vous technique.
4. The hospital stay in patients who have undergone this technique is low compared to those with open surgery.

Limitri n abordul laparoscopic al herniilor incizionale - pot fi depite?


Limitations for Laparoscopic Approach of Incisional Hernias - Can We Overcome Them?
V. Calu (1), R. Prvulescu (2), M. Oun (2), B. Sturzu (2), A. Miron (1)
(1) Universitatea de Medicin i Farmacie Carol Davila / Spitalul Universitar de Urgen Elias, Clinica Chirurgie, Bucureti, Romnia
(2) Spitalul Universitar de Urgen Elias, Clinica Chirurgie, Bucureti, Romnia
Hernia incizional este o complicaie frecvent a interveniilor chirurgicale abdominale. Numeroase tehnici sunt descrise n chirurgia deschis, iar progresele
recente ale chirurgiei minim invazive au permis abordul laparoscopic cu bune rezultate. Exist ns muli factori care limiteaz abordul laparoscopic, n ciuda
progresul tehnic.
Autorii prezint un studiu retrospectiv al cazurilor de hernie incizional operate n Clinica Chirurgie a Spitalului Universitar de Urgen Elias n perioada
1.01.2014-1.03.2016. Au fost analizai factori ca: vrsta, sexul, BMI, comorbiditile, antecedentele de chirurgie abdominal, mrimea defectului. Fiecare dintre
aceti factori poate reprezenta o limitare n chirurgia laparoscopic, la care se adaug i experiena chirurgului i resursele financiare alocate interveniei. O
revizie a literaturii pe acest subiect este de asemenea fcut.
Concluzia este c exista nc multipli factori de limitare a abordului laparoscopic n chirurgia herniei incizionale, care pot fi depii n conditiile unui centru cu
experien, spre beneficiul evident al pacienilor.

Incisional hernia is a frequent complication after abdominal surgery. There are numerous techniques described in open surgery, and recent progress in minimal
access surgery allowed the laparoscopic approach with good results.
The authors present a retrospective study of cases with incisional hernia operated in the department of Surgery, Elias University Emergency Hospital between 1st
of January 2014 and 1st of March 2016. There were several factors submitted to analysis: age, sex, BMI, comorbidities, previous abdominal surgery, size of the
defect. Each one of these factors can be a limitation for laparoscopic surgery, associated with the surgeons experience and financial resources allocated for the
procedure. A revision of the literature on the subject is also done.
The conclusion is there are still many factors of limitation for laparoscopic approach in incisional hernia surgery, but they can be overcome in an experienced
center, for the obvious benefit of the patients.

Managementul laparoscopic al limfangioamelor chistice abdominale


Laparoscopic Management of Cystic Abdominal Lymphangioma
E. Trcoveanu (1), A. M. Vasilescu (1), N. Dnil (1), C. Bradea (1), . O. Georgescu (1), R. Moldovanu (2)
(1) Universitatea de Medicin i Farmacie Gr. T. Popa/ Spitalul Clinic Judeean de Urgene Sf. Spiridon, Clinica I Chirurgie, Iai, Romnia
(2) Clinique Sainte Marie, L'Unit de Chirurgie Viscrale, Digestive et Oncologique, Cambrai, Frana
Limfangioamele chistice (LC) sunt tumori benigne rare, cu origine limfatic (anomalie vascular congenital). Se localizeaz cel mai frecvent n regiunea feei i
gtului (75% - higroma chistic), urmate de localizrile mediastinale i axilare (20%) i 5% cu alte localizri. LC retroperitoneale reprezint <1% din cazuri. Material
i Metod: Prezentm o serie de 7 cazuri de LC abdominale operate prin abord laparoscopic din 17 LC operate n ultimii 10 ani, n Clinica 1 Chirurgie, Spitalul Sf.
Spiridon. Rezultate: Raportul sex feminin/masculin a fost de 6/1, cu o vrst medie de 35,6 ani (extreme 20-51 ani). Principalele simptome au fost durerea,
distensie abdominal i mas abdominal palpabil. Pacienii au fost examinai clinic, ecografic i CT. Diagnosticul de CL a fost suspectat preoperator doar n 3
cazuri. Explorarea laparoscopic a descoperit existena tumorii retroperitoneale, n 2 cazuri, iar n mezenter, n mare epiploon i n mezocolon cte un 1 caz. S-a
practicat excizia laparoscopic a chistului cu evoluie postoperatorie favorabil. Dimensiunea medie a tumorii a fost de 11,4 cm. Durata medie de spitalizare a fost
de 3,4 zile. Concluzii: Abordul laparoscopic este fezabil (standardul de aur), certific diagnosticul i permite excizia chirurgical complet, cu risc redus de
recidiv.

Cystic Lymphangioamas (CL) are rare benign tumors, with lymphatic origin (congenital vascular anomaly). They locate most frequently in the cranial region - face
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and neck (75% - cystic hygroma), mediastinum and axilla (20%) and 5% other locations. CL retroperitoneal represents <1% of cases. Methods: We report a series
of 7 cases of abdominal CL operated by laparoscopic approach from 17 CL, operated in the last 10 years in the First Surgical Clinic, St. Spiridon Hospital. Results:
The ratio female/male was 6/1, with a mean age of 35.6 years (20-51 years). The main symptoms were pain, abdominal distension and palpable abdominal mass.
Patients were examined clinically, ultrasound and CT. The diagnosis of CL was suspected preoperatively only in 3 cases. Laparoscopic exploration reveals the
existence of retroperitoneal tumor in 2 cases, in mesentery, in great omentum and in right mesocolon in 1 case each. We performed laparoscopic excision of the
cyst with favorable postoperative course. Mean tumor size was 11.4 cm. Mean hospital stay was 3.4 days. Conclusions: Laparoscopic approach is feasible (gold
standard), certified diagnosis and allows complete surgical excision, which reduces the risk of relapse.

Fistulojejunoanastomoza laparoscopic pe ans n y a la roux pentru fistul pancreatic extern dup pancreatit
acut balthazar e
Laparoscopic Fistulojejunostomy Roux-En-Y Loop for External Pancreatic Fistula after Acute Pancreatitis Balthazar E
F. Zaharie (1), C. Zdrehu (1), Roxana Zaharie (1), M. Tanu (1), Andrada Vduva (2), A. Pop (2), C. Iancu (1)
(1) Universitatea de Medicin i Farmacie Iuliu Haieganu, Institutul Regional de Gastroenterologie i Hepatologie Prof. Dr. Octavian Fodor, Cluj-Napoca,
Romnia
(2) Institutul Regional de Gastroenterologie i Hepatologie Prof. Dr. Octavian Fodor, Chirurgie 3, Cluj-Napoca, Romnia
Pacient n vrst de 54 ani se interneaz n oct. 2014 cu diagnosticul de pancreatit acut biliar sever Balthazar E (10/10). Ecografic i colangio RMN litiaz
coledocian i vezicular multipl. ERCP <48 h extrage peste 10 calculi coledocieni, plasare stent biliar. CT cu contrast la 1 luna dup internare deceleaz necroz
pancreatic central cu ruptur de duct Wirsung. La 7 sptmni de la debut se practic colecistectomie laparoscopic, necrosectomie laparoscopic pancreatic,
drenaje multiple. S-a practicat hemodiafiltrare pentru 96 de ore postoperator, tratament antibiotic conform antibiogramei, extragere stent. Evoluie favorabil, se
externeaz la 30 zile postoperator cu fistul pancreatic extern debit mediu 300 ml/zi. Se reinterneaz peste 6 luni, se practic fistulojejunoanastomoza pe ans
n Y a la Roux, adezioliz. Externare la 2 sptmni postoperator. Din datele din literatur, pn acum este primul caz de fistulojejunoanastomoza efectuat pe
cale laparoscopic, dup necrozectomie pancreatic laparoscopic.

54-year-old female patient is admitted in October 2014 with diagnosis of acute pancreatitis by biliary etiology severe form Balthazar E (10/10). Abdominal
ultrasound and colangio-MRI developed multiple stone in CBD and gallbladder. ERCP is performed <48 hours after onset pancreatitis, with extraction more than
10 stones from CBD, stent placement. After 1 month CT scan develop central pancreatic necrosis with Wirsung rupture at this level. 7 weeks after onset, we
performed laparoscopic cholecystectomy, laparoscopic pancreatic necrosectomy, multiple external drainage. 96 hours in TI hemodiafiltration was performed,
also antibiotic treatment according with antibiogram, stent removal. We discharge the patient 1 month after surgery with external pancreatic fistula (approx. 300
ml/day). After 6 months, the patient was readmitted in hospital. We performed laparoscopic fistulojejunostomy with Roux-en-Y loop, adesiolisis. This case appears
to be the first case in literature with laparoscopic fistulojejunostomy after laparoscopic pancreatic necrosectomy after acute pancreatitis.

Rolul laparoscopiei n abdomenul acut non-traumatic


Laparoscopy for Management of Non-Traumatic Acute Abdomen
A. Cotrle (1), Laura Gavril (2), E. Popa (3), Raluca Cosa (3)
(1) Universitatea Vasile Alecsandri, Spitalul Municipal de Urgen, Clinica de Chirurgie, Moineti, Romnia
(2) Institutul Regional de Oncologie, Clinica de Anestezie i Terapie Intensiv, Iai, Romnia
(3) Spitalul Municipal de Urgen, Clinica de Chirurgie, Moineti, Romnia
Introducere: Laparoscopia n abdomenul acut are att rol n stabilirea diagnosticului, confirmndu-l n situaiile echivoce, ct i n orientarea strategiei terapeutice
cu avantajele chirurgiei minim invazive.
Material i metod: Studiul nostru evalueaz 873 de cazuri de abdomen acut non-traumatic (exceptnd colecistita acut) abordate laparoscopic n perioada
2011-2015, urmrindu-se concordana diagnosticului pre i postoperator, stabilirea unui diagnostic intraoperator cert, incidena interveniilor laparoscopice, ct i
complicaiile acestora.
Rezultate: Diagnosticul intraoperator a fost de apendicit acut n 653 (75%) de cazuri, urgenele ginecologice au fost certificate la 146 (17%) pacieni (chist
ovarian eclatat, sarcin extrauterin, boal inflamatorie pelvin), 52 (6%) pacieni au fost diagnosticai cu ulcer perforat, 22 de cazuri fiind nregistrate cu alte
patologii (pancreatite acute, perforaii intestinale cu peritonite, diverticul Meckel perforat, infarcte enteromezenterice, peritonit TBC). Incidente i accidente au
fost ntlnite la 56 (6,5%) pacieni, au fost nregistrate 33 (3,7%) de conversii, complicaii postoperatorii fiind nregistrate n 37 (4,2%) de cazuri.
Concluzii: Laparoscopia diagnostic este o modalitate optim diagnostic n cazurile de abdomen acut non-traumatic, fiind salutar n cazurile de apendicit
acut, urgene ginecologice i peritonit de etiologie neprecizat cu posibilitatea rezolvrii pe aceast cale a patologiei identificate.

Aims: Laparoscopy for acute abdomen is important either for diagnostic, when there is uncertainty in establishing the etiology, and also has a therapeutic role
with the well-known advantages of minimally invasive surgery.
Material and Methods: Our study evaluates 873 patients of non-traumatic acute abdomen (excepting acute cholecystitis), approached laparoscopically between
2011 and 2015. The following factors were pursued: the concordance between pre and postoperative diagnostic, the establishment of a certain intraoperative
diagnostic, incidence of laparoscopic interventions and their complications.
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Results: There were 653 (75%) cases of acute appendicitis, 146 patients with gynecological (ruptured ovarian cyst, extrauterine pregnancy, inflammatory pelvic
disease), 52 (6%) patients with perforated ulcer, 22 cases with other pathologies (acute pancreatitis, enteral perforations, perforations of Meckel diverticulum,
entero-mesenteric infarction, tuberculous peritonitis), confirmed laparoscopically. Incidents and accidents were encountered in 56 (6,5%) cases, there were 33
(3,7%) conversions to open technique and for 37 (4,2%) patients there were recorded postoperative complications.
Conclusions: Diagnostic laparoscopy is an optimal method of diagnostic confirmation for cases of non-traumatic acute abdomen, especially for acute appendicitis,
gynecological emergencies and peritonitis of unknown etiology with the possibility of laparoscopic treatment of these pathologies.

Managementul laparoscopic al unui incidentalom suprarenalian stng voluminos prin abord transperitoneal
Laparoscopic Management of Voluminous Left Adrenal Incidentaloma by Transperitoneal Approach
R. C. Popescu, Cristina Dan
Spitalul Clinic Judeean de Urgen Sf. Apostol Andrei, Chirurgie General, Constana, Romnia
Obiectivul studiului: Suprarenalectomia laparoscopic reprezint actual principalul abord pentru masele tumorale suprarenaliene descoperite incidental
(incidentaloame), chiar i pentru cele cu dimensiuni peste 5 cm.
Material i metode: Prezentm cazul unui pacient de sex feminin, 40 ani, la care s-a descoperit incidental n urma unei echografii de rutin o formaiune chistic
suprarenalian stng de aprox. 8 cm, confirmat i prin examen IRM. S-a practicat suprarenalectomie stng laparoscopic prin abord transperitoneal cu
minipulare minim a glandei, fr incidente intraoperatorii. Durata operaiei aprox. 140 min.
Rezultate: Evoluie postoperatorie simpl, fr complicaii. Externare n ziua 2 postoperator. Examenul histopatologic nu a evideniat malignitate.
Concluzii: Incidentaloamele suprarenaliene pot fi abordate sigur i eficient pe cale laparoscopic, de ctre echipe antrenate n laparoscopia avansat, asigurnd
o recuperare postoperatorie rapid.

Objective: Laparoscopic adrenalectomy has become the main approach for adrenal masses discovered incidentally, even for those larger than 5 cm.
Material and Methods: We present the case of a female patient, 40 years old, discovered at a routine ultrasound with a left adrenal incidentaloma of 8 cm,
confirmed at MRI. The operation performed was a left laparoscopic adrenalectomy through transperitoneal approach, without intraoperative incidents. Operative
time aprox. 140 min.
Results: No postoperative complications occured. Discharge on the second postoperative day. Histopathological exam without malignancy.
Conclusions: Left adrenal incidentaloma can be safely approached laparoscopically with adequate experience, ensuring early recovery.

Studiu comparativ multicentric randomizat ntre abordul transabdominal preperitoneal (TAPP) i total
extraperitoneal (TEP) n tratamentul herniei inghinale
A Multicentric Randomized Comparison of Transabdominal (TAPP) versus Totally Extraperitoneal (TEP) Laparoscopic
Hernia Repair
D. Moga (1), V. tefnescu (2), V. Oprea (3)
(1) Spital Militar de Urgen Alexandru Augustin, Secia Chirurgie, Sibiu, Romnia
(2) Spitalul Universitar de Urgen Militar Central, Secia Chirurgie 1, Bucureti, Romnia
(3) Spitalul Militar de Urgen, Secia Chirurgie, Cluj-Napoca, Romnia
Scopul studiului a fost de a compara abordul transabdominal preperitoneal (TAPP) cu cel total extraperitoneal (TEP) n tratamentul minim invaziv al herniei
inghinale. n intervalul ianuarie 2014 - august 2015, n cele 3 secii de chirurgie n care activeaz autorii am efectuat un studiu prospectiv randomizat. Au fost luai
n studiu 100 de pacieni (TEP, 50; TAPP, 50) la care am analizat comparativ aspecte intraoperatorii i de evoluie pn la 1 lun postoperator. Cele dou grupuri
au fost comparabile n ceea ce privete profilul demografic i tipurile herniare. Nu am constat diferene semnificative statistic n ceea ce privete durata operaiei
(62,72 versus 65,60 minute, p=0.425), durerea postoperatorie (folosind scala vizual analoag), satisfacia pacientului (p=0.301). Pe lng anumite particulariti
i avantaje ale unei tehnici fa de cealalt, concluzia general a studiului este c fiecare dintre tehnici este fezabil i reproductibil. Nu poate fi susinut
superioritatea unei tehnici fa de cealalt.

The purpose of this study was to provide a comparison between extraperitoneal (TEP) approach and transabdominal (TAPP) as a minimally invasive treatment for
inguinal hernia. Between January 2014 - August 2015, we performed a prospective randomized study in all three departments where the authors have worked.
There have been included in the study 100 patients (TEP, 50; TAPP, 50) and we have compared intraoperatory and evolution aspects up to 1 month after surgery.
Both groups were comparable in terms of demographic profile and hernia characteristics. There werent significant statistics differences concerning the duration
of the operation (62.72 versus 65.60 min, p=0.425), postoperatory pain intensity (using a visual analogue scale), patients satisfaction (p=0.301). Besides certain
advantages and particularities of one technique to the other, the general conclusion of the study is that each one is feasible and reproducible. It cant be
sustained superiority of one procedure to the other.

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Abordul laparoscopic al chisturilor splenice


Laparoscopic Approach for Splenic Cysts
E. Trcoveanu, C. Bradea, A. M. Vasilescu, C. Lupacu, . O. Georgescu, N. Dnil
Universitatea de Medicin i Farmacie Gr. T. Popa/ Spitalul Clinic Judeean de Urgene Sf. Spiridon, Clinica I Chirurgie, Iai, Romnia
Introducere: Chisturile splenice sunt clasificate n chisturi primare (parazitare i nonparazitare) sau secundare (posttraumatice). Scopul acestui studiu a fost de a
evalua eficacitatea abordului laparoscopic n tratamentul chirurgical al chisturilor splenice.
Material i metod: Din 2006 pn n 2015, 11 pacieni au fost operai laparoscopic pentru chisturi splenice i abcese splenice: 7 splenectomii laparoscopice (3
chisturi hidatice, 2 chisturi nonparasitic, 2 chisturi posttraumatice) i excizie chist laparoscopic (tratament conservator) pentru 4 chisturi: 1 nonparazitar, 2
posttraumatice i 1 abces splenic. S-a utilizat abordul lateral cu patru trocare. Au fost urmrite datele demografice ale pacienilor, diagnosticul si rezultatele.
Rezultate: n splenectomia laparoscopic volumul splinei a fost de 300 ml, iar pierderile sanguine de 30 - 65 ml. Nu am nregistrat nicio conversie i nici
morbiditate postoperatorie semnificativ. Nu au fost observate complicaii tardive la o perioad de urmrire care a variat ntre 1-5 ani.
Concluzii: Abordul laparoscopic al chisturilor splenice ofer multe avantaje i poate fi tratamentul de alegere pentru aceast patologie. Tehnicile de conservare
splenice sunt indicate n cazul chisturilor nonparazitice.

Background: Splenic cysts are classified as primary (parasitic and nonparasitic) or secundary cysts (pottraumatic). The aim of this study was to evaluate the
efficacy of laparoscopic approach in surgical treatment of splenic cysts.
Methods: From 2006 to 2015, 11 patients underwent laparoscopic approach for splenic cysts and abscess: 7 laparoscopic splenectomy (3 hydatic cysts, 2
nonparasitic cysts, 2 posttraumatic cysts) and laparoscopic cyst excision (conservative treatment) for 4: nonparasitic cysts - 1, posttraumatic cysts - 2, and splenic
abcess - 1. The lateral approach with a four-trocar technique was used. Patient demographics, diagnosis, and outcomes were reviewed.
Results: In laparoscopic splenectomy, spleen volume was 300 ml and blood loss 30-65 ml. No conversion and postoperative morbidity were observed. No late
complications were observed during the 1-5-year follow-up.
Conclusions: The laparoscopic approach to splenic cysts offers many advantages and may be the treatment of choice for this pathology. Spleen-preserving
techniques should be attempted in every case of splenic nonparasitic cyst.

Eficiena terapiei cu vacuum n tratamentul plgilor complexe


Effectiveness of Vacuum Assisted Closure in Complex Wounds
M. D. Hogea, A. Cucu, E. Pandi
Spitalul Clinic Judeean de Urgen, Secia de Chirurgie, Braov, Romnia
Introducere: Managementul plgilor dificile rmne o provocare pentru chirurg, acestea fiind asociate cu o morbiditate crescut i costuri de tratament
semnificative.
Alturi de alte metode moderne de tratament, terapia cu vacuum s-a impus n ultimii ani n tratamentul plgilor complexe.
Beneficiile folosirii terapiei cu presiune negativ sunt reprezentate de: ndeprtarea exudatului i reducerea edemului plgii, creterea i mbuntirea
vascularizaiei, stimularea formrii esutului de granulaie, scderea necesarului de antibiotice, posibilitatea tratamentului n ambulator.
Aceast terapie s-a impus, de asemenea, prin reducerea timpului de vindecare al plgii, posibilitatea efecturii procedurii n ambulator, uurina utilizrii
dispozitivului, mbuntirea calitii vieii pacientului (reduce durerea, pansamentul se schimb la 2-3 zile).
Scopul lucrrii este acela de a prezenta experiena noastr n tratamentul plgilor dificile prin aceast metod, precum i prezentarea beneficiilor terapiei n
scopul introducerii acestei metode n algoritmul de tratament al plgilor complexe.
Plgile la care s-a aplicat aceast tehnic au fost reprezentate de: plgi complexe la pacieni imunodeprimai, escare de decubit de dimensiuni mari, proteze
vasculare i herniare cu risc de infecie, plgi cronice la pacieni diabetici.
Concluzii: Considerm c tratamentul plgilor cu ajutorul presiunii negative reprezint un real beneficiu n special la pacienii cu plgi cronice complexe. Aceast
metod grbete vindecarea i permite realizarea n siguran a tratamentului n regim ambulator.

Wound management remains a challenge for the surgeon, because of the increased morbidity and significant treatment costs.
Along with other modern methods of treatment, vacuum therapy was used in recent years in the treatment of complex wounds.
The benefits of using negative pressure therapy are: removal of wound exudate and reduced wound edema, tissue formation, decreased antibiotic usage and
possibility of treatment in outpatient settings.
This therapy also reduces the healing time, permits an early patient discharge, and improves quality of life (less painful dressing changes, every 2-3 days).
The purpose of this paper is to present our experience in the treatment of difficult wounds with this method, as well as presenting the benefits of this therapy,
and also the implementation of this method in the treatment algorithm of complex wounds.
We used this technique for immuno-compromised patients with complex wounds, large pressure sores, vascular grafts or herniar mesh with a high risk of
infection, chronic wounds in diabetic patients.
We believe that the treatment of wounds using negative pressure represents a real benefit, especially in patients with complex chronic wounds. This method can
accelerate the healing process, and enables a secure treatment at home.

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Herniile incizionale gigante: uor de diagnosticat i apoi?
Giant Incisional Hernias: Easy to Diagnose But What After?
C. V. Oprea Aron, D. Leuca, D. Gheorghescu, F. Buia, R. Anghelu
Spitalul Militar de Urgen Dr. Constantin Papilian, Secia de Chirurgie, Cluj-Napoca, Romnia
Introducere: Prezentm o serie de hernii incizionale gigante operate electiv prin 3 tehnici chirurgicale distincte: protezarea retromuscular Rives-Stoppa,
separarea anterioar a componentelor cu sau fr protezare i separarea posterioar a transversului abdominal cu protezare. Scopul este de a evalua rezultatele
acestor proceduri.
Metode: S-au analizat retrospectiv documentele medicale ale pacienilor internai n Spitalul Militar Cluj ntre 2013 i 2015. Au fost nregistrate datele demografice,
comorbiditile, tipul tehnicii de reconstrucie a peretelui abdominal, i evoluia postoperatorie.
Rezultate: Au fost luai i studiu 88 de pacieni cu vrsta medie de 58 ani. Timpul de mediu de urmrire a fost de 14 luni (2-24 luni). Dimensiunea medie a
defectului, msurat n sens transversal, a fost de 19 cm (15-32 cm), defectele recidivate deinnd o pondere de 52%. Operaia Rives-Stoppa a fost aplicat la 36
de pacieni, separarea anterioar a componentelor la 31 i separarea posterioar la 21 de pacieni. Complicaiile plgii au aprut la 32%, mai mult de jumtate
fiind reprezentate de infecii. Rata de recidiv a fost de 15% cu o medie de apariie de 16 luni. n raport cu tipul procedurii, recidiva a fost stratificat astfel:
Rives-Stoppa - 5 pacieni, separarea anterioar - 6 pacieni i separarea posterioar - 1 pacient.
Concluzii: Separarea posterioar, n ciuda datelor insufuciente pare s reprezinte operaia de elecie pentru herniile incizionale gigante.
Cuvinte cheie: hernie incizional, protez, separarea componentelor

Background: We present a consecutive series of large incisional hernias repaired electively with 3 different surgical procedures: retro-rectus prosthetic repair
(Rives-Stoppa), anterior component separation and transversus abdominis release with prosthetic reinforcement. We attempt to determine the outcomes of these
procedures.
Methods: Medical records from patients undergoing elective reconstruction of large incisional hernias admitted from 2013 to 2015 were reviewed. Demographics,
co-morbidities, specific type of reconstruction and postoperative events including wound events, surgical site infections (SSIs), and recurrence rate were
recorded.
Results: 88 patients were reviewed. Median age was 58 years and the median follow-up at the time of review was 14 months (2-24 months). Average size of the
fascial defect was 19 cm (15-32 cm) in width with recurrent defects making up 52% of repairs. In respect to the type of repair, Rives-Stoppa was applied to 36
patients, component separation in 31 and transverses release in 21. Wound events occurred in 32% of cases more than a half being SSIs. Recurrence rate was
15% with mean time of appearance of 16 months. According with the procedure the recurrence rate was: 5 patients for Rives-Stoppa, 6 for anterior component
separation and 1 for transverses abdominis release.
Conclusions: Even if we dont have enough data transverses release is a successful technique with acceptable rate of recurrence and complications for giant
abdominal wall hernias.
Key words: incisional hernia, prosthetics, component separation

Laparoscopie versus tehnica Rives n tratamentul herniilor incizionale


Laparoscopic versus Rives Technique in Ventral Hernia Repair
P. A. Radu, M. N. Brtucu, N. D. Garofil, Cristina Iorga, C. Iorga, M. Zurzu, V. Paic, F. Popa, V. D. E. Strmbu
Spitalul Clinic de Nefrologie Dr. Carol Davila, Chirurgie General, Bucureti, Romnia
Exist numeroase modaliti de reparare a herniei: numai cu nchidere primar, nchidere primar cu incizii de relaxare, nchideri primare cu ntrirea prin plas,
soluii alloplastice cu plasarea plasei retro-rectal, procedee laparoscopice. Am analizat dou procedee, laparoscopic i Rives: Au fost selecionai 60 de pacieni
pe o perioad de 3 ani, 30 de pacieni laparoscopic i 30 - procedeul Rives. Interveniile pentru hernia ombilical, hernia parastomal, procedurile non-selective,
procedurile realizate concomitent cu alte intervenii au fost excluse. Complicaiile postoperatorii au fost evaluate n mod prospectiv. Pacienii operai laparoscopic
au avut o rat mai scazut a complicaiilor post-operatorii i pe termen lung. Timpul operaiei a sczut semnificativ (p< 0.05). Timpul de spitalizare a fost mai
scazut (p<0.05). Infectarea plgii i ileusul postoperator au fost responsabile pentru rata crescut a complicaiilor la pacienii operai pe cale deschis. Herniile
efectuate pe cale deschis au avut o suprafa medie de 34.1 cm2, iar dimensiunea plasei a fost n medie de 47.3 cm2. Pentru grupul pacienilor operai
laparoscopic, defectul herniar a avut n medie 33.0 cm2, iar dimensiunea plasei n medie 67.4 cm2 Tratamentul laparoscopic, reduce complicaiile i rata de
recidiv, elimin reinterveniile datorate infectrii plasei, reduce timpul operator, scurteaz n mod considerabil timpul de spitalizare. Interveniile chirurgicale pe
cale laparoscopic pot fi efectuate n aproape toate cazurile de echipe antrenate n chirurgie laparoscopic parietal.

Exist numeroase modaliti de reparare a herniei: numai cu nchidere primar, nchidere primar cu incizii de relaxare, nchideri primare cu ntrirea prin plas,
soluii alloplastice cu plasarea plasei retro-rectal, procedee laparoscopice. Am analizat dou procedee, laparoscopic i Rives: Au fost selecionai 60 de pacieni
pe o perioad de 3 ani, 30 de pacieni laparoscopic i 30 - procedeul Rives. Interveniile pentru hernia ombilical, hernia parastomal, procedurile non-selective,
procedurile realizate concomitent cu alte intervenii au fost excluse. Complicaiile postoperatorii au fost evaluate n mod prospectiv. Pacienii operai laparoscopic
au avut o rat mai scazut a complicaiilor post-operatorii i pe termen lung. Timpul operaiei a sczut semnificativ (p< 0.05). Timpul de spitalizare a fost mai
scazut (p<0.05). Infectarea plgii i ileusul postoperator au fost responsabile pentru rata crescut a complicaiilor la pacienii operai pe cale deschis. Herniile
efectuate pe cale deschis au avut o suprafa medie de 34.1 cm2, iar dimensiunea plasei a fost n medie de 47.3 cm2. Pentru grupul pacienilor operai
laparoscopic, defectul herniar a avut n medie 33.0 cm2, iar dimensiunea plasei n medie 67.4 cm2 Tratamentul laparoscopic, reduce complicaiile i rata de
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recidiv, elimin reinterveniile datorate infectrii plasei, reduce timpul operator, scurteaz n mod considerabil timpul de spitalizare. Interveniile chirurgicale pe
cale laparoscopic pot fi efectuate n aproape toate cazurile de echipe antrenate n chirurgie laparoscopic parietal.

Hernie ventral operat prin abord laproscopic procedeu Rives - Stoppa


Ventral Hernia Repair by Rives - Stoppa Technique - Laparoscopic Approach
V. G. Radu, tefania Ene, Adriana Radu, M. Lic
Life Memorial Hospital, Chirurgie, Bucureti, Romnia
Tratamentul chirurgical al herniilor ventrale a trecut prin diferite etape: procedeele tisulare (astzi abandonate), procedeele alloplastice deschise, procedee
laparoscopice. Cu toate c rezolvarea minim-invaziv a acestor hernii prezint multe avantaje (absena complicaiilor plgii operatorii, recuperare rapid i
spitalizare de scurt durat), totui costul ridicat al protezelor compozite precum i suspiciunea apariiei unor complicaii legate de plasarea protezei n contact
direct cu viscerele abdominale reprezint pentru muli chirurgi motive pentru care acest procedeu nu este utilizat. Repararea herniilor ventrale pe cale
laparoscopic folosind procedeul Rives, aa cum ilustreaz i aceast prezentare video, nltur cu totul suspiciunile amintite. Este vorba de cazul unei paciente
n vrst de 58 de ani, cu o hernie epigastric veche, ncarcerat, care a fost rezolvat prin abord laparoscopic, procedeu alloplastic retromuscular Rives.
Operaia, care a durat 3 ore, a decurs fr incidente. Am folosit o protez de polipropilen de 15/15 cm montat retromuscular i fixat cu agrafe resorbabile,
dup refacerea prealabil a liniei albe. Pacienta a fost externat a 3-a zi postoperator.

The surgical treatment of ventral hernias has gone through various stages: tissue procedures (no more in use nowadays), open alloplastic procedures,
laparoscopic procedures. Although performing minim-invasive procedures has lot of advantages (minimal postoperative wound complications, fast recovery and
short hospital stay), the high price of composite prosthesis and the suspicion of complications caused by placement of the prosthesis in contact with viscera,
prompting surgeons to not perform these procedures frequently. As seen in this video, laparoscopic ventral hernias repair using Rives technique remove the
mentioned suspicions. This video present a 58 y.o. patient, female, presenting an epigastric incarcerated hernia, treated by laparoscopically approach,
Rives-Stoppa (sublay) technique. Procedure lasted for 3 hours without intraoperative incidents. I used a sublay 15/15cm polypropylene mesh, fixed with
absorbable tacks, after previous reconstruction of linea alba. Patient was discharged safely 3 days later.

Managementul chirurgical al herniilor ombilicale la pacieni cu ciroz hepatic i ascit rezistent


Management of Umbilical Hernias Associated with Hepatic Cirrhosis and Resistant Ascites
G. Anghelici (1), S. Pisarenco (1), O. Crudu (1), Maria Danu (1), I. Prac (2), G. Lupu (1), T. Zugrav (1)
(1) Universitatea de Stat de Medicin i Farmacie Nicolae Testemianu, Catedra Chirurgie Nr. 2, LC Hepatochirurgie, Clinica Chirurgie Constantin brn,
Chiinu, Republica Moldova
(2) Spitalul Clinic Municipal Sfnta Treime, Secia Chirurgie Septic, Chiinu, Republica Moldova
Introducere: Managementul chirurgical al herniilor ombilicale la pacieni cu ciroz hepatic cu ascit masiv rezistent rmne a fi n curs de dezbatere.
Scopul: Elaborarea tacticii chirurgicale de tratament n herniile ombilicale la pacienii cirotici cu ascit rezistent.
Material i metode: Studiul include 102 pacieni cirotici cu ascit masiv i hernii ombilicale complicate. I lot: 48 (47%) pacieni cirotici operai n mod urgent,
inclusiv 36 (75%) - cu eruperea sacului herniar, cu revrsarea lichidului ascitic i 12 (25%) cu hernii strangulate. La 9 (18,8%) pacieni concomitent s-a efectuat
hemostaz endoscopic pentru hemoragii variceale. II lot: 54 (53%) pacieni cirotici cu ascit masiv i risc de erupie spontan a herniei, operai programat,
dup o pregtire minuioas preoperatorie, exfuzia dozat preoperatorie a ascitei. Metoda plastiei tension-free no mesh monofilament. Plombarea
endoscopic profilactic a varicelor s-a efectuat la 29 (53,7%) pacieni.
Rezultate: Au decedat postoperator n I lot 7 (14,6%) pacieni prin insuficien hepatic, inclusiv 4 cu hemoragii variceale i 3 cu ascit-peritonit. n lotul II 1 (1,9%)
deces prin insuficien hepato-renal. Eventraii postoperatorii la 3-6 luni: I lot - 10 (20,8%); II lot 2 (3,7%).
Supurarea plgii postoperatorii: I lot 8 (16,7%), II lot fr complicaii.
Concluzii. La pacienii cirotici cu ascit, herniile ombilicale necesit tratament chirurgical programat. Hernioplastia de preferin este tension-free no mesh cu
suturi monofilament. Drenarea abdominal postoperatorie micoreaz riscul ascit-peritonitei. Examenul endoscopic preoperator pentru profilaxia hemoragiei
variceale este o condiie obligatorie.

Introducere: Managementul chirurgical al herniilor ombilicale la pacieni cu ciroz hepatic cu ascit masiv rezistent rmne a fi n curs de dezbatere.
Scopul: Elaborarea tacticii chirurgicale de tratament n herniile ombilicale la pacienii cirotici cu ascit rezistent.
Material i metode: Studiul include 102 pacieni cirotici cu ascit masiv i hernii ombilicale complicate. I lot: 48 (47%) pacieni cirotici operai n mod urgent,
inclusiv 36 (75%) - cu eruperea sacului herniar, cu revrsarea lichidului ascitic i 12 (25%) cu hernii strangulate. La 9 (18,8%) pacieni concomitent s-a efectuat
hemostaz endoscopic pentru hemoragii variceale. II lot: 54 (53%) pacieni cirotici cu ascit masiv i risc de erupie spontan a herniei, operai programat,
dup o pregtire minuioas preoperatorie, exfuzia dozat preoperatorie a ascitei. Metoda plastiei tension-free no mesh monofilament. Plombarea
endoscopic profilactic a varicelor s-a efectuat la 29 (53,7%) pacieni.
Rezultate: Au decedat postoperator n I lot 7 (14,6%) pacieni prin insuficien hepatic, inclusiv 4 cu hemoragii variceale i 3 cu ascit-peritonit. n lotul II 1 (1,9%)
deces prin insuficien hepato-renal. Eventraii postoperatorii la 3-6 luni: I lot - 10 (20,8%); II lot 2 (3,7%).
Supurarea plgii postoperatorii: I lot 8 (16,7%), II lot fr complicaii.
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Concluzii. La pacienii cirotici cu ascit, herniile ombilicale necesit tratament chirurgical programat. Hernioplastia de preferin este tension-free no mesh cu
suturi monofilament. Drenarea abdominal postoperatorie micoreaz riscul ascit-peritonitei. Examenul endoscopic preoperator pentru profilaxia hemoragiei
variceale este o condiie obligatorie.

Reconstrucia regiunii inghinale dup rezecii parietale i inghinale extinse


Regional Reconstruction After Parietal and Extensive Inguinal Resections
V. Muntean, O. Fabian, R. Tognel, T. Oniu, I. Simon, C. Lungoci, F. Murean, G. E. Petre, Emilia Ptru, D. Constantinescu
Spitalul Clinic Ci Ferate, Universitatea de Medicin i Farmacie Iuliu Haieganu, Clinica Chirurgie IV, Departamentul de Chirurgie, Cluj-Napoca, Romnia
Obiectivele studiului: Reconstrucia regiunii inghinale dup rezeciile parietale i inghinale extinse pentru tumori maligne sau infecii necrozante este dificil i
condiioneaz n multe situaii evoluia postoperatorie nefavorabil a pacienilor. Plecnd de la experiena pe 15 pacieni tratai ntre 2006-2015, prezentm
procedeul nostru de reconstrucie inghinal.
Material i metode: Partea de exerez a interveniei chirurgicale se face n limite de siguran oncologic i viabilitate tisular, fr economie, dar fr sacrificii
tisulare inutile. Peretele musculo-aponevrotic al regiunii inghinale se nlocuiete cu plas neresorbabil ancorat la faa profund a peretelui abdominal restant.
Ligamentul inghinal este refcut prin plierea plasei i ancorarea ei la pube, respectiv spina iliac antero-superioar, apoi plasa se aplic pe regiunea femural,
vasele iliace externe i muchiul iliopsoas. Plasa este separat de organele abdominale prin marele epiploon preparat pe vasele gastroepiploice stngi/drepte.
La suprafa plasa este acoperit de lambouri fascio-cutanate locale rotate, sau preferabil prin lambou miocutanat de drept abdominal. O variant o reprezint
acoperirea plasei cu marele epiploon i plastie cutanat cu piele despicat.
Rezultate: La 9 din cei 15 pacieni analizai evoluia postoperatorie a fost simpl; 3 pacieni au prezentat necroze pariale ale lambourilor cutanate de acoperire i
3 infecii de plag (toate tratate conservativ). La 2 pacieni evoluia postoperatorie a fost nefavorabil, prin recidiva rapid, n cursul internrii, a tumorii inghinale.
Concluzii: Prin procedeul prezentat am reuit o reconstrucie solid a regiunii inghinale i o vindecare rapid, condiie esenial a relurii tratamentului
multimodal care se impune la cei mai muli pacieni cu exereze inghinale extinse pentru cancer.

Study objectives: Regional reconstruction after parietal and extensive inguinal resections for malignant tumors or necrotizing infections is difficult and often
determinant for poor postoperative outcome. With experience gained in 15 patients (2006-2015) we present our procedure of inguinal reconstruction.
Patients and methods: Surgical resection is performed while observing oncological margins and tissue viability, without excessive tissue savings or unnecessary
tissue sacrifice. Muscular and aponeurotic layers of the inguinal region are reconstructed using a non-resorbable mesh anchored to the deep surface of the
remaining abdominal wall. The inguinal ligament is reconstructed by folding and anchoring the mesh to the pubis and the anterior-superior iliac spine,
respectively. Then the mesh applies over the femoral region, external iliac vessels and iliopsoas muscle. A great omentum flap pedicled on the left/right
gastro-epiploic vessel is interposed between abdominal organs and mesh, which is then covered with fascial and cutaneous locally-rotated flap, or preferably
with myocutaneous rectus abdominus muscle flap. Another option is covering the mesh with a great omentum flap, then covered with free split skin graft.
Results: In 9 of the 15 patients analyzed, postoperative outcome was uneventful; 3 patients had parietal necrosis of cutaneous flaps and 3 had secondary wound
infections (non-operative treatment for all). In two patients postoperative outcome was unfavorable with rapid (same hospital stay) recurrence of the inguinal
tumor.
Conclusion: Using our technique we performed a solid reconstruction of the inguinal area with fast healing, an essential determinant for the continuation of the
multimodal treatment necessary after extensive inguinal cancer resections.

Tratamentul eventraiilor abdominale - un studiu pe 165 de cazuri


The Treatment of Incisional Hernias - A Study on 165 Cases
V. C. Diaconu (1), F. A. Secureanu (1), Diana Stnescu (1), Claudia Mehedinu (2), D. Ulmeanu (3)
(1) Spitalul Clinic Nicolae Malaxa, Secia de Chirurgie General, Bucureti, Romnia
(2) Spitalul Clinic Nicolae Malaxa, Secia de Ginecologie, Bucureti, Romnia
(3) Spitalul Regina Maria, Secia de Chirurgie General, Bucureti, Romnia
Lucrarea i propune s prezinte experiena noastr n tratamentul minim invaziv al herniilor incizionale fcnd o comparaie cu tehnicile clasice n ceea ce
privete rata recidivelor, rata complicaiilor intraoperatorii, postoperatorii, cheltuielile globale, timpul de spitalizare, suferina postoperatorie a pacientului.
Statistica noastr se bazeaz pe 165 de cazuri, operate att laparoscopic ct i clasic (116 operaii laparoscopice, 49 operaii clasice) n ultimii 3 ani.
Vom prezenta diverse tehnici chirurgicale (metode de fixare, modaliti de tratare a defectelor parietale - nchiderea defectelor, separaia elementelor parietale
etc.) utilizate n tratamentul minim invaziv al herniilor incizionale i vom ncerca s tragem concluzii pertinente n ceea ce privete utilitatea acestora.

The study presents our experience in the minimal invasive treatment of incisional hernias comparing the rate of intraoperatory, and postoperatory complications,
the global expense, the time of hospitalization, the postoperatory patient suffering and the rate of relapse with classic technics results.
Our experience is based on 165 cases, operated laparoscopic and also by classic technics (116 laparoscopic, 49 classic) in the last 3 years.
We will present several surgical technics (methods of fixation, methods of treating the parietal defects - closing the defects, element separation technics etc.)
used in the minimal invasive treatment of incisional hernias and we will try to draw relevant conclusions.

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Abdomenul deschis - nchidere fascial precoce sau tardiv
Abdominal Wall Closure After Open-Abdomen: Early or Delayed?
C. V. Oprea Aron, D. Leuca, D. Gheorghescu, F. Buia, R. Anghelu
Spitalul Militar de Urgen Dr. Constantin Papilian, Secia de Chirurgie, Cluj-Napoca, Romnia
Introducere: Abdomenul deschis reprezint o terapie multistadial eficient destinat catastrofelor abdominale secundare chirurgiei generale sau traumatismelor
i care rmne nc o provocare major att pentru chirurg ct i pentru pacient. n studiu analizam retrospectiv o serie de pacieni cu abdomen deschis pentru a
determina momentul optim al nchiderii fasciale: precoce sau tardiv.
Metode: Au fost analizate documentele medicale ale tuturor pacienilor tratai cu abdomen deschis n secia Chirurgie a Spitalului Militar Cluj-Napoca ntre
ianuarie 2010 i decembrie 2015. Au fost consemnate datele demografice, comorbiditile, etiologia abdomenului deschis precum i momentul i tehnicile de
nchidere fascial. Au fost consemnate morbiditatea i mortalitatea nchiderii peretelui. Pacienii cu abdomen deschis au fost clasificai dup scorul Bjork.
Rezultate: Au fost nregistrai n studiu 27 de pacieni (9 de sex feminin) cu vrsta medie de 63 de ani. Timpul mediu de meninere al abdomenului deschis a fost
de 12 zile (2-39 zile). Cauzele au fost fistulele digestive n peste 50% din cazuri, urmate de perforaii viscerale, pancreatit acut sever, sindromul de
compartiment abdominal i ischemia mezenteric n proporii oarecum egale. Dimensiunea medie a defectului rezultat a fost de 21 cm (17-27 cm). Abdomenul a
fost nchis la 16 pacieni (59%) din care au decedat 6. Mortalitatea global se ridic la 17 pacieni (63%).
Concluzii: Mortalitate ridicat att datorit afeciunii de baz ct i datorit complicaiilor metodei n sine.

Background: Open - abdomen is an effective treatment for abdominal catastrophes in traumatic and general surgery with a formidable task upon both surgeon
and patient. We analyze a retrospective series of patients with open abdomen in order to determine when is the best moment for fascial closure: early or delayed.
Methods: Between January 2010 and December 2015 all medical records of patients with open abdomen admitted in the Department of Surgery of the Military
Hospital from Cluj-Napoca were reviewed. Demographics, co-morbidities, etiology of the open-abdomen and the time and methods of fascial closure were
recorded. Patients were classified according to Bjork open abdomen grading system. The morbidity and mortality of the method and of the fascial closure were
analyzed.
Results: 27 patients (9 female) with a median age of were analyzed. Average time for open abdomen therapy was 12 days (2-39 days). Etiology of open abdomen
was a major leakage of visceral anastomoses in over 50% of the cases. Other causes: visceral perforation, severe acute pancreatitis, abdominal compartment
syndrome and mesenteric ischemia. Mean width of the abdominal defect - 21 cm (17-27 cm). The abdomen was open in 16 patients (59%) out of which 6 died.
Global mortality - 63%.
Conclusions: High mortality rate for both primary cause and method too.

Tratamentul chirurgical al eventraiilor postoperatorii - tehnica deschis versus tehnica laparoscopic


The Surgical Treatment of Incisional Hernias - Open Surgery vs. Laparoscopic Approach
B. Mastalier, Violeta Deaconescu, V. Popescu, A. Zarafin, B. Ghi, Irina Nicoleta Penciuc, C. Botezatu
Spitalul Clinic Colentina, Clinica de Chirurgie, Bucureti, Romnia
Introducere: Eventraiile postoperatorii reprezint o patologie frecvent la pacienii cu istoric de intervenii chirurgicale abdominale, afectndu-le acestora n mod
semnificativ calitatea vieii. Pe lng disconfortul pe care eventraiile le creeaz, ele pot determina complicaii evolutive, cum ar fi trangularea sau eroziunea
tegumentelor supraiacente. Tratamentul chirurgical adresat acestei patologii, indicat la minim 6 luni de la operaia primar, este reprezentat fie de chirurgia
deschis, fie de cea laparoscopic, fiecare dintre cele dou variante avnd avantajele i dezavantajele sale.
Material i metod: n Clinica Chirurgie General a Spitalului Colentina Bucureti, n perioada 2011-2015, au fost operai 468 de pacieni diagnosticai cu
eventraie postoperatorie. n 312 cazuri, eventraiile au fost localizate pe linia median, 144 subcostale drepte i 12 subcostale stngi. 352 dintre cazuri au fost
reprezentate de eventraii necomplicate, 93 dintre pacieni s-au prezentat n faza de ocluzie intestinal prin trangulare, iar 23 de cazuri prezentau, la momentul
internrii, eroziuni tegumentare supraiacente. Tehnica chirurgical deschis a fost utilizat la 326 dintre pacieni, iar cea laparoscopic n 142 de cazuri.
Rezultate: Dup chirurgia deschis, complicaiile postoperatorii la distan au fost reprezentate de recidiv i supuraii parietale prin fenomenul de rejet al
plasei, iar dup cura laparoscopic, ocluzie intestinal prin aderene postoperatorii i recidiv.
Concluzii: Stabilirea unor indicaii precise pentru alegerea metodei optime de tratament al eventraiilor postoperatorii, o bun tehnic chirurgical, precum i tipul
materialelor aloplastice utilizate, reprezint elemente cheie n obinerea unei evoluii postoperatorii lipsite de complicaii.
Cuvinte cheie: eventraie postoperatorie, chirurgie "deschis, laparoscopie

Introduction: The postoperative incisional hernias represent a frequent pathology in patients with a history of abdominal surgery, significantly affecting their
quality of life. Besides the fact that incisional hernias create discomfort, they can cause developmental complications such as strangulation or superjacent skin
erosions. The surgical treatment addressed to this pathology, to be performed at least 6 months after the primary intervention, is either "open" surgery or the
laparoscopic approach, both variants having advantages and disadvantages.
Material and method: In the Surgical Clinic of Colentina Hospital, Bucharest, between 2011-2015, 468 patients diagnosed with incisional hernias were operated.
There were 312 cases with incisional hernias located on the midline, 144 right subcostal and 12 left subcostal. 352 of the cases were uncomplicated incisional
hernias, 93 of the patients presented intestinal obstruction through strangulation, and 23 cases presented, at the time of the admission, superjacent skin
erosions. We used "open" surgery in 326 of the cases and the laparoscopic approach in 142 cases.
Results: After "open" surgery, the distance postoperative complications were represented by recurrence and parietal suppuration due to the mesh rejection
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phenomenon, and after the laparoscopic cure, there were registered postoperative ileus by adhesions relapse.
Conclusions: Setting precise indications for choosing the optimal method of treatment of the incisional hernias, a proper surgical technique and the type of
alloplastic materials used, represent the key elements to obtaining a postoperative evolution without complications.
Key words: incisional hernias, open surgery, laparoscopic approach

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Physicians Session Video Presentations
Dificultile de visceroliz la protezele intraperitoneale ntlnite la reexplorarea laparoscopic
Adhesiolysis-Related Difficulties During Laparoscopic Re-Exploration After Prior Incisional Hernia Repair
F. Turcu, B. Smeu, Simona Filip, Bogdana Bnescu, C. Copescu, I. Hutopil
Spitalul Ponderas, Secia de Chirurgie General, Bucureti, Romnia
Utilizarea protezelor intraperitoneale pentru tratamentul eventraiilor postoperatorii este de dat relativ recent i exist o experien limitat cu reexplorarea
cavitii abdominale, pe cale deschis sau laparoscopic, la aceti pacieni. Montajul video prezint experiena clinicii Ponderas cu reexplorarea i visceroliza
laparoscopic la pacinii cu proteze intraperitoneal.
Indicaiile de reexplorare laparoscopic la cei 10 pacieni din seria prezentat au fost: serom infectat (n=3), eventraie recidivat (n=2), sindrom ocluziv (n=2),
anexectomie (n=1), adenocarcinom rectal (n=1), eventraie (alta decat cea protezat, n=1). Cu excepia unui caz, au fost gsite aderene la proteze, n marea
majoritate a cazurilor epiploonul fiind cel implicat. Au utilizat clasificarea lui Jenkins pentru dificultatea viscerolizei, care n seria noastr a fost n medie de
2.60.9 (maximum = 5). Suprafaa de protez acoperit de aderene a fost n medie de 60-80%, iar timpul de visceroliz la protez a fost n medie de 1917 min.
Nu au fost incidente / accidente legate de timpul de visceroliz.
n concluzie, dei visceroliza la protez este dificil, reabordarea cavitii peritoneale pe cale laparoscopic este justificat.

The purpose of this video presentation is to highlight the difficulties we have encountered during relaparoscopic with adhesiolysis to intraperitoneal non
absorbable-barrier-coated meshes.
Indications for the 10 patients laparoscopic re-exploration were: infected seroma (n=3), recurrent incisional hernia (n=2), occlusive syndrome (n=2), gynecologic
pathology (n=1), rectal adenocarcinoma (n=1), other incisional hernia (n = 1). Adhesions were found at intraperitoneal mesh in all cases except one. We have used
Jenkins's scale to characterize the adhesion tenacity and the mean was 2.60.9. The majority of the patients had the omentum adherent to the mesh. The
average surface of the mesh covered by the omentum was 60-80%, and the average time of adhesiolysis to the mesh was 1917 min.
Our conclusion is that, despite the difficulties of adhesiolysis to the intraperitoneal mesh, laparoscopic re-exploration is the best option for the patient.

Cura laparoscopic a herniei ombilicale cu plas ventralex


Laparoscopic Umbilical Hernia Repair Using VENTRALEX Hernia Patch
A. Nicolau, Raluca Vasile
Spitalul Clinic de Urgen Floreasca, Chirurgie, Bucureti, Romnia
Abordul laparoscopic al defectelor parietale ventrale devine tot mai actual, avn n vedere avantajele binecunoacute ale chirurgiei miniminvazive, la care se
adaug incidena mai redus a recidivelor postoperatorii comparativ cu abordul deschis cu, respectiv, fr plas. Prezentm tehnica curei laparoscopice a herniei
ombilicale utiliznd plasa bifaetat, polipropilen i PTFE, circular, predimensionat (diametru de 6,4 i 8 cm), fixat cu 4 fire de sutur transparietale. Plasa
respectiv este conceput pentru chirurgia deschis. Am folosit tehnica la 13 pacieni din noiembrie 2014, far incidente intraoperatorii, complicaii. Durata
operaiei a fost n medie de 50 de min, herniile au fost medii i mari, spitalizare postoperatorie 24-48 de ore. Avantajul este dat de forma circular, fixarea prin
sutur transfascial, costuri.

The laparoscopic approach of abdominal ventral hernia gains a clear advantage in comparison with the open approach through the well-known particularities of
minimally invasive surgery and the low incidence of postoperative recurrences. We present the technique of laparoscopic umbilical hernia repair using a
self-expanding polypropylene and ePTFE patch, circular shape, predimensionated, fixated with 4 transfascial sutures. The mesh is designed for tension-free open
repair. We used the technique on 13 patients without incidences and complications. Operative time was of 50 min, the postoperative hospital stay around 24-48
hours. The advantages are the circular shape, transfascial suturing and the costs.

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Chirurgie minim invaziv pentru diverticul esofagian mediotoracic - prezentare de caz video
Minimally Invasive Surgery (MIS) for Esophageal Midthoracic Diverticula - Video Case Report
S. Constantinoiu, M. Gheorghe, P. Hoar, I. F. Achim
Universitatea de Medicin i Farmacie Carol Davila Bucureti, Spitalul Clinic Sf. Maria, Clinica de Chirurgie General i Esofagian, Bucureti, Romnia
Obiectivul studiului: Diverticulii esofagieni reprezint o patologie rar. Chirurgia este rezervat doar pentru pacienii simptomatici. Chirurgia minim invaziv
pentru diverticulii esofagieni este o metod ce necesit utilizarea toracoscopiei, laparoscopiei precum i a endoscopiei intraoperatorii, proceduri i tehnologii
moderne, cu rezultate ncurajatoare, aa cum este subliniat n literatura de specialitate recent.
Material i metode : Prezentm video nceputul experienei chirugicale minim invazive toracice cu un caz de diverticul mediotoracic, la care am analizat
simptomatologia i investigaiile preoperatorii, tehnica chirurgical toracoscopic folosit, datele de urmrire postoperatorie precum i datele din literatur.
Rezultate : Pacient de 59 de ani, cu obezitate morbid, s-a prezentat pentru odinofagie i regurgitaii. Investigaiile preoperatorii au identificat prin tranzit baritat,
EDS i CT toracic, diverticul mediotoracic. Manometria esofagian a fost normal. S-a practicat diverticulectomie i miomectomie esofagian infradiverticular pe
cale toracoscopic. Timpul operator a fost de 190 de minute. Urmrile postoperatorii au fost simple.
Concluzii: Chirurgia minim invaziv diverticular esofagian este fezabil dar dificil, potenialul morbiditii postoperatorii fiind semnificativ. Utilizarea
procedeelor minim invazive a dus la scderea ratei complicaiilor, mai ales a celor nechirurgicale iar rezultatele pe termen lung sunt similare celor obinute prin
chirurgie deschis. Se recomand utilizarea procedeelor minim invazive la pacieni selectionai, n msura existenei unei platforme tehnice adecvate, n centre
cu experien n chirurgia esofagian.

Purpose: Diverticula of the esophagus represent a rare pathological entity. Surgery should be reserved for symptomatic patients only. Minimally invasive surgery
(MIS) for treatment of esophageal diverticula encompasses thoracoscopy, laparoscopy and intraoperative endoscopy, modern technologies and procedures with
encouraging results, as underlined in the recent literature.
Methods: We present the beginning of our experience by a video case report of a midthoracic esophageal diverticula, with regards to preoperative symptoms and
investigations, surgical technique and follow-up data as well as data from the literature.
Results: A 59-year old female patient, with morbid obesity, is investigated for odynophagia and regurgitations by endoscopy, thoracic CT scan, and barium
swallow. A midthoracic esophageal diverticula was identified. Esophageal manometry was normal. We performed a diverticulectomy and infradiverticular
myotomy by thoracoscopy. Operating time was of 195 minutes with no surgical complications.
Conclusions: Minimally invasive surgery (MIS) for esophageal diverticular disease is feasible but also challenging, the potential postoperative morbidity being
significant. MIS entail lower rates of complications especially for non-surgical ones and the long term results are similar in comparison with open surgery. MIS is
recommended for selected patients only, in centers with adequate technique platform and expertise in esophageal surgery.

Trombembolectomie de arter mezenteric superioar pentru ischemia mezenteric acut - prezentare de caz
Superior Mesenteric Artery Embolectomy for Acute Mesenteric Ischemia - Case Report
V. Florescu (1), M. D. Clin (1), C. Zamfir (2), C. Bllu (1), A. Simion (1), Simona Bobic (1), V. A. Sandu (1), V. D. Constantin (1)
(1) Spitalul Clinic de Urgen Sfntul Pantelimon, Chirurgie General, Bucureti, Romnia
(2) Spitalul Clinic de Urgen Sfntul Pantelimon, Chirurgie Vascular, Bucureti, Romnia
Ischemia mezenteric acut de cauz arterial poate fi depistat n faz incipient pn la instalarea necrozei intestinale prin angioCT sau angiografie. Ca i
cauz de abdomen acut chirurgical non- traumatic, ischemia mezenteric ocup ntre 17 i 31% din cazuri. n 2/3 din cazuri cauza este ocluzia arterei mezenterice
superioare, ceea ce justific necesitatea unui tratament de specialitate de revascularizare, procedur care se poate face prin abord deschis sau endovascular.
Abordul deschis este preferat n cazul existenei peritonitei i a necesitii efecturii unei rezecii intestinale sau n lipsa unui serviciu de radiologie intervenional.
Prezentm cazul unui pacient de 75 ani internat pentru dureri abdominale n etajul inferior iradiate lombar, grea i inapeten. Din antecedente reinem
intervenii neurochirurgicale pentru stenoza de canal lombar L3-L4 i fibrilaie atrial far anticoagulare la domiciliu. Investigaiile uzuale evideniaz leucocitoz
far alte modificri. Evoluia pacientului se agraveaz rapid cu aprare muscular n etajul inferior, transpiraii reci, scaune cu mucus i snge motiv pentru care
se decide intervenia chirurgical. Intraoperator: ischemie mezenteric acut, vase mezenteriale goale artera mezenteric superioar nepulsatil. Se solicit
chirurgul vascular i n echip mixt se descoper artera mezenteric superioar submezolic, se practic arteriotomie transversal se introduce sonda Fogarty i
se extrag cheaguri de snge cu obinere de flux arterial bun, n jet, arteriorafie, lavaj, drenaj. Postoperator: evoluie favorabil sub tratament anticoagulant,
externare n ziua 12 postoperator, revenire n clinic la 3 luni pentru cura chirurgical a herniei inghinale. n concluzie asocierea tratamentului vascular poate mri
supravieuirea n ischemia mezenteric.

Acute mesenteric ischemia caused by arterial occlusion can be detected at an early stage until installation of intestinal necrosis with angioCT examination or
angiography. As the cause of non-traumatic acute surgical abdomen mesenteric ischemia occupies between 17 and 31% of cases. In two thirds of cases the cause
is superior mesenteric artery occlusion which justifies the need for a specialized treatment - revascularization procedure which can be done by open or
endovascular approach. Open surgery is preferred in cases of peritonitis and intestinal resections necessity of making or in the absence of interventional
radiology service. We present a patient, 75 years old, hospitalized for abdominal pain in the lower abdomen irradiated lumbar, nausea and lack of appetite. From
patient history we retain neurosurgery for stenosis L3-L4 lumbar canal and atrial fibrillation without anticoagulation at home. Investigations usually highlight
leukocytosis without other changes. The evolution of the patient worsens quickly with muscular defense in the lower abdomen, cold sweat, stools with mucus
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and blood, which is why surgical intervention is decided upon. At laparotomy acute mesenteric ischemia is found with empty vessels - and superior mesenteric
artery pulseless. With the help of a vascular surgeon we exposed the superior mesenteric artery submesocolic, transverse arteriotomy, Fogarty probe inserted
and extracted blood clots with obtaining good arterial flow. Postoperative anticoagulant treatment favorable development, on the 12th day postoperative
discharge, return to the clinic 3 months later for surgical cure of inguinal hernia. In conclusion, association of vascular therapy can increase survival rate in
mesenteric ischemia.

Abordul laparoscopic asociat cu separarea anterioar endoscopic a componentelor n repararea eventraiei


voluminoase m3w3
Incisional Hernia M3W3 Repaired by Laparoscopic Approach and Anterior, Endoscopic Component Separation
V. G. Radu, Adriana Radu, M. Lic, tefania Ene
Life Memorial Hospital, Chirurgie, Bucureti, Romnia
Una dintre marile provocri ale chirurgiei parietale o reprezint eventraiile voluminoase.
Folosirea procedeelor alloplastice, n care defectul parietal este acoperit cu protez, dar fr restaurarea liniei albe, nu restabilete fiziologia peretelui abdominal.
Pentru aceasta marginile defectului trebuie suturate. n condiiile unui orificiu herniar de mari dimensiuni (>10cm) vom recurge la operaia de separare a
componentelor. Acest film prezint cura laparoscopic a unei eventraii mediane voluminoase, cu un defect parietal de 16/13cm, realiznd o separare anterioar a
componentelor prin abord total endoscopic. Operaia a durat 3 ore, fr incidente. Pacientul a fost externat a doua zi postoperator.
Avantajele separrii endoscopice a componentelor sunt: disecie curat, non-agresiv i eficient a straturilor musculoaponevrotice.
Eventraiile cu pierdere important de substan (stadiul W3) pot fi abordate complet pe cale endoscopic - att separarea componentelor ct i tratarea
defectului parietal.

One of the biggest challenges in the abdominal wall surgery is the large incisional hernia. Covering a large gap with a prosthesis without restauration of the linea
alba does not restore the abdominal wall physiology. The solution is to approximate the edges of the defect. In this case (width >10cm) the key is component
separation. This video presents treatment of a large (L16cm, W13cm), median incisional hernia by laparoscopic approach end endoscopic anterior component
separation. These procedure allows the approximation of the defect edges (L17cm W12,4 cm) under physiological tension. Procedure last for 3 hours without
incidents. The patient was discharge safely 2 days later.
The advantages of endoscopic component separation are: clean, non-aggressive and safe dissection of musculo-aponeurotic layers.

Proctocolectomie total restaurativ cu rezervor ileal n J pentru PAF asociat cu malignizare la nivelul
sigmoidului
Restorative Proctocolectomy with Ileal J Pouch - Anal Anastomosis for FAP with Malignisation at the Sigmoid Level
A. Martiniuc, C. Stroescu, T. Dumitracu
Institutul Clinic Fundeni, Centrul de Chirurgie General i Transplant Hepatic, Bucureti, Romnia
Prezentm cazul unei paciente de 26 de ani, decelat colonoscopic cu multipli polipi adenomatoi ce se ntind de la canalul anal pn la cec, cu suspiciune de
malignizare la nivelul sigmoidului. S-a practicat o proctocolectomie total restaurativ cu ligatura la origine a arterei mezenterice inferioare, ligatura venei
mezenterice inferioare la marginea pancreasului datorit prezenei unei tumori sigmodiene. S-a practicat o anastomoz ileo-anal cu rezervor ileal n J.

We present the case of a 26-year old woman diagnosed at colonoscopy with multiple adenomatous polyps from the anal canal to the cecum, with suspicion of
malignancy at the sigmoid level. A restorative total proctocolectomy was performed, with high ligation of the inferior mesenteric artery and vein due to the
presence of a sigmoid tumor. An ileal J pouch - anal anastomosis was performed.

Patologie tumoral retroperitoneal dreapt - abord laparoscopic


Right Retroperitoneal Tumor Pathology - Laparoscopic Approach
A. Miron, V. Calu, M. C. Ardelean, O. Enciu
Spitalul Universitar de Urgen Elias, Chirurgie, Bucureti, Romnia
Sunt prezentate patru cazuri de formaiuni tumorale retroperitoneale drepte cu aspect tomografic asemntor sugernd: chist renal voluminos, incidentalom
suprarenalian, feocromocitom i limfagiom chistic.
Toate cazurile au beneficiat de intervenii laparoscopice prin abord transperitoneal.
Lucrarea prezint filmele interveniilor chirurgicale respective subliniind particularitile de tehnic n fiecare caz.
Explorarea intraoperatorie a confirmat diagnosticul tomografic n dou cazuri - feocromocitom i chist renal. Incidentalomul suprarenalian drept s-a dovedit a fi un
hematom cu surs retroperitoneal iar limfangiomul s-a dovedit a fi mezoteliom peritoneal multischistic benign.
Examenul histopatologic a confirmat diagnosticul intraoperator.

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Four cases of right retroperitoneal tumors with similar CT imaging findings suggesting: large renal cyst, adrenal incidentaloma, pheochromocytoma and cystic
lymphangioma are presented.
All cases were managed by a transperitoneal laparoscopic approach.
The presentation discusses the surgical videos highlighting particularities of surgical technique for each case.
The intraoperative exploration confirmed the CT diagnosis in two cases - pheochromocytoma and renal cyst. The adrenal incidentaloma proved to be a
hematoma with retroperitoneal source and the lymphangioma proved to be a benign multicystic peritoneal mesothelioma.
The pathology report confirmed the intraoperative diagnosis.

Pancreatosplenectomie subtotal modular antegrad modificat pentru tumor de istm pancreatic


Modified Antegrade Subtotal Pancreatosplenectomy for Pancreatic Neck Tumor
A. Martiniuc, T. Dumitracu
Institutul Clinic Fundeni, Centrul de Chirurgie General i Transplant Hepatic, Bucureti, Romnia
Prin definiie, pancreatectomia distal presupune rezecia corpului i a cozii pancreatice, limita dreapt fiind reprezentat de artera i vena mezenteric
superioar. n 2003 Strasberg propune o alternativ la splenopancreatectomia clasic, n mod traditional efectuat de la stnga la dreapta. Disecia n
pancreatosplenectomia modular antegrad radical (ramps) presupune secionarea timpurie a pancreasului cu ligatura vaselor splenice i limfodisecie la nivelul
trunchiului celiac. Planul de disecie, dup secionarea pancreasului i a vaselor splenice, continu iniial ntr-un plan sagital, repectnd artera mezenteric
superioar i trunchiul celiac, pn la nivelul aortei. Ulterior, disecia continu lateral, ntr-o manier modular, anterior sau posterior de glanda suprarenal.
Prezentm cazul unui pacient n vrst de 59 de ani operat n clinica noastr, diagnosticat cu o tumor de istm pancreatic pentru care s-a practicat o
pancreatosplenectomie subtotal modular antegrad, modificat.

By definition, distal pancreatectomy removes the body and tail of the pancreas to the left of the superior mesenteric artery and vein. In 2003 Strasberg proposed
an alternative approach to the traditional left-to-right splenopancreatectomy. The dissection in radical antegrade modular pancreatosplenectomy (ramps)
procedure commences from right to left, with early division of the pancreatic neck and splenic vessels and celiac node dissection. The plane of dissection runs
posteriorly in a sagittal plane along the superior mesenteric artery and celiac trunk to the level of the aorta and then laterally either anterior or posterior to the
adrenal gland.
We present a modified approach of the radical antegrade modular pancreatosplenectomy performed for a pancreatic neck tumor in a 59-year old patient
operated in our department.

Esofagectomie minim invaziv prin triplu abord modificat McKeown pentru cancerul esofagian toracic - prezentare
video
Minimally Invasive Esophagectomy Using Modified Mckeown Triple Approach for Thoracic Esophageal Cancer Video Presentation
S. Constantinoiu, Rodica Daniela Brl, D. Predescu, A. Constantin, P. Hoar, I. F. Achim, M. Gheorghe, M. Boeriu, Elena-Roxana Timofte, A. Caragui
Spitalul Clinic Sf. Maria, Clinica de Chirurgie General i Esofagian, Bucureti, Romnia
Prezentm n sesiunea video experiena iniial a primelor cazuri de esofagectomie minim invaziv efectuat prin triplu abord McKeown modificat.
Pentru abordul toracic am folosit poziia de decubit lateral iar pentru timpul laparoscopic i cervical poziia francez de decubit dorsal.
n timpul toracoscopic, seciunea crosei venei azygos a fost efectuat cu un stapler vascular iar disecia esofagului i limfadenectomia mediastinal s-au facut cu
electrodul monopolar i cu pensa Ligasure.
Timpul laparoscopic de mobilizare a grefonului gastric cu seciunea pediculului coronar (folosind un stapler vascular) i limfadenectomia la nivelului plexului
celiac este urmat de incizie laterocervical stng i secionarea esofagului cervical i extragerea piesei de esofagectomie printr-o minilaparotomie.
Prepararea grefonului gastric poate fi efectuat folosind tehnica Akiyama cu rezecia micii curburi gastrice sau tehnica Nakayama care implic rezecia cardiei cu
un stapler liniar, se mai practic piloroplastie extramucoas i montarea unei jejunostomii de alimentaie.
Gastric pull-up prin mediastinul posterior urmat de anastomoz esogastric cervical au fost efectuate. Evoluia postoperatorie a fost marcat la unele cazuri de
apariia unor fistule cervicale care au fost tratate conservator.
Selecia preoperatorie a cazurilor este important pentru a mbuntii rezecabilitatea i a reduce rata de conversie i a evita accidentele din timpul
toracoscopic(lezarea membranei traheale, a bronhiilor sau a marilor trunchiuri vasculare). Indicaia pentru abordul minim invaziv este reprezentat de cancerele
incipiente sau pacienii cu bun rspuns la tratament neoadjuvant.

We are presenting in the video session the initial experience of the first minimally invasive esophagectomy cases using modified McKeown triple approach.
For the thoracoscopic approach we used the left lateral decubitus position while for the laparoscopic and cervical approach the French supine position.
During the thoracoscopic interval, the section of the azygos vein was performed using a vascular stapler and the dissection of the thoracic esophagus and the
mediastinal lymphadenectomy were done using monopolar electrode and Ligasure forceps.
Laparoscopic gastric mobilization, with sectioning of the left gastric pedicle (using a vascular stapler) and celiac plexus lymphadenectomy is followed by a left
lateral cervical incision and by the cutting of the esophagus and extraction of the esophagectomy specimen by an epigastric mini laparotomy.
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Preparation of the graft can be done using the Akiyama technique with gastric tubing and resection of the lesser gastric curvature or the Nakayama technique
that implies the resection of the cardia with a linear stapler and practicing an extra mucosal pyloroplasty and mounting a feeding jejunostomy.
Gastric pull-up through the posterior mediastinum followed by a cervical esophageal-gastric anastomosis were performed. Postoperative evolution was marked
in some cases by the appearance of a cervical fistula that was treated conservatively.
Preoperative selection of the cases is important in order to improve resectability chances without converting and to avoid accidents during the thoracoscopic
stage (tracheal membrane, bronchial or major vascular trunks lesions). The indication for a minimally invasive approach is represented by early tumors or those
with good response to neoadjuvant treatment.

Hernia incizional M3W3 reparat prin separare posterioar a componentelor, T.A.R. i protez retromuscular
Incisional Hernia M3W3 Repaired by Posterior Component Separation, T.A.R. and Sublay Mesh
V. G. Radu, Adriana Radu, tefania Ene, M. Lic
Life Memorial Hospital, Secia de Chirurgie, Bucureti, Romnia
Una dintre marile provocri din chirurgia peretelui abdominal este hernia incizional voluminoas (W3, diametrul peste 10 cm). Acoperirea unui mare defect
parietal cu o protez de plastic fr a sutura marginile defectului nu va putea restabili fiziologia peretelui abdominal. Soluia este abandonarea bridging-ului i
restaurarea liniei albe. Cum? n acest caz cheia este separarea componentelor. Acest film prezint separarea posterioar a componentelor cu relaxarea
transversului abdominal (TAR) i protezare retromuscular. Aceast procedur permite apropierea marginilor defectului (lungime 17cm, diametru 12,4cm) sub
presiune fiziologic. Operaia a durat 4,5 ore fr incidente. Pacienta a fost externat pe cale de vindecare a 5-a zi postoperator.

One of the biggest challenges in the abdominal wall surgery is the large incisional hernia (W3, width >10 cm). Covering a large gap with a plastic prosthesis
without suturing the abdominal wall defect does not restore the abdominal wall physiology. The solution is to abandon bridging and restore the linea alba. How?
In this case the key is component separation. This video presents the posterior component separation with TAR (transversus abdominis release) and sublay mesh.
This procedure allows the approximation of the defect edges (L 17 cm W 12,4 cm) under physiological tension. Procedure lasts for 4,5 hours without incidents. The
patient was discharged safely 5 days later.

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Hernia hiatal complex - studiu de caz
Hiatal Complex Hernias - Case Report
C. D. Vidrighin, . B. Persu, M. Bojan, S. Popescu, D. S. Ilie
Spitalul Municipal, Secia de Chirurgie, Caracal, Romnia
Herniile hiatale reprezint o varietate special de hernii diafragmatice n care se produce migrarea transdiafragmatic n torace a stomacului prin hiatusul
esofagian sau printr-un defect diafragmatic separat de inelul hiatal prin cteva fibre musculare ale pilierului diafragmatic stng. Majoritatea herniilor hiatale sunt
asimptomatice i descoperite ntmpltor, rar putnd aprea complicaii ce pun n pericol viaa pacientului: volvulusul gastric sau strangularea. Exist patru tipuri
recunoscute: de alunecare (tip I), paraesofagian (tip II), mixt (tip III) i complex (tip IV).
Prezentm cazul unei paciente n vrst de 77 de ani, din mediul urban, cu fibrilaie atrial, internat pentru epigastralgii, eructaii postprandiale, pirozis, dispnee.
Se efectueaz endoscopie digestiv superioar - hernie hiatal voluminoas, aspect de gastrit, radiografie eso-gastro-duodenal cu substan baritat-stomac
situat n totalitate intratoracic, esofag sinuos.
Se intervine chirurgical printr-o incizie median xifo-subombilical, se constat defect al hiatusului esofagian (aproximativ 10 cm) cu fornixul i corpul gastric i
colonul transvers situate intratoracic, n mediastinul posterior. Se practic reducerea n totalitate a stomacului i a colonului transvers, refacerea hiatusului
diafragmatic prin sutura pilierilori anterior i posterior de esofag cu fire separate de nylon 8 i hemifundoplicatur anterioar Dor.
Evoluie postoperatorie favorabil, iar radiografia eso-gastro-duodenal cu substan baritat efectuat n a 8-a zi evideniaz stomac situat n totalitate n
cavitatea abdominal, esofag inferior cu lumen ngustat, pliuri suple.

Hiatal hernias represent a special variant of diaphragmatic hernia in which there is a transdiaphragmatic migration of the stomach through the esophageal hiatus
or a diaphragmatic defect separate from hiatal ring by several muscle fibers of the left diaphragmatic pillar. Most hiatal hernias are asymptomatic and discovered
incidentally, rare complications can occur that endanger the patient's life: gastric volvulus or strangulation. There are four recognized types: sliding (type I),
paraesophageal (type II), mixed (type III) and complex (type IV).
We present a 77-year-old patient with atrial fibrillation, admitted for heartburn, belching postprandial heartburn, shortness of breath. EDS is performed
voluminous hiatal hernia, gastritis, Rx EGD with barium-located totally intrathoracic stomach, esophagus tortuous.
The surgery approach is a median incision, defective esophageal hiatus is found (about 10 cm) with fornix and body stomach intrathoracic and transverse colon
located in the posterior mediastinum. We practiced a full stomach reduction and transverse colon, restoring diaphragmatic hiatus by suturing the anterior and
posterior esophageal pillars with separate nylon yarn 8 and antirefluxe procedure type Dor.
Favorable postoperative evolution and eso-gastro-duodenal radiography with barium substance made in the 8th day highlights a stomach located entirely in the
abdominal cavity, the lower esophagus lumen narrowing, supple pleats.

Leziune de tip IV Bismuth de cale biliar dup colecistectomia laparoscopic - prezentare de caz
Type IV Bismuth Bile Duct Injury after Laparoscopic Cholecystectomy - Case Presentation
S. Vlcea (1), B. Dumitriu (1), G. N. Andrei (2), I. B. Diaconescu (2), M. Beuran (2)
(1) Spitalul Clinic de Urgen Floreasca, Clinica de Chirurgie General, Bucureti, Romnia
(2) Spitalul Clinic de Urgen Floreasca, Clinica Chirurgie III, Bucureti, Romnia
Introducere: Leziunile de cale biliar pot aprea loc ntr-un spectru larg de manifestri patologice, precum chirurgia biliar, gastric sau pancreatic,
colecistectomia laparoscopic fiind responsabil pentru 80%-85% dintre ele.
Material i metod: Prezentm cazul unui pacient de sex masculin n vrst de 64 ani admis prin transfer de la o alt unitate spitaliceasc la 7 zile dup
colecistectomia laparoscopic, cu istoric de intervenie deschis la 3 zile dup laparoscopie pentru fistul bilar extern. Drenajul zilnic la internare a fost de 700
ml de bil pe 24 de ore, cu culturi pozitive pentru Staphylococcus aureus. ERCP a evideniat stop complet al substanei de contrast la nivelul coledocului
supraduodenal. Intraoperator s-a constatat leziune de tip IV Bismuth, cu ligatur de canal hepatic stng i scurgere de bil de la nivelul canalului hepatic drept.
Rezultate: A fost efectuat porto-jejunostomie, cu rezultat postoperator favorabil. Culturile din dreanj au fost negative. Externare n ziua 10 postoperator.
Concluzii: Mecanismele leziunilor de cale biliar, ncercrile anterioare de reparare, riscul chirurgical i starea general de sntate influeneaz abordarea
diagnostic i terapeutic a fiecrui caz n parte. O abordare multidisciplinar - medicin intern, chirurgie, endoscopie i radiologie intervenional - este
necesar pentru a gestiona n mod corespunzator aceste leziuni complexe.
Cuvinte cheie : leziune, colecistectomie, fistul, multidisciplinar

Introduction: Bile duct injuries (BDI) take place in a wide spectrum of clinical settings. BDI may occur after gallbladder, pancreas and gastric surgery, with
laparoscopic cholecystectomy responsible for 80%-85% of them.
Materials and Method: We present the case of a 64-year-old male patient admitted by transfer from another hospital unit, 7 days after laparoscopic
cholecystectomy with open surgery at 3 days after laparoscopy for bile leak. The daily drainage at admission was 700 ml bile per 24 hours, with positive cultures
for Staphylococcus aureus. ERCP revealed complete stop of contrast substance at the level of common bile duct. Intraoperatively a type IV Bismuth BDI was
found, with ligated left hepatic duct and bile leak from right hepatic duct.
Results: Porto-jejunostomy was performed, with favorable postoperative outcome. Negative cultures from drainage. Discharge on the 10th postoperative day.
Conclusions: The mechanisms of injury, previous attempts of repair, surgical risk and general health status importantly influence the diagnostic and therapeutic
decision-making pathway of every single case. A multidisciplinary approach including internal medicine, surgery, endoscopy and interventional radiology
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specialists is required to properly manage this complex disease.
Keywords: injury, cholecystectomy, leak, multidisciplinary

Paragangliom gangliocitic pancreatic - prezentare de caz


Pancreatic Gangliocytic Paraganglioma - Case Presentation
Luminia Furcea (1), F. Graur (1), I. Catru (2), Simona Mrgrit (3), Ioana Rusu (4), R. Badea (5), Andrada Seicean (6), Mihaela Lee (7), N. Al Hajjar (1)
(1) Universitatea de Medicin i Farmacie Iuliu Haieganu / Institutul Regional de Gastroenterologie i Hepatologie Prof. Dr. Octavian Fodor, Clinica Chirurgie
III, Cluj-Napoca, Romnia
(2) Institutul Regional de Gastroenterologie i Hepatologie Prof. Dr. Octavian Fodor, Clinica Chirurgie III, Cluj-Napoca, Romnia
(3) Universitatea de Medicin i Farmacie Iuliu Haieganu / Institutul Regional de Gastroenterologie i Hepatologie Prof. Dr. Octavian Fodor, Clinica de
Anestezie i Terapie Intensiv, Cluj-Napoca, Romnia
(4) Institutul Regional de Gastroenterologie i Hepatologie Prof. Dr. Octavian Fodor, Anatomie Patologic, Cluj-Napoca, Romnia
(5) Universitatea de Medicin i Farmacie Iuliu Haieganu / Institutul Regional de Gastroenterologie i Hepatologie Prof. Dr. Octavian Fodor, Radiologie
Imagistic, Cluj-Napoca, Romnia
(6) Universitatea de Medicin i Farmacie Iuliu Haieganu / Institutul Regional de Gastroenterologie i Hepatologie Prof. Dr. Octavian Fodor, Clinica Medical
III, Cluj-Napoca, Romnia
(7) Spitalul Judeean de Urgen Dr. Constantin Opri, Secia Chirurgie General, Baia Mare, Romnia
Paragangliomul gangliocitic este o tumor neuroendocrin rar localizat n poriunea a doua a duodenului, cu predilecie n regiunea periampular. Prezentm
cazul unei paciente n vrst de 53 ani cu paragangliom gangliocitic de istm pancreatic, o localizare extrem de rar. Explorrile paraclinice efectuate (ecografia
abdominal simpl i cu substan de contrast, tomografia computerizat, ecoendoscopia) au evideniat o formaiune tumoral localizat la nivelul istmului
pancreatic, inomogen, bine delimitat, care nu invadeaz structurile adiacente i prezint captare arterial intens la ecografia cu substan de contrast,
elemente ce sugereaz o tumor neuroendocrin. Tratamentul chirurgical a constat n pancreatectomie central cu pancreato-jejunoanastomoz T-L pe ans
exclus n Y la Roux i sutura bontului pancreatic proximal. Diagnosticul de paragangliom gangliocitic a fost stabilit pe baza examenului histopatologic corelat
cu imunohistochimie.
Cuvinte-cheie: paragangliom gangliocitic, tumor neuroendocrin, pancreatectomie central

Gangliocytic paraganglioma is a rare neuroendocrine tumor located on the second portion of the duodenum in the periampullary region. We present a female
patient aged 53 with gangliocytic paraganglioma of the pancreatic isthmus, localization extremely rare. Paraclinical examination (abdominal ultrasound, CEUS, CT
scan, EUS) showed a tumor located on the pancreatic isthmus, inhomogeneous, well delimited, not adherent to adjacent structures and presenting high contrast
perfusion at CEUS, elements suggesting a neuroendocrine tumor. Surgical treatment consisted in central pancreatectomy with pancreato-jejunoanastomosys T-L
on Roux-en-Y loop and suture of the proximal pancreatic stump. The diagnosis of gangliocytic paraganglioma was established based on histopathological
examination correlated with immunohistochemistry.
Keywords: gangliocytic paraganglioma, neuroendocrine tumor, central pancreatectomy

Neoplazia intraepitelial biliar asociat colecistitei cronice


Biliary Intraepithelial Neoplasia in Chronic Cholecystitis
Alina Gabriela Mihaela Grigore, M. C. Stoicea
Laboratorul Central de Referin Synevo, Departamentul de Histopatologie, Chiajna, Romnia
Obiectivul studiului: Neoplazia intraepitelial biliar (BilIN) constituie o leziune precursoare n colangiocarcinogenez, cu risc de evoluie malign proporional cu
gradul histologic. Studiul actual a urmrit prevalena BilIN ntr-un lot de colecistite cronice, distincia de modificrile epiteliale reactive i confirmarea
prezenei/absenei acesteia pe bontul colecistic.
Material i metode: Au fost reevaluate histopatologic cazurile de colecistit cronic diagnosticate n laboratorul nostru n perioada ianuarie-decembrie 2015.
Cazurile BilN au fost separate n BilIN de grad sczut (BilIN1, BilIN2) i BilIN de grad nalt (BilIN3), i evaluate suplimentar histochimic (PAS-AB) i imunofenotipic
prin stabilirea indicelui de proliferare (Ki67) i a expresiei p53.
Rezultate: S-au identificat 237 cazuri de colecistit cronic, 64 (27%) cu modificri epiteliale reactive, 11 cazuri BilIN (4,64%), cu raport pe sexe M/F=2/9 i vrste
ntre 26 i 75 ani, dintre care 9 cazuri BilIN de grad sczut i 2 cazuri cu BilIN de grad nalt. Majoritatea cazurilor au prezentat localizare corporeal i fundic, un
caz (M, 26 ani) cu BilIN1 i BilIN2 la nivel infundibular cu interesarea bontului colecistic. Cazurile cu modificri epiteliale reactive, BilIN1 i BilIN2 au prezentat o
expresie p53 redus, cu o cretere progresiv a Ki67. Cazurile BilIN3 au prezentat expresie p53 intens n peste 70% din celule, Ki67 nalt i niveluri de coloraie
albastru alcian comparabile cu BilIN1 i BilIN2.
Concluzii: Recunoaterea neoplaziei intraepiteliale biliare este posibil printr-o eantionare anatomic judicioas a specimenelor excizionale, pe criterii
histochimice i imunohistochimice, i permite emiterea unui semnal de monitorizare a tractului biliar restant pentru decelarea unui context litiazic asociat cu
modificri epiteliale similare.

Aim: Biliary intraepithelial neoplasia is a precursor lesion in cholangiocarcinogenesis, showing a progression risk proportional with histological grade. The
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present study followed BilIN prevalence in a group of patients with chronic cholecystitis, the differential diagnosis with reactive epithelial changes as well as the
presence/absence of these changes on the excisional stump.
Material and methods: Cases diagnosed as chronic cholecystitis in our laboratory during January-December 2015 were reevaluated morphologically. BilIN cases
were split into low grade BilIN (BilIN1, BilIN2) and high grade BilIN (BilIN3), and were further evaluated histochemically (PAS-AD) and immunophenotyped using
proliferation index Ki67 and p53 expression.
Results: We identified 237 chronic cholecystitis cases, 64 (27%) with reactive epithelial changes compared to 11 BilIN cases (4,64%), with sex ratio M/F=2/9, 26 to
75 years old, of which 9 cases were low grade BilIN (BilIN1 in 1 case, BilIN1 with BilIN2 in 8 cases) and 2 cases were high grade BilIN (BilIN3). Most of the cases
were located at corporeal and fundic levels; one case (M, 26 yeras old) showed BilIN1 and BilIN2 at infundibular level extending at the excisional stump. Reactive
epithelial changes, BilIN1 and BilIN2 had a reduced p53 expression, with progressive increase in Ki67. BilIN3 displayed an intense p53 expression in more than
70% of cells, a high proliferation index and alcian blue coloration levels comparable with BilIN1 and BilIN2.
Conclusions: Identifying biliary intraepithelial neoplasia is possible with thorough anatomical sampling of excisional specimens, using histochemical and
immunohistochemical criteria, allowing a warning to monitor the biliary tract to detect an associated lithiasis and similar epithelial changes.

Abord combinat retro-duodeno-pancreatic i arterial mesenteric medio-uncinat n cancerul de pancreas local


avansat
Combined Posterior Retro-Duodeno-Pancreatic and Medial Uncinate Mesenteric Artery First Approach for Locally
Advanced Pancreatic Cancer Resection
A. C. Dima, Teodor Artenie, Florina Bold, N. Tnase, P. I. Oprea
Spitalul Universitar de Urgen Militar Central, Clinica Chirurgie I, Bucureti, Romnia
Obiectivul studiului: Obinerea unei posibiliti de abordare mai bun, ce poate oferi o disecie mai rapid i sigur a arterei mezenterice superioare pentru
evitarea the point of no return n chirurgia cancerul de pancreas local avansat.
Material i metode: Un abord posterior combinat, retro-duodeno-pancreatic i medio-uncinat cu first-approach al arterei mezenterice superioare a fost realizat
pentru cazurile cu cancer pancreatic local avansat n care invazia vascular a venei mezenterice superioare, venei porte sau confluentului veno-mezenteric a fost
prezent.
Disecia arterei mezenterice superioare este esenial naintea oricrui gest pe pancreas pentru a se asigura c nu exist invazie arterial. Procedeul trebuie s
asigure sigurana rezeciei venoase, cu pierdere minim de snge, precum i respectarea principiilor oncologice (rezecie R0, ndeprtare n ntregime a ariilor de
drenaj limfatic loco-regionale i limite de siguran n esut sntos).
Rezultate: Propunem astfel n aceast lucrare un abord combinat ce a fost practicat cu succes la 3 pacieni cu adenocarcinom de cap de pancreas tratai n
departamentul nostru.
n toate cazurile s-a practicat duodenopancreatectomie cu rezecie n bloc a confluentului venos spleno-mezenteric-portal i disecie radical a ligamentului
hepato-duodenal, trunchiului celiac (360), arterei splenice i arterei mezenterice superioare (aproximativ 270). Reconstrucia vascular a fost realizat prin
anastomoz termino-terminal porto-mezenteric fr interpoziie de protez. n plus, anastomoza pancreato-gastric (Peng modificat), hepato-jejunal
termino-lateral i gastro-enteric pe ans transmezocolic au fost realizate.
Concluzii: Abordul combinat retro-duodeno-pancreatic i medio-uncinat s-a dovedit sigur i posibil de realizat tehnic. Serii mai mari de pacieni sau cohorte sunt
ns necesare pentru confirmarea utilitii sale.

Aim: To obtain a better approach for a safer and faster dissection of the superior mesenteric artery in order to avoid the point of no return in the surgery of
locally advanced pancreatic cancer.
Methods: A combined posterior retro-duodeno-pancreatic and medial uncinate mesenteric artery first approach was assessed for locally advanced pancreatic
cancer cases, in which vascular involvement of superior mesenteric vein, portal vein or spleno-mesenteric confluent was present.
The dissection of the mesenteric superior artery is essential before any other gesture on pancreas to ensure that there are no arterial invasions. The process must
involve safety venous resection, with minimum blood loss, and oncologic compliance (R0 resection, loco-regional lymphadenectomy, safety limits in healthy
tissue).
Results: We herein propose a combined approach that proved to be a good option in three patients with cephalic pancreas adenocarcinoma treated in our
department.
In all cases cephalic duodenopancreatectomy with en bloc resection of the splenic - mesenteric - portal venous confluence and radical lymph dissection in the
hepato-duodenal ligament, celiac trunk (360), splenic artery, and superior mesenteric artery (approximately 270) was performed. The vascular reconstruction
was assessed by termino - terminal porto - mesenteric anastomosis without graft interposition. Furthermore, pancreatic - gastric (Peng modified) anastomosis,
hepatic - jejunostomy termino - lateral, and gastroenteric anastomosis on transmesocolic anse respectively were then realized.
Conclusions: The combined retro-duodeno-pancreatic and posterior medial uncinate approach proved to be safe and feasible. Larger series of patients or cohorts
are needed in order to confirm its utility.

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Rolul interveniilor minim invazive n tratamentul cancerului pancreatic depit chirurgical i a pancreatitei cronice
recidivante
The Role of Minimally Invasive Surgical Treatment in Advanced Pancreatic Cancer and Chronic Relapsing
Pancreatitis
V. Hotineanu, A. Cazac, A. Hotineanu
Universitatea de Stat de Medicin i Farmacie Nicolae Testemianu, Catedra 2 Chirurgie, LC Chirurgie Reconstructiv a Tractului Digestiv, Chiinu,
Republica Moldova
Introducere: Tratamentul antalgic ineficace n cancerul pancreatic nerezecabil (CPN), pancreatita cronic recidivant (PCR), statusul biologic precar al pacientului
n cazurile n care o intervenie cu viz patogenic este contraindicat, impun intervenii chirurgicale miniinvazive pentru diminuarea durerii i icterului. Material i
metode: Studiul include 56 (69,14%) pacieni cu PCR i 22 (27,16%) pacieni cu CPN, 3 (3,7%) pacieni cu cancer cu localizare nepancreatic nerezecabil,
desfsurat n perioada anilor 2008-2015 n cadrul Catedrei 2 Chirurgie. Lotul de pacieni cu PCR a inclus 49 (87,5%) brbai i 7 (12,5%) femei, vrsta medie 52,1ani (limitele28-72ani). Lotul de pacieni cu CPN - 20 (90,91%) brbai, 2 (9,09%) femei, vrsta medie - 58ani (limitele 45-78 ani). Scop: Evaluarea rolului
splanhnicectomiei toracoscopice (SPLT) n tratamentul sindromului de durere n PCR i CPN. Rezultate: S-au practicat 68 (83,95%) SPLT pe stnga, 13 (16,05%)
SPLT pe dreapta (4 (4,94%) pacieni, au necesitat i SPLT dreapt la 2 luni dup SPLT stng, datorit rspunsului terapeutic minimal). SPLT i protezarea
endoscopic a CBP au fost efectuate n 15 (68,18%) cazuri de CPN complicat cu icter mecanic. Efectul analgetic pe termen scurt (<3 luni) este denotat de
eficacitatea n 56 (100%) cazuri de PCR i 20 (90,90%) cazuri de CPN. ntre 3-6 luni eficacitatea analgeziei s-a meninut la 38 (67,86%) cazuri de PCR (continund
ulterior dup 6 luni) i 14 (63,63%) cazuri de CPN, 11 (50%) dup 6 luni. Mortalitatea perioperatorie - 0. Spitalizarea medie postoperatorie a fost de 3,3 zile (2-5
zile). Concluzii: SPLT i protezarea endoscopic a CBP reprezint soluii miniinvazive cu implicaii asupra ratei de supravieuire n cazurile de CPN complicat cu
icter mecanic. Tratamentul miniinvaziv prezint avantaje multiple pentru pacient n special n diminuarea sindromului algic, lipsa de complicaii i implicit costuri
mai mici n controlul durerii din CPN i PCR refractar la tratamentul antalgic conservator.

Introduction: The ineffective treatment for the algic syndrome in unresectable pancreatic cancer (CPN), chronic pancreatitis recidives (CPR), the precarious
biological status of the patient in cases where a visa pathogen intervention is contraindicated, require minimally invasive surgeries for reduction of pain and
jaundice. Material and metods: The study includes 56 (69,14%) patients with CPR and 22 (27,16%) patients with CPN, 3 (3,7%) patients with extrapancreatic
unresectable cancer, held during the years 2008-2015 in the Clinic No. 1. The patients with CPR included 49 (87.5%) men and 7 (12.5%) women, the average age 52,1 years (28-72 years). The patients with CPN -20 (90.91%) men and 2 (9.09%) women, average age - 58 years (within 45-78 years). Purpose: The rating of
thoracoscopic splanchnicectomy (SPLT) in the treatment of pain syndrome in relapsing CPR and CPN. Results: They practiced 68 (83.95%) SPLT on the left 13
(16.05%) SPLT on the right, (4 (4.94%) patients also required SPLT on the right on 8 weeks after SPLT on the left due tot he minimal therapeutic response). The
analgesic effect on short-term (<3 months) had an efficacy in 56 (100%) relapsing CPR cases and 20 (90.9%) cases of CPN. Between 3-6 months, the analgesia
efficacy was maintained at 38 (67,86%) cases of relapsing CP (continuing after 6 months) and 14 (63,63%) cases, 11 (50%) cases of CPN (after 6 months). The
perioperative mortality was 0. Mean postoperative hospital stay was 3.3 days (2-5 days). Conclusion: SPLT and endoscopic stenting of CBP represent
minimally-invasive procedures a safe surgery in CPN with jaundice. This procedures presents the advantages of the minimally invasive approach, especially in the
absence of complications, lower costs in CPN and CPR pain control during the conservative analgesic treatment.

Aspecte anatomo - clinice i imagistice n chistul hidatic hepatic


Anatomic, Clinical and Radiological Aspects in Hepatic Hydatid Cyst
Octavia Cristina Rusu (1), M. Hasouna (1), A. Chirca (1), R. V. Costea (1), Carmen Ursu (2), . Neagu (1)
(1) Spitalul Universitar de Urgen / Universitatea de Medicin i Farmacie Carol Davila, Clinica Chirurgie II, Bucureti, Romnia
(2) Spitalul Universitar de Urgen / Universitatea de Medicin i Farmacie Carol Davila, Clinica Radiologie, Bucureti, Romnia
Introducere: Boala hidatic se caracterizeaz prin afectarea frecvent a ficatului (70% din cazuri), lobul drept fiind interesat la 85% dintre bolnavi.
Simptomatologia frust, nespecific, cu rare manifestri alergice este caracteristic stadiului de debut al bolii.
Material i metod: Prezentm aspecte imagistice ntlnite n dou cazuri de chist hidatic hepatic voluminos ale unor paciente internate i tratate n clinica
noastr n perioada mai 2015-martie 2016, la care descoperirea chistului a fost incidental, n urma unor investigaii de rutin (echografie abdominal). Pacientele
au fost asimptomatice anterior depistrii chistului hidatic hepatic.
Concluzii: Screening-ul echografic este deosebit de important n depistarea chistelor hidatice hepatice asimptomatice, permind descoperirea acestora n stadiul
de debut al bolii.

Introduction: Hydatid disease is characterized by frequent liver damage (70% of cases), right lobe is interested in 85% of patients. Less manifestly and nonspecific
symptoms, with rare allergic manifestations are characteristic for early stages of the disease.
Material and methods: We present the imaging features encountered in two cases of voluminous liver hydatid cysts of some patients admitted and treated in our
clinic between May 2015-March 2016; the discovery of the cyst was incidental, following routine investigations (abdominal ultrasound). The patients were
asymptomatic before liver hydatid cyst detection.
Conclusions: Abdominal ultrasound screening is particularly important in detecting asymptomatic liver hydatid cysts, allowing their discovery in early stages of the
disease.
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Managementul diagnostic i curativ n patologia obstructiv benign a cii biliare principale pe fundal de
duodenostaz
Diagnostic and Treatment Management in Benign Obstructive Pathology of Main Biliary Ducts on the Background of
Duodenostasis
A. Hurmuzache (1), V. Hotineanu (2), A. Hotineanu (2), A. Cotone (3), A. Ferdohleb (2), E. Bort (1), I. Blan (4), Tamara ibrigan (5)
(1) Universitatea de Stat de Medicin i Farmacie Nicolae Testemianu, LC Chirurgia reconstructiv a tractului digestiv, Chiinu, Republica Moldova
(2) Universitatea de Stat de Medicin i Farmacie Nicolae Testemianu, Catedra Chirurgie Nr. 2, Chiinu, Republica Moldova
(3) Spitalul Clinic Republican, Secia Endoscopie, Chiinu, Republica Moldova
(4) Spitalul Internaional Medpark, Departamentul Chirurgie, Chiinu, Republica Moldova
(5) Spitalul Clinic Republican, Departamentul Imagistic Medical, Chiinu, Republica Moldova
Introducere: Tratamentul de elecie n patologia benign a cilor biliare extrahepatice (CBE): stenoza papilei duodenale mari (PDM), stricturi ale cii biliare
principale (CBP), colangite, coledocolitiaza pe fundalul malrotaiei duodenale (MRD) asociat cu duodenostaz, este chirurgical. Metodele endoscopice:
colangiopancreatografia retrograd endoscopic (CPGRE), papilosfincterotomia endoscopic (PSTE) cu sau fr litextracie permit stabilirea diagnosticului de
patologie a CBE i a tratamentului.
Scopul studiului: Optimizarea diagnosticului i tratamentului chirurgical la pacienii cu patologia benign a cii biliare principale (CBE) pe fundal de malrotaie
duodenal (MRD) asociat cu duodenostaz. Material i metode: Lotul de cercetare - 140 pacieni selectai n perioada 1998-2014. Toi au fost examinai conform
algoritmului diagnostic stabilit n Clinica Chirurgie Nr. 2 IP USMF Nicolae Testemianu. Apreciate clinic trei grade ale duodenostazei: compensat,
subcompensat, decompensat.
Rezultate: Tratamentului chirurgical - bazat pe principii etiopatogenetice n funcie de gradele clince.
I - Stricturile PDM i duodenostaz compensat - CPGRE+PSTE - 130 pacieni (92,8%);
II - Stricturile PDM + coledocolitiaz + angiocolit i duodenostaz subcompensat - CPGRE+PSTE+litextracie+sanarea CBE cu terapie medicamentoas complex
- 98 pacieni (70,0%);
III - Megalocoledoc i duodenostaz decompensat - transsecie supraduodenal de CBP cu implantarea ei n ansa jejunal n Y a la Roux, cu o lungime optim
a ansei de 80 cm - 12 pacieni (8,57%).
Concluzii: Metoda tratamentului chirurgical aplicat depinde de gravitatea patologiei CBE i stadializarea duodenostazei. Eficiena acestui tratament chirurgical
este determinat de dispariia semnelor clinice de colangit cronic, cu rezultate bune n perioada postoperatorie - 131 (93,57%) pacieni, ce au fost reintegrai
socio-familial i profesional.

Introduction: The elective treatment in the pathology of extrahepatic biliary ducts (EBD): stenosis of large duodenal papilla (LDP), stricture of the main biliary duct
(MBD), cholangitis, coledocholithiasis on the background of duodenal malrotation (DMR) associated with duodenostasis is a surgical one. Endoscopic methods:
Endoscopic retrograde cholecistopancreatography (ERCP), endoscopic papilosphyncterotomy (EPST) with or without litextraction can determine the diagnosis of
EBD pathology and treat it as well.
The aim: Optimizing the surgical treatment of patients with benign EBD pathology on the background of DMR associated with duodenostasis.
Material and methods: Studied group - 140 patients selected from 1998 to 2014 period. All of them were examined according to the algorithm proposed by
Surgical Department No. 2. There were three clinical stages of duodenostasis: compensated, subcompensated, decompensated.
Results: Surgical treatment - based on ethiopathogenetic principles related to clinical stages.
I - LDP strictures and compensated duodenostasis - ERCP+EPST - 130 patients (92,8%);
II - LDP strictures + choledocolithiasis + cholangitis and subcompensated duodenostasis - ERCP+EPST+litextraction+MBD sanation and complex drug therapy - 98
patients (70,0%)
III - Megalocholedoc and decompensated duodenostasis - supraduodenal transsection of MBD with its implantation in a 80 cm long Y a la Roux intestinal loop 12 patients (8,57%).
Conclusions: The chosen surgical method depends on the gravity of EBD pathology and duodenostasis stage. The efficiency of surgical treatment is determined
by the disappearance of clinical signs of chronic cholangitis with good postoperative results - 131 (93,75%) patients reintegrated in socio-familial and professional
aspects.

146

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Neo-colecist litiazic post colecistectomie incomplet - prezentare de caz


Residual Gallbladder Stones after Cholecystectomy - Case Report
M. Ierima, A. Chiotoroiu, B. Stoica, I. Tnase, S. Pun, M. Beuran
Spitalul Clinic de Urgen Floreasca, Chirurgie General, Bucureti, Romnia
Introducere: Neo-colecistul sau colecistul de neoformaie este o patologie rar, aprut n urma colecistectomiei incomplete, reprezentat prin rezecia veziculei
biliare la nivel infundibular sau prin secionarea la distan de coledoc a canalului cistic.
Prezentare de caz: Pacient n vrst de 63 ani, cunoscut cu colecistectomie, se interneaz pentru dureri abdominale colicative la nivelul hipocondrului drept i
grea postprandial. Ecografia abdominal deceleaz vezicul biliar de aspect cvasi-normal, de 3/2,6 cm, rotund-ovalar locuit de un calcul. Colangio-RMN
evideniaz aspectul de neovezicul (sau bont cistic dilatat) cu dou imagini micronodulare - calculi. Endoscopia digestiv superioar fr modificri patologice.
Intraoperator se confirm prezena unei formaiuni pseudotumorale cu aspect de neo-colecist, cu diametrul aprox. 3/2 cm locuit de calculi. S-a practicat
colecistectomia, iar vezicula biliar de neo-formaie s-a trimis la examenul histopatologic. Evoluia postoperatorie a fost favorabil cu dispariia
simptomatologiei, iar examenul histopatologic al piesei de rezecie a decelat aspectul de colecistit cronic - descris prin fibroz subseroas.
Concluzii: Colecistectomia incomplet poate reprezenta o soluie de moment, cu menionarea ulterioar a posibilitii reapariiei simptomatologiei de tip biliar.
Completarea colecistectomiei prin metoda deschis sau laparoscopic, este soluia optim pentru tratarea litiazei veziculare post colecistectomie.

Introducere: Neo-colecistul sau colecistul de neoformaie este o patologie rar, aprut n urma colecistectomiei incomplete, reprezentat prin rezecia veziculei
biliare la nivel infundibular sau prin secionarea la distan de coledoc a canalului cistic.
Prezentare de caz: Pacient n vrst de 63 ani, cunoscut cu colecistectomie, se interneaz pentru dureri abdominale colicative la nivelul hipocondrului drept i
grea postprandial. Ecografia abdominal deceleaz vezicul biliar de aspect cvasi-normal, de 3/2,6 cm, rotund-ovalar locuit de un calcul. Colangio-RMN
evideniaz aspectul de neovezicul (sau bont cistic dilatat) cu dou imagini micronodulare - calculi. Endoscopia digestiv superioar fr modificri patologice.
Intraoperator se confirm prezena unei formaiuni pseudotumorale cu aspect de neo-colecist, cu diametrul aprox. 3/2 cm locuit de calculi. S-a practicat
colecistectomia, iar vezicula biliar de neo-formaie s-a trimis la examenul histopatologic. Evoluia postoperatorie a fost favorabil cu dispariia
simptomatologiei, iar examenul histopatologic al piesei de rezecie a decelat aspectul de colecistit cronic - descris prin fibroz subseroas.
Concluzii: Colecistectomia incomplet poate reprezenta o soluie de moment, cu menionarea ulterioar a posibilitii reapariiei simptomatologiei de tip biliar.
Completarea colecistectomiei prin metoda deschis sau laparoscopic, este soluia optim pentru tratarea litiazei veziculare post colecistectomie.

Chistul hidatic - localizare rar


Hydatid Cyst - Rare Localization
Mihaela Andronic, D. Andronic, M. Costache, N. Dnil
Spitalul Clinic Judeean de Urgene Sf. Spiridon, Chirurgie I, Iai, Romnia
Dezvoltarea la nivelul retroperitoneului a chistului hidatic este considerat o localizare rar a acestuia iar atunci cnd nu se asociaz cu leziuni de tip hidatidoz la
nivelul altor organe vorbim despre chist hidatic retroperitoneal primar. V prezentm cazul unui brbat n vrst de 32 de ani, prezentat n urgen pentru o
formaiune intraabdominal gigant dur, dureroas cu fenomene de compresiune la nivel intestinal. Se exploreaz clinic i paraclinic (CT abdominal) ce
deceleaz 3 formaiuni chistice neomogene la nivel pelvin, situate retroperitoneal, fr demarcaie cu vasele iliace stngi i ureteral stng, ce comprim
sigmoidul i compresiune la nivelul mezenterului. S-a intervenit chirurgical, aspectul macroscopic plednd pentru chist hidatic retroperitoneal pelvin, confirmat
ulterior anatomopatologic i fr alte leziuni evidente de hidatitoz intraperitoneal. n zonele considerate endemice n faa unei formaiuni chistice
intraabdominale, diagnosticul diferenial cu chistul hidatic trebuie luat n considerare. Succesul terapeutic i totodat gold standardul const n excizia
chirurgical total a chistului, indiferent de localizarea chistului hidatic.

The development of the hydatid cyst in the retroperitoneum area is considered a rare location and when its not accompanied by lesions in other organs it is
defined as primary retroperitoneal hydatid cyst. We present the case of a man aged 32 years old presented in emergency with an abdominal giant, hard mass,
painful and with phenomena of compression. The clinical and paraclinical explorations (abdominal CT) are detecting three heterogeneous pelvic cystic formations
located retroperitoneal without any demarcation, with left iliac vessels and left ureteral which compress the sigmoid and the mesentery. It was decided on
surgery. Intraoperatory, the macroscopic pleading was for hydatid cyst retroperitoneal and pelvic, later confirmed by pathology and with no other intraperitoneal
lesion obvious for the hydatid cyst. In the endemic areas before an abdominal cystic formation, the differential diagnosis with hydatid cyst should be considered.
The gold standard therapeutic success lies in total surgical excision of the hydatid cyst, regardless of location.

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Factori predictivi n evoluia pancreatitelor acute severe


Predictive Factors in the Evolution of Severe Acute Pancreatitis
D. G. Popa (1), Ioana Iulia Cojocaru (2), C. M. Coarc (3), Garofia Bambor (2), Laura-Denisa Lata (2), R. Pisic (2), V. Habor (2), D. Szava (2), A. Strat (1),
C. Copotoiu (1)
(1) Universitatea de Medicin i Farmacie, Clinica Chirurgie 1, Trgu Mure, Romnia
(2) Spitalul Clinic Judeean de Urgen, Clinica Chirurgie 1, Trgu Mure, Romnia
(3) Universitatea de Medicin i Farmacie, Anatomie, Trgu Mure, Romnia
Pancreatita acut, n special forma sever (PAS), prezint o evoluie greu predictibil, fiind asociat cu o serie de complicaii ce pun n pericol viaa pacientului.
Diferenierea cazurilor de pancreatit acut sever precum i probabilitatea de apariie a acestor complicaii revine unor factori clinici, biochimici sau imagistici
cuprini n diferite sisteme de scoruri.
a. Scopul studiului vizeaz criteriile de clasificare a formelor grave de pancreatit conform criteriilor Atlanta, utiliznd scorurile de severitate, evoulia pacienilor
sub tratament i principalele complicaii survenite.
b. Pentru acest studiu am utilizat un lot de 408 pacieni internai n Clinica Chirurgie 1 pe perioada 01.01.2007-31.12.2015. Pentru analiz au fost folosite scorurile
Ranson, SAPS II, APACHE II, Balthazar i indicele de severitate CT.
c. Din lotul studiat, 53 de pacieni au prezentat pancreatit acut sever, 48 dintre acestia necesitnd intervenii chirurgicale. Ca i complicaii locale la pacienii
operai, cele mai frecvente au fost supuraiile de perete abdominal i necroza pancreatic infectat iar dintre cele generale au fost insuficiena de organ, unic
sau multipl, tranzitorie sau persistent, i sepsisul, unde mortalitatea a fost peste 50%.
d. Pancreatita acut este o boal imprevizibil care, n ciuda progreselor, nc are o rat a mortalitii ridicat n cazul formelor grave. Scorurile de prognostic au
rol important n diferenierea formelor grave i modularea tratamentului adecvat.

Acute pancreatitis, especially its severe form, shows an evolution hardly predictable, being associated with a powerful series of complications that endanger the
patient's life. Differentiating cases of severe acute pancreatitis and its complications returns to clinical, biochemical or imagistic factors enrolled in different
system scores.
a. The aim of the study is to classify sever forms of acute pancreatitis using Atlanta criteria based on severity scores, patients' clinical evolution under treatment
and major complications occurred.
b. For this study we used a lot of 408 patients hospitalized in the Surgery Clinic 1 of Targu Mures during 01.01.2007-12.31.2015. For the analysis were used
severity scores like Ranson, SAPS II, APACHE II and CT severity index.
c. 53 patients from the study group were diagnosed with severe acute pancreatitis, 48 of whom required surgery. As local co