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Jurnalul de Chirurgie, Iai, 2011, Vol. 7, Nr. 3 [ISSN 1584 9341]
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CUPRINS
EDITORIAL
ARTICOLE DE SINTEZ
ARTICOLE ORIGINALE
III
Cuprins Jurnalul de Chirurgie, Iai, 2011, Vol. 7, Nr. 3 [ISSN 1584 9341]
IV
Cuprins Jurnalul de Chirurgie, Iai, 2011, Vol. 7, Nr. 3 [ISSN 1584 9341]
CAZURI CLINICE
V
Cuprins Jurnalul de Chirurgie, Iai, 2011, Vol. 7, Nr. 3 [ISSN 1584 9341]
ARTICOLE MULTIMEDIA
ISTORIA CHIRURGIEI
RECENZII I NOUTI
VI
Editorial Jurnalul de Chirurgie, Iai, 2011, Vol. 7, Nr. 3 [ISSN 1584 9341]
Correspondence to: Prof. Dr. Robrecht Van Hee, Institute of the History of Medicine and Natural
Sciences, University of Antwerp, Belgium, e-mail: bob.van.hee@skynet.be.
INTRODUCTION
Inguinal hernia most probably has been a disease ever since mankind existed1.
In view of its existence in different kinds of animals2, and in particular of
primates3, one can assume that already prehistoric human beings were affected with the
disease4. Written proof of this statement became available from manuscripts and founds
in Mesopotamian5 and Egyptian6 cultures. So does the famous papyrus Ebers, dating
from around 1550 BC, refer to patients suffering from inguinal hernia, quoting its
appearance during coughing7. Another passage8 mentions its treatment:
Then you shall say concerning it This is a swelling of the coverings of his
abdomen, an illness which I will treat. It is the heat of his bladder in front of his belly
which creates it. Falling to the ground, it returns likewise. You should heat (shemen)
it to imprison it in his belly. You treat it like the sahemen treatment9.
1
Several publications on the history of inguinal hernia and its treatment have been published in the previous years. They can be
divided into four categories: 1. Historical monographs, amongst others Ren Stoppa et al. in 1998c; 2. Introductory chapters in
general survey books on hernia, amongst others Raymond Read in 1989 & 1994, Jos Patino in 1995, Brendan Devlin et al. in 1998,
Fernando Carbonell Tatay in 2001, John Skandalakis et al. in 2002; 3. Articles in journals, amongst others R.I.Carlson in 1956,
Michael Sachs et al. in 1997, Wayne Lau in 2002, D.A.McClusky et al., Philippe Bonnichon & Olivier Oberlin in 2010; 4. Articles
dealing with specific aspects of the history of anatomy, pathology or treatment of hernia: these will be cited at their respective places
in this article.
2
See for instance Slatter pp.452-459 and Ramadan & Abdin-Bey pp.57-61.
3
See for instance Sonia Wolfe-Coote p. 1935.
4
See Albert Lyons internet article (consulted 19.06.2011)
5
Hammurabi of Babylon described inguinal hernia. See also Skandalakis et al., p. 29.
6
So was the mummy of Ramses V (1157 B.C.) found to have a scrotal hernia and/or hydrocele. See Skandalakis et al. p.29.
7
See Lyons and Petrucelli p.92.
8
Ebers 872.
9
For this translation, see John Nunn p.166.
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It remains however unclear if the text refers to application of gentle heat to the
protruding mass or to aggressive cauterisation designed to create scarring and ensuing
occlusion of the hernia sac10.
GRECO-ROMAN TIMES
The Old Masters of Greek and Roman Antiquity wrote more elaborate treatises
on hernia pathology and devoted specific chapters to its origin, symptoms and
treatment.
So do we read in the Hippocratic Corpus, that hernia was the result of either
drinking water from large rivers11, or experiencing a traumatic event to the belly12.
In the 3rd century BC, Alexandrian medical scientists clearly advocated surgery
for hernia. They obtained preoperative sedation with a root extract of mandrake, while
haemostasis was achieved with vascular ligature13.
The original manuscripts were lost with the destruction of the library of
Alexandria, but were transmitted and later reiterated in Roman times, not the least by
the encyclopaedist Aulus Cornelius Celsus (fl.30-50 AD).
He collected the contemporary knowledge on hernia in his De Re Medica,
written around 30 AD. Herein he describes reduction of hernia content by taxis, and
states that at operation not only haemostasis is realised by ligature, but also that the
testes are spared14.
One century later Heliodorus (fl.125 A.D.) equally avoids castration, and deals
with the hernia sac by twisting its neck15.
Galen (130-200), not only wound surgeon of gladiators, but also physician of
two consecutive Roman emperors, ascribed the origin of hernias to rupture of the
peritoneum and overstretching of the overlying fascia and muscles16.
His treatment consisted of a ligature of the hernia sac, together with the
spermatic cord, and resection of the testicle17.
Galens words became like a medical Bible and were followed and applied for
centuries.
10
See Nunn p.167.
11
See for this passage of Hippocrates: Littr Vol.II p.37.
12
See for this quote of Hippocrates : Littr Vol.V.pp.81-83.
13
According to Patino, p.4, citing Leo Zimmerman & Ilza Veith 1961.
14
See Celsus De Re Medica, Book VII, Capitula XVIII to XXI. For an English translation of the corresponding passus, see Patino,
p.4.
15
See Read 1994, p.1.
16
Patino p.4, citing Read.
17
Patino p.4.
18
For a comprehensive review of hernia treatment in the Byzantine epoch, see Lascaratos et al., 2003.
19
See de Moulin p.24.
20
See de Moulin p.24.
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Arab surgeons continued hernia treatments in line with Byzantine authors like
Aetius of Amida (502-575) or Paulus Aeginetus. The most notorious writer Albucasis
(936-1013) discusses hernia at length in chapters 65 to 67 of the Maqalat, the 30th
book of his al-Tasrif21. In his chapter 67 Albucasis acknowledges that early hernia
swellings may reduce spontaneously, but mostly may become permanent through
formation of adherences.
They develop as a consequence of distension and weakening of the inguinal
peritoneum and should be treated by cauterisation22.
In chapter 65 the author elaborates on scrotal hernia, called oudara maaiya or
enterocele. Here the author is very reluctant to perform cauterisation. Instead, after
placing the patient in a supine position, the hernia is progressively reduced, after which
the patient is operated upon, the hernia sac transfixed with a cross stitch, and the testicle
removed23. Finally the scrotum is drained inferiorly.
The Arab influence of cauterising the pubic region in case of inguinal hernia
became widely adopted in the western late Middle Ages, in particular through the Latin
transcription of Albucasis al-Tasrif by Gerard of Cremona (1114-1187) in Toledo in
the late 12th century24.
So did Guy de Chauliac (1298-1368) borrow extensively from Albucasis
textbook. For inguinal hernia he proposes six different treatments25:
1. After skin incision, the hernia sac is transfixed and the distal spermatic cord with
the testicle is amputated (method of Galen).
2. Cauterisation of the external swelling with the red hot iron (method of
Albucasis).
3. Scar formation by using a cauterium potentiale, a plaster with escharotic
capacity, as for instance arsenic (method of Theodoric of Cervia [1205-1298]).
4. Applying a transcutaneous suture around the spermatic cord, and tying it on an
external wooden slat, until the cord becomes sectioned (method of Roger of
Salerno [late 12th century]).
5. Incising the suprapubic area and introducing a hot iron cauter directly on the
spermatic cord (method of Lanfranchi of Milan [?-1315]).
6. After incision, applying a golden thread around the spermatic cord, to tie it just
enough to ensure closure of the hernia sac (method of Guy de Chauliac)26.
The surgical textbooks of Guy became the New Testament in surgery. For more
than three hundred years, the different methods were in use, with a progressive
preponderance for Guys technique with the Golden Thread.
21
I used the French edition, commented by Sad Mestiri. See the corresponding chapters on hernia: pp.151-154. There is also the
English translation and commentary by M.S.Spink & E.L. Lewis (London: The Wellcome Institute of the History of Medicine;
Oxford: The University Press, 1973).
22
Albucasis. Ch.67.Let the patient lie on his back, in front of you ; make a transverse incision of approximately three finger
breaths, over the neck of the inguinal swelling and dissect the subcutaneous membranes. Then take a wooden stiletto and apply it
on the top side of the peritoneal sac, so as to reduce it in the interior of the abdomen; use two good sutures above the stiletto and
knot them; then remove the wooden stiletto with care not to section the peritoneum, nor to touch the testicle, as I teached you
previously; continue by applying a normal wound dressing; when the sutures fall off, the wound is infecting and the peritoneal
retraction prevent recurrence. Cauterisation has the most beneficial effects in the inguinal region.
23
Mestiri, pp.153-154, supposes this citation of orchiectomy may be the result of a faulty transcription, instead of representing
Albucasis idea.
24
See de Moulin p. 30
25
See de Moulin pp.57-58.
26
de Chauliac gives credit to Master Bernard for this technique. For de Chauliacs treatise on hernia, see de Chauliac ff.CCXCII vo.
till CCXCVI ro. According to Read, the Golden Thread was later effectively used by Gerard de Metz in 1412.
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Most surgeons in the late Middle Ages however remained very reluctant to
perform surgery. So did Roland of Parma (fl.1264) follow Albucasis in enhancing taxis
of the hernia by using a supine patient position27.
THE RENAISSANCE
Renaissance surgeons dared more than their medieval predecessors perform
surgical interventions for inguinal hernia28.
This may on the one hand have been the result of a better knowledge of
anatomical structures, on the other of new emerging expertise in instrument making.
Several surgeons benefited from the dawn of printing to ventilate their increased
knowledge and ideas concerning such surgical hernia repair.
So did Pierre Franco (ca.1500-1561) publish the first monograph, primarily
devoted to herniotomy, and written in vernacular.
In the second edition of his work, published in 1561 under the title Trait des
hernies, Franco discusses in detail the nature, cause and treatment of herniation29.
Surgical treatment differed according to the type of hernia.
In the inguinal form (bubonocele), Franco remains very conservative and after
reduction only uses a plaster or a truss 30.
In scrotal hernia with omental content (epiplocele) or with intestinal content
(enterocele) surgical treatment proves indicated and generally consisted of castration at
that side.
In sliding hernia (hitherto not described in literature) Franco opens the hernia
sac, separates the viscera from the peritoneal sac and subsequently proceeds as
mentioned before31.
Franco for the first time also dares to operate strangulated hernia. Via a high
scrotal incision a small and flattened rod is introduced into the hernia sac, so as to
identify the abdominal muscular hernia defect; then careful reduction could be
realised32, after which a similar radical procedure is performed as mentioned above.
According to Franco, forms with gangrenous intestines however were deemed to
33
be fatal .
At the time Franco produced his treatises, the German wound surgeon Kaspar
Stromayr (?-1566/67) published his Practica Copiosa, in which he elaborates
extensively on hernia treatment. In this marvellously illustrated work, Stromayr for the
first time presents a differentiation between direct and indirect inguinal hernia34.
The work of Franco found its reception in the well-known French surgeon
Ambroise Par (1510-1590) (Fig.1), who took over Francos account on hernia, and
published it in 156435 without however citing his source!!
27
What is now called a Trendelenburg position!
28
For a more elaborate discussion on Renaissance surgery for inguinal hernia, see Van Hee 2011.
29
See Franco 1561.
30
See Franco pp.26-27.
31
See Franco pp.42-44.
32
Therby following the technique previously proposed by Paul of Aegina and Albucasis.
33
See Franco pp.45-46.
34
See Stromayr 1559.
35
See Pars Dix Livres de Chirurgie.
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Par in a special chapter treats about the Point dor, method chosen only if
other treatments prove without result, and if the patient asks for it. After an incision just
above the pubic bone, a rod as described above is introduced to reduce the hernia
content in the abdomen; subsequently the hernia sac is loosened from testicular vessels
and cremaster muscle, using small forceps; then the sac is transfixed with 5-6 golden
threads, after which an extra thread ties strongly the hernia sac together with both edges
of the wound. This thread is left long outside the wound until it putrefies and falls off.
Just like de Chauliac, Par also discusses the various other methods of treatment,
including cauterisation.
Moreover Par discusses hydrocele, treating it either with a plaster or a seton
consisting of a silk thread inserted through the liquid sac in the scrotum, or else an
incision of the sac with evacuation of its content and tent-like insertion of a gauze until
cicatrisation37.
In all cases does Par try at all price to prevent orchiectomy, not only to obviate
infection, pain and death, but also to retain generative function38.
17TH CENTURY
In the 17th century Francos surgical treatments were followed and reiterated in
most countries through the textbooks of Par.
The Silesian surgeon Gottfried Purmann (1649-1711)39 definitively dismissed
the cauterizing methods which de Chauliac had taken over from the Arab surgeons.
Also in the Low Countries did surgeons mainly use trusses, or perform hernia repairs by
means of the Golden thread40.
36
Here the 13th edition of Pars Oeuvres has been used. See Par p.188.
37
See Par p.193.
38
See Par pp.192-193.
39
See Purmann 1692. For an overview on life and work of Purmann, see Sachs 1994.
40
See for an outstanding overview on Dutch hernia surgery in the 17th and 18th century: de Moulin pp.230-242.
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In their operative treatment for scrotal hernia they now all paid particular
attention to the spermatic vessels, since they recognized the danger of inadvertently
ligaturing or harming the vessels together with the ligature of the hernia sac, what then
could lead to testicular necrosis or gangrene41.
After elaborate studies in anatomy Franois Poupart (1661- 1709) in 1695
recognized the importance in hernia pathology of the inguinal ligament42, already
described previously by Gabriele Falloppio (1523-1562).
18TH CENTURY
In the 18th century renewed and extensive studies of specific anatomical
structures took place, in particular of the inguinal canal.
Anatomists like Giovanni Lancisi (1654-1720), Petrus Camper (1722-1789),
Antonio de Gimbernat (1734-1790)43 (Fig.2), and others gave beautiful descriptions of
topographical relations of inguinal structures, in particular of important ligaments.
The Gttingen professor of surgery August Gottlieb Richter (1742-1812)
produced a two volume treatise on hernia in 1777-1779, in which for the first time he
describes a strangulated hernia involving only part of the intestine44.
Therapeutically the 18th century saw the first report of a successful
transabdominal repair of inguinal hernia45. It was published by the Romanian prince
Demetrius Cantemir (1673-1723) (Fig.3) in 1716 and relates how Albanian surgeons
operated a hernia patient, made a low abdominal incision into the peritoneum, inverted
the hernia sac in the peritoneal cavity and tied it with a coarse thread, which was left in
the wound.
The abdominal incision was left open, and filled with whites of eggs, that were
regularly renewed. The patient was left for more than a fortnight in bed, before being
allowed to move. After a month or so the wound got healed, and the patient had
recovered46!
Some years later, Lorenz Heister (1683-1758) reported that already in 1701 Jean
Mry, surgeon at the Htel-Dieu in Paris, via laparotomy resected necrotic bowel from a
strangulated inguinal hernia, thereby performing definitive bowel diversion47.
Moreover, surgeons now more and more tried to spare the testicles and their
vasculature during herniotomy. Alas, in view of wound infection and/or bleeding, the
testes often became necrotic or atrophic48.
19TH CENTURY
In the 19th century anatomical studies continued to reveal specific anatomic
structures in the inguinal region.
Many fascias and ligaments today are still known by the names of their
discoverers: Antonio Scarpa (1752-1832)49, Franz Kaspar Hesselbach (1759-1816)50,
41
See de Moulin p. 238.
42
Which Poupart called Suspenseur de labdomen. (1695).
43
The Spanish surgeon Don Antonio de Gimbernat demonstrated the lacunar ligament in 1768, but published it in 1793.
44
See Richter 1777-1779.
45
See for a history of abdominal hernia repair, Richard Meade 1965.
46
For an extensive account of this extraordinary operation, see A. Nicolau 2009.
47
See the Dutch edition of Heister, published by Ulhoorn in 1741, p. 914.
48
See Read 1994 p.1.
49
See Scarpa, 1809. This work was published in French in 1812. Scarpa gave his name to a fascia and to a triangle.
50
See his first publication in 1806, called Anatomisch-chirurgische Abhandlung ber den Ursprung der Leistenbrche, as well as
his later publication of 1814. Herein he describes the interfoveolar ligament.
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Also the English famous anatomist and surgeon Sir Astley Paston Cooper (1768-
1841) published new and original anatomical views on the inguinal canal with two
publications in 1804 and 180754 (Fig.4). Continuing specific additions of inguinal
structures by his 18th century predecessors, Cooper described the therapeutically
important pectineal or superior pubic ligament, since then named after him, as well as
the transversal fascia, so important in the aetiology of direct hernias55.
The 19th century provokes a breakthrough in the treatment of inguinal hernia, not
the least because of the introduction of anaesthesia and techniques of asepsis and
antisepsis into surgical practice. Prior to these events, it remains difficult to find
accounts, quoting postoperative long term results. One can presume that high recurrence
rates will have occurred in patients surviving surgical hernia repair.
Anaesthesia and antisepsis in the mid 19th century however now allowed more
time-consuming dissections and elaborate techniques in order to diminish the number of
recurrences. Particularly anatomical repairs focussing on strengthening the posterior
wall of the inguinal canal became feasible56.
It was the Italian surgeon Eduardo Bassini (1844-1924)57 (Fig. 5), who around
1884 invented such new concept with his muscular reinforcement technique of the
posterior wall.
The first publication of this Paduan professor of surgery dates from 188758.
Already one and two years later he presented the results of larger series of patients
operated upon59. His technique consisted of suturing the falx aponeurotica (or conjoined
51
See Thomas Mortons textbook of 1841. Thomas Morton, got 4 prizes, eventually was admitted to the Royal College of Surgeons
in 1835, and was appointed house surgeon at the North London (later University College) Hospital. He became assistant surgeon in
1842, but never was given a professorship. Morton got depressed, what together with obsessive drinking ended in a suicide by
taking prussic acid , on 30 October 1849.
52
Thomson, 1836-1837, describing the ileopubic tract, later named after him. For a biography, see Rheault et al. pp. 601.
53
See Patino pp.7-8.
54
See Cooper 1804 & 1807.
55
See Raymond Read 1992.
56
In contrast to the non-anatomical concept of cicatrix formation in the past.
57
For biographical notes on Bassini, see Read 1987.
58
A first series of 38 patients was reported by Bassini at a congress of the Italian Society of Surgeons in Genova in 1887. See
Bassini 1887a & b.
59
See Bassini 1888 and 1889.
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tendon) to the inguinal ligament of Poupart. The results were astonishing. So was the
infection rate reduced to 4%60.
In 1890 Bassini produced a larger monograph with excellent illustrations, which
became the basis of a German translated article that now made him known worldwide61.
Fig. 4 Sir Astley Cooper - 1804. Fig. 5 Eduardo Bassini with his signature
Anatomy of the groin region
Fig. 6 Ernest Juvara Fig. 7 Henry Marcy. Anatomy of the inguinal canal
60
See Read 1994 p.2.
61
See Bassini 1890 (Italian) and 1890 (German).
62
Notably W.T.Bull 1891, A.Wlfler 1892, W.B.Coley 1895, P.Berger 1902. The famous William Halsted in 1889 transposed the
spermatic cord above the external oblique aponeurosis. It became known as the Halsted I procedure. This technique was later
followed by Martin Kirschner (1879-1942) and Peter Theodor Hackenbruch (1865-1924) .
63
See Palade 2005.
64
See Popa et al. 2010.
65
Marcy read his first paper on Cure of Hernia before the Section on Surgery at the 37th Annual Meeting of the American Medical
Association in May 1886 (published it in 1887), and edited his marvellously illustrated book on hernia treatment in 1892.
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20TH CENTURY
General developments in anaesthesia, introducing local forms of anaesthesia,
had also their effect on inguinal hernia repair. As a resident in the Johns Hopkins
Hospital in Baltimore, the young surgeon Harvey Cushing (1869-1939) (Fig.8) reported
hernia surgery under local cocaine infiltration already in 189874 (Fig.9 a & b). Halsted
later reported the experiences of his pupil in 1922.
In the 20th century75 a new step forward was developed in the 1940s by the
Canadian surgeon Earle Shouldice (1891-1965) of Toronto76 (Fig.10).
Shouldice proposed a technique based on Bassinis repair, however effectuated
under local anaesthesia and consisting of a four layer muscular closure of the posterior
wall, using continuous sutures77.
His results in terms of recurrence rate were clearly superior to those obtained
with previous methods78. The technique was taken over by many other teams from the
USA or Europe79, and became for many years a standard operation80.
Many surgeons progressively got persuaded that surgical techniques of hernia
repair had to be adapted to specific types of inguinal hernia.
It led several scientists to reconsider the anatomic principles of surgical hernia
repair , respectively to define and categorise the different types of hernia82.
81
66
See Marcy 1887.
67
Halsted originally brought the spermatic cord under the skin (the so-called Halsted I technique from 1889), but later abandoned
his cord transposition technique and inbricated the aponeurotic flaps of the external oblique as proposed by Edward Wyllis
Andrews: it became the so-called Halsted II repair.
68
See Andrews 1899.
69
Ferguson pointed first at the dangers of cord transposition in view of the testicular atrophy which could follow cord trimming and
transposition. See Ferguson 1899 & 1907.
70
For a review on the contribution of these American surgeons, see Summers 1947. See also Rutkow 1993a, p.516.
71
See Lotheissen 1898.
72
See McVay 1948 and McVay & Anson 1949.
73
So did Berliner in 1994 report an 11% recurrence rate! See Berliner p. 203.
74
See Cushing 1898 & 1900.
75
For a selective history of inguinal hernia repair in the 20th century, see Ira Rutkow 1993b.
76
See for a historic perspective on Earle Shouldice: Welsh & Alexander 1993, p. 454.
77
See Shouldice 1953.
78
For results of the Shouldice repair, see Shearburn & Myers 1969.
79
See Glassow 1984.
80
See Nicholson 1999.
81
For instance Henri Fruchaud (1894-1960). See also Stoppa & Van Hee 1998a.
82
Early classifications included those of Kaspar Stromayr in 1559, reiterated in 1844 by Astley Cooper (indirect and direct hernias),
and more recently those by Casten D.F. in 1967 and Gilbert A.I. in 1989.
309
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Fig. 8 Harvey Cushining, aged 29 Fig. 9a Cushing.Patient, three weeks after right
hernia repair, with lstill present left hernia
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To cope with this tension, at first relaxing incisions into the rectus fascia sheath
were proposed.
Already recommended by Anton Wlfler (1850-1917) in 1892, Halsted
popularized this procedure, witch was later adapted by Norman Tanner (1906-1982) by
sliding part of the rectus sheath lateral and downwards to Pouparts ligament, and so
reinforcing the Bassini-type of hernia repair.
Another idea to diminish tension on the muscular closure was invented by the
German Martin Kirschner (1879-1942), who for the first time used autologous material,
namely pedicled or free fascia from the thigh to bridge the inguinal muscular defect88.
The idea of free fascia lata grafts was taken over by William Gallie (1882-1959)
& Arthur Lemesurier (1889-1982), who used them as tension-free inlay on the
weakened posterior inguinal wall89. The technique was later popularized by Geoffrey
Keynes (1887-1982).
However also non-autologous materials soon were used to bridge the posterior
wall defect. Already in 1896 did Albert Narath (1864-1924) make use of silver
filigree90. Years later Francis Usher (1908-1980)91 (Fig.11) in 1958 used polypropylene
as first successful synthetic prosthesis92.
The tension free concept got its breakthrough with Irving Lichtenstein (1920-
2000) (Fig.12) from Los Angeles in the second edition of his well-known hernia
monograph93.
88
See Kirschner 1910.
89
See Gallie & Lemesurier 1923.
90
See Read 1994, p.3.
91
For a biography of Francis Cowgil Usher, see Read 1999. See also the internet article of the De Bakey Clinic:
http://www.debakeydepartmentofsurgery.org/home/content.cfm_id=270.
92.The famous R/Marlex mesh.
93 See Lichtenstein 1970.
94 See Lichtenstein 1964.
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95
See Ayta et al. 2004, who found a recurrence rate of 0.8% after Lichtenstein repair versus 4.1% after Shouldice repair. Equally
Amid et al. found only 4 recurrences on 3250 patients in a 1 to 8 year follow-up from 1984 to 1992 (see Amid et al. p.185.).
96
The tension free repair has now become the treatment of choice: see Macintyre 2003. Particularly the Lichtenstein repair is still
the first recommended operation for inguinal hernia, not only in the Netherlands (see Simons et al., 2003), but also in many other
countries. See the European Hernia Society guidelines (Simons et al., 2009).
97
See Kingsnorth et al. 2002.
98
Quoted by Richard Meade in 1965.
99
See Bates 1913.
100
For notes on La Roques biography and techniques, see Rutkow 1993b pp. 397-398.
101
See La Roque 1919.
102
See Henry 1936.
103
See Cheatle 1920.
104
Stoppa popularized the procedure from 1973 onwards. See Stoppa 1973, Stoppa et al. 1984, and Stoppa & Van Hee 1998b.
312
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LAPAROSCOPIC APPROACH
With the advent of computer chip technology, laparoscopic visualisation and
treatment of inguinal hernia got introduced in the surgical arena106.
Ralph Ger was the first in 1982 to report a transabdominal closure of an inguinal
hernia defect during a laparoscopy for other reasons107. His technique consisted of
transfixing with Michel staples the peritoneal hernia sac together with the surrounding
tissues108, thereby trying to prevent hernia recurrence. The good results incited Ger to
continue on the same track, and to build up experience with experimental work on
animals, now inserting the stapler device via a second separate laparoscopic trocar 109.
Some years later, in 1989, the gynaecologist S.Bogojavalensky110 showed a
video demonstrating the laparoscopic intraabdominal incision of the peritoneal hernia
sac, subsequently closing the visible muscular defect with a rolled-up piece of
polypropylene mesh.
The early 1990s saw a rapid rise of the number of publications, confirming the
feasibility of laparoscopic hernia repair111.
Whereas the first interventions were confined to a plug and patch repair112, later
transabdominal approaches opted for the fixation of a large preperitoneal mesh, either
sutured or stapled to the posterior muscular wall113.
A first attempt was made by applying a synthetic mesh to the peritoneal
defective wall. It got the name IPOM (IntraPeritoneal Onlay Mesh).
Another approach consisted in making an intraperitoneal U-type incision in the
peritoneal wall and inserting the mesh in a preperitoneal position. It became known as
the TAPP technique (TransAbdominal PrePeritoneal approach).
Soon other surgeons proposed a complete extraperitoneal insertion of the
preperitoneal mesh, namely Dulucq in 1992, Ferzli et al. in 1992, Himpens in 1992, and
Barry Mac Kernan and Laws in 1993114. The technique was soon followed by many
others. It became known as the TEP technique (Total ExtraPeritoneal approach). Even
a special balloon dissector was introduced to facilitate this extraperitoneal approach115.
Several discussions and symposia followed the introduction of laparoscopic
techniques in inguinal hernia repair116.
105
See Wagh et al. 1974.
106
See for a historical overview of these recent developments: Jos Cervantes 2004.
107
See Ralph Ger 1982.
108
Resembling what Franco had done from the outside in the 16th century!
109
See Ger et al. 1990.
110
Video-presentation at the 18th Annual Meeting of the American Association of Gynaecological Laparoscopists in Washington
D.C.
111
The first reports were published by Leonard Schultz et al. in 1990, and J. Corbitt , Bob Fitzgibbons et al., and Frederick Toy and
Smoot. in 1991 (and many other authors in the following years!) ,
112
E.g. those of Schultz et al., and Corbitt.
113
See Morris Franklin 1992, Arregui et al. 1992, Himpens 1992, and others.
114
See Ferzli et al., 1992, Dulucq 1992, Himpens 1992, and McKernan & Laws, 1993.
115
See Kieturakis 1995.
116
See Van Hee 1998.
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In the first place ethical issues were put forward117. Indeed, many surgeons
worldwide had immediately started their laparoscopic experience on patients, in contrast
to various other techniques in surgical practice, where animal experiments precede
evaluation in humans.
Moreover in an era where trials were in common use for new drugs, instruments
or techniques, trials in laparoscopy on the contrary were performed scarcely and late,
and yielded results only years after the already liberal use of laparoscopy.
When the first trials with often small numbers of patients were published, no
real differences in outcome were observed between standard Shouldice or Lichtenstein
repairs and laparoscopic techniques118. Neither was there at first significant difference
between the TAPP and TEP forms of laparoscopic repair119.
However in all trials reduced pain, as well as earlier ambulation and return to
work became strongly apparent120. These advantages had to counteract the soon
observed higher risk of nerve lesion, resulting in so-called meralgia paresthetica121, and
the higher financial costs of the use of laparoscopic apparatus.
In a later stage, many surgeons favoured the extraperitoneal TEP approach, in
view of the absence of adhesion risks in the abdomen122.
However, both TAPP and TEP techniques continued to be used in the last 15
years, and are advised as evidence based techniques, equal to Lichtenstein repair123.
A second series of discussions focussed on technical aspects of laparoscopic
repair. So were surgeons concerned about the optimal size124 or structure of the mesh125,
or tried newer forms of cameras, trocars or instruments.
As it stands now, as well open techniques with tension free repair (type
Lichtenstein repair), as laparoscopic techniques with preperitoneal mesh placement
(type TAPP or TEP) are the evidence-based and accepted methods in use to deal with
adult inguinal hernia126.
It will be interesting to evaluate how these actual types of hernia repair evolve in
the future.
CONCLUSION
Inguinal hernia repair has made enormous progress throughout the ages. The
main reasons for intervention however remained the same: continuous growth of the
inguinal and/or scrotal swelling, the risk of incarceration of the hernia content and the
bad results of conservative methods like truss placement.
Surgical techniques have rapidly evolved since Eduardo Bassini proposed his
first successful reconstruction of the inguinal floor.
The various adaptations of his technique did however not result in a substantial
reduction in the number of recurrences.
The tension free repair, introduced by Irving Lichtenstein, caused a dramatic
drop in the recurrence rate and became the procedure of choice.
117
See Van Hee 1994.
118
See Barkun et al 1995, Juul & Christensen 1999.
119
See Van der Schelling et al 1996; Van Hee et al. 1998b.
120
See Wall et al. 2008.
121
See Kraus 1993.
122
See Himpens et al. 1994.
123
See The European Hernia Society guidelines: Simons et al. 2009.
124
See Knook et al. 2001 and Tott et al. 2005.
125
See for an overview of the history of different mesh types: James DeBord 2005.
126
See Van Hee 2007.
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INTRODUCERE
Introducerea abordului miniinvaziv nonoperator n tratamentul pseudochisturilor
de pancreas (drenaj percutan, endoscopic) au adus sperana rezolvrii nonchirurgicale a
acestora. Totui, crearea unei comunicri minime pseudochistodigestive i
imposibilitatea explorrii interiorului cavitii pentru evacuarea necrozelor au dus n
multe cazuri la recidiv sau apariia altor complicaii(suprainfecie, hemoragie) ce au
determinat scderea entuziasmului iniial pentru metod i selecia atent a cazurilor. n
ntmpinarea acestor dificulti a venit abordul laparoscopic ca variant miniinvaziv a
procedeelor consacrate, abord ce i propune s reuneasc avantajele metodelor
precedente.
Tehnicile de drenaj laparoscopic ale pseudochisturilor pancreatice respect
principiile chirurgiei clasice: drenajul decliv, biopsia peretelui, explorarea i debridarea
pereilor i hemostaza minuioas. Ele reprezint, n mare msur, realizarea
procedeelor clasice cu mijloace miniinvazive. Cu toate acestea exist unele procedee
proprii laparoscopiei n care abordul miniinvaziv aduce un avantaj cert. Abordul
laparoscopic necesit att o planificare minuioas a interveniei pe baza explorrilor
preoperatorii ct i ndemnri deosebite n chirurgia laparoscopic.
*
received date: 07.04.2011
accepted date: 24.06.2011
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SCURT ISTORIC
n 1994 separat Gagner [1] i Way [2] public primele chisogastrostomii
laparoscopice intraluminale. Trias i colab. [3] modific procedura n 1995 utiliznd
sutura mecanic. Tot n 1994 sunt descrise primele aborduri transgastrice (Meltzer i
Amaral [4]). Morino [5] imagineaz n 1995 abordul posterior, actualizat de Park n
1999 [6]. n aceeai perioad sunt descrise i anastomozele pseudochistojejunale
laparoscopice [7]. Cushieri public prima splenopancreatectomie caudal laparoscopic
n 1996 [8]. Evoluia tehnologiei a permis abordul chirurgical al pseudochistului prin
orificiile naturale (NOTES), n fapt una dintre cele mai fireti utilizri ale acestei tehnici
[9]. La noi n ar primele derivaii interne laparoscopice ale pseudochisturilor
pancreatice au fost publicate n 2002 [10].
METODE
Exist trei tipuri de drenaj chirurgical miniinvaziv ale pseudochisturilor de
pancreas:
I. Tehnici de drenaj laparoscopic derivate din chirurgia deschis:
1. Pseudochistogastrostomia laparoscopic transgastric;
2. Pseudochistogastrostomia laparoscopic pe cale posterioar
3. Pseudochistojejunostomia pe ans Roux
4. Drenajul extern
5. Pancreatectomia corporeo-caudal.
II. Tehnici de drenaj proprii laparoscopiei
1. Chistogastrostomia laparoscopic intraluminal
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Unii autori[16] consider c abordul posterior este mai puin laborios, ofer o
vizibilitate mai bun i determin o sngerare redus comparativ cu abordul anterior,
scznd concomitent i posibilitatea nchiderii comunicrii chisto-gastrice.
A. B.
C. D.
n cele mai utilizate tehnici operatorii [17-20] pacientul este aezat n poziie de
litotomie joas, chirurgul ntre picioarele bolnavului. Se folosesc 4 sau 5 trocare: un port
supraombilical de 5 sau 10 mm pentru camer, un trocar de 5 mm pentru deprttor n
zona subxifoidian, un trocar de 11 mm n cadranul superior stng pentru stapler i nc
un trocar de 5 mm n regiunea subcostal stng. Accesul n cavitatea retrogastric se
face la nivelul marelui epiploon care este secionat la nivelul marii curburi gastrice cu
ajutorul disectorului cu ultrasunete, stapler-ului sau a electrocauterului. Stomacul este
ridicat cu ajutorul deprttorului sau suspendat cu un fir trecut transparietal fixat cu o
pens i este cutat un loc potrivit pentru anastomoz, la limita zonei de aderen dintre
pseudochist i faa posterioar a stomacului. Pseudochistul este identificat vizual i
prezena sa este confirmat prin puncie aspiraie. Cu electrocauterul sau disectorul cu
ultrasunete este creat chistotomia i gastrotomia posterioar.
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Brea mezenteric este suturat cu fir 2-0 neresorbabil, n puncte separate pentru
a evita hernierea intern. Se face un lavaj peritoneal abundent pentru a nltura lichidul
care a contaminat cavitatea peritoneal i eventualele detritusuri din cavitatea
pseudochistului.
Poziia trocarelor variaz n funcie de autor, unii recomandnd introducerea
acestora n etajul supraombilical: trocar optic ombilical, dou trocare lateral stnga de
ombilic i cranial fa de acesta, unul similar pararectal drept i unul stng ct mai
lateral de 12 mm pentru stapler.
Unii autori realizeaz anastomoza pseudochistojejunal manual pentru a evita
dificultile legate de grosimea pereilor pseudochistului.
Ali autori [22,23] descriu aceast anastomoz cu o ans jejunal n continuitate
chiar fr a realiza o anastomoz de tip Braun, reducnd timpul interveniei i costurile
acesteia.
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CONCLUZII
Drenajul laparoscopic reprezint relansarea chirurgiei n competiie cu
endoscopia intervenional n tratamentul miniinvaziv al pseudochisturilor de pancreas.
Drenajul laparoscopic const att n realizarea tehnicilor din chirurgia deschis
cu mijloace miniinvazive ct i din metode originale, proprii laparoscopiei. Dei iniial
competitive, n timp cele dou metode au devenit complementare. Rezultatele sunt
excelente, cu complicaii minime i conversie excepional.
Avantajele fa de abordul endoscopic sunt reprezentate de obinerea unui
specimen reprezentativ pentru anatomopatologie, explorarea i debridarea cavitii,
tratamentul pseudochisturilor caudale sau care nu au contact cu un perete digestiv i
crearea unei anastomoze largi ce evit recidiva.
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Coresponden: Dr. Mihaela Blaj, doctorand Universitatea de Medicin i Farmacie Gr. T. Popa Iai,
medic primar ATI, Clinica A.T.I., Sp. Sf. Spiridon, str. Independentei, nr. 1, 700111, e-mail:
miblaj@yahoo.com*.
INTRODUCERE
n algoritmul de tratament al pacientului critic resuscitarea volemic reprezint
un obiectiv terapeutic major. Corectarea precoce a hipovolemiei i optimizarea perfuziei
tisulare asigur ameliorarea prognosticului.
Managementul terapiei cu fluide vizeaz momentul optim de iniiere a
resuscitrii volemice, cantitatea de fluide, tipul de fluide precum i ritmul de
administrare al acestora n funcie de particularitile clinice ale pacientului pe care l
tratm. Strategiile inadecvate de resuscitare volemic duc la creterea morbiditii i
mortalitii [1].
Terapia cu fluide trebuie considerat ca o medicaie esenial la pacientul critic
dar care, ca orice drog, are indicaii, contraindicaii i efecte toxice adverse, periculoase
[2].
*
received date: 12.05.2011
accepted date: 29.06.2011
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Tabel 1
Valoarea PIA dup gradul de severitate al afeciunii
Tabel 2
Clasificarea hiperpresiunii intraabdominale
Gradul PIA(mmHg) PIA(cmH2O)
Gradul I 12 -15 mmHg 16 20 cmH2O
Gradul II 16 - 20 mmHg 21 24 cmH2O
Gradul III 21-25 mmHg 25 30 cmH2O
Gradul IV > 25 mmHg > 30 cmH2O
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Hipertensiune intraabdominal
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B. COMPLIAN
PARIETAL SCZUT
A. COMPLIAN
PARIETAL NORMAL
hipertensiune abdominal
ischemia mucoasei intestinale Scade transportul
de oxigen
Creste
permebilitatea MSOF
capilar
transloca
translocaie bacterian
apoptoz
necroz pancreatic
Metabolism
anaerob
Formare de acidoz
radicali liberi
de oxigen
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10% nu este necesar terapia
cu fluide
10 %
%
24% trebuie asigurat aport de
fluide
Tabel 3
Valoarea predictiv a parametrilor hemodinamici n evaluarea rspunsului la terapia cu fluide.
Parametru hemodinamic Tehnica de msurare Predictivitate (AUC- aria de
sub curb)
Variaia presiunii pulsului Cateter arterial 0.94 (0.93-0.95)
(PPV)
Variaia presiunii sistolice Cateter arterial 0.86 (0.82-0.90)
(SPV)
Variaia volumului sistolic Cateter arterial 0.84 (0.78-0.88)
(SVV)
Aria telediastolic a ecocardiografie 0.64 (0.53-0.74)
ventricolului stng (LVEDA)
Volumul telediastolic global Termodiluie transpulmonar 0.56 (0.37-0.67)
(GEDV)
Presiunea venoas central Cateter venos central 0.55 (0.48-0.62)
(PVC)
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Utilizarea diureticelor de ans are rezultate bune, dar mai eficiente n reducerea
HIA s-au dovedit tehnicile de hemofiltrare ce asigur eliminarea excesului de fluide i
reducerea edemului parietal, visceral; astfel se va ameliora compliana abdominal i
presiunea de perfuzie abdominal [46].
CONCLUZII
Terapia cu fluide la pacientul critic este o provocare pentru clinician; pentru
alegerea conduitei terapeutice adecvate trebuie s se evalueze corect statusul volemic al
pacientului i s se intervin prompt pentru optimizarea clinic i paraclinic. n
constelaia de parametri clinici , biologici, hemodinamici ce informeaz asupra gradului
de oxigenare tisular , pentru o viziune corect asupra statusului volemic al pacientului
critic, este obligatorie monitorizarea PIA i PPA ; interpretarea corect a parametrilor
hemodinamici n funcie de valoarea presiunii intraabdominale i aplicarea msurilor de
resuscitare volemic ghidate de obiectivul evitrii / reducerii HIA, vor asigura
ameliorarea prognosticului pacientului critic.
Managementul pacienilor cu HIA /SCA implic ca strategie terapeutic
nonchirurgical reducerea aportului de fluide i bilanul hidric negativ dup ziua a 3-a
de resuscitare volemic; aceast atitudine terapeutic coroborat cu alte intervenii
specifice , contribuie la ameliorarea prognosticului pacientului cu HIA.
BIBLIOGRAFIE
1. Kirkpatrick AW, Balogh Z, Ball CG, Ahmed N, Chun R, McBeth P, Kirby A, Zygun DA. The
secondary abdominal compartment syndrome:iatrogenic or unavoible? J Am Coll Surg 2006;
202(4): 668-679.
2. Goldstein SL. Fluid is a drug that can be overdosed in the ICU. In Vincent JL. ed. Annual
Update in Intensive Care and Emergency Medicine 1st ed. Springer, 2011; p. 307.
3. Chappell D, Jacob M, Hofmann-Kiefer K, Conzen P, Rehm M. A rational approach to
perioperative fluid management. Anesthesiology 2008; 109(4): 723740.
4. Cheatham ML. Abdominal Compartment Syndrome: pathophysiology and definitions. Scand J
Trauma Resusc Emerg Med. 2009; 17: 10.
5. Boyd JH, Forbes J, Nakada TA, Walley KR, Russell JA. Fluid resuscitation in septic shock a
positive fluid balance and elevated central venous pressure are associated with increased
mortality. Crit Care Med. 2011; 39(2): 259-265.
6. Vincent JL, Weil MH. Fluid challenge reviewed. Crit Care Med 2006; 34(5): 1333-1337.
7. Dellinger RP. Surviving Sepsis Campaign: international guidelines for management of severe
sepsis and septic shock: 2008. Intensive Care Med. 2008; 34(1): 17-60.
8. Dellinger RP. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic
shock. Crit Care Med. 2004; 32(3): 858-873.
9. Lopes MR, Oliveira MA, Pereira VO, Lemos IP, Auler JO Jr, Michard F. Goal-directed fluid
management based on pulse pressure variation monitoring during high-risk surgery: a pilot
randomized controlled trial. Crit Care Med. 2007; 11(5): R100.
10. Sakr Y, Dubois MJ, De Backer D, Creteur J, Vincent JL. Persistent microcirculatory alterations
are associated with organ failure and death in patients with septic shock. Crit Care Med. 2004;
32(9): 1825-1831.
11. Kwan I, Bunn F, Roberts I; WHO Pre-Hospital Trauma Care Steering Committee. Timing and
volume of fluid administration for patients with bleeding following trauma. Cochrane Database
Syst Rev. 2001; (1): CD002245.
12. Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, Peterson E, Tomlanovich M;
Early Goal-Directed Therapy Collaborative Group. Early goal-directed therapy in the treatment
of severe sepsis and septic shock. N Engl J Med. 2001; 345(19): 1368-1377.
13. Balogh Z. Supranormal trauma resuscitation causes more cases of abdominal compartment
syndrome. Arch Surg. 2003; 138: 637-643.
14. Matthew B. The association between fluid administration and outcome following major burn.
Ann Surg. 2007; 245(4): 622628.
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31. Cheatham ML, Malbrain ML, Kirkpatrick A, Sugrue M, Parr M, De Waele J, Balogh Z,
Leppniemi A, Olvera C, Ivatury R, D'Amours S, Wendon J, Hillman K, Wilmer A. Results
from the International Conference of Experts on Intra-abdominal Hypertension and Abdominal
Compartment Syndrome. II. Recommendations. Intensive Care Med. 2007; 33(6): 951-962.
32. Cheatham ML, White MW, Sagraves SG, Johnson JL, Block EF. Abdominal perfusion pressure:
a superior parameter in the assessment of intra-abdominal hypertension. J Trauma. 2000; 49(4):
621-626.
33. Malbrain ML, Deeren D, De Potter TJ. Intra-abdominal hypertension in the critically ill: it is
time to pay attention. Curr Opin Crit Care. 2005; 11(2): 156-71.
34. Michard F, Teboul JL. Predicting fluid responsivness in ICU patients: a critical analysis of the
evidence. Chest 2002, 121(6): 2000-2008.
35. Ganter MT, Hofer CK. Assessment of perioperative fluid balance. In Vincent, JL. ed. Yearbook
of Intensive Care and Emergency Medicine. Berlin, Springer-Verlag, 2008; p. 523-535.
36. Monnet X, Anguel N, Osman D, Hamzaoui O, Richard C, Teboul JL. Assessing pulmonary
permeability by transpulmonary thermodilution allows differenciation of hydrostatic pulmonary
edema from ALI/ARDS. Intensive Care Med 2007; 33(3): 448-453.
37. Marik PE, Cavallazzi R, Vasu T, Hirani A. Dynamic changes in arterial waveform derived
variables and fluid responsiveness in mechanically ventilated patients: a systematic review of the
literature. Crit Care Med. 2009; 37(9): 2642-2647.
38. Boushel R, Langberg H, Olesen J, Gonzales-Alonzo J, Blow J, Kjaer M. Monitoring tissue
oxygen availability with near infrared spectroscopy (NIRS) in health and disease. Scand J Med
Sci Sports. 2001; 11(4): 213-222.
39. Marik PE, Baram M, Vahid B. Does the central venous pressure predict fluid responsiveness? A
systematic review of the literature and the tale of seven markes. Chest 2008, 134(1): 172-178.
40. Valenza F, Chevallard G, Porro GA, Gattinoni L. Static and dynamic components of esophageal
and central venous pressure during intra-abdominal hypertension. Crit Care Med 2007;35(6):
1575-1581.
41. Solus-Biguenet H, Fleyfel M, Tavernier B, Kipnis E, Onimus J, Robin E, Lebuffe G, Decoene C,
Pruvot FR, Vallet B. Non-invasive prediction of fluid responsiveness during major hepatic
surgery. Br J Anaesth. 2006; 97(6): 808-816.
42. Renner J, Gruenewald M, Quaden R, Hanss R, Meybohm P, Steinfath M, Scholz J, Bein B.
Influence of increase intra-abdominal pressure on fluid responsiveness predicted by pulse
pressure variation and stroke volume variation in a porcine model. Crit Care Med 2009; 37(2):
650-658.
43. Mahjoub Y, Touzeau J, Airapetian N, Lorne E, Hijazi M, Zogheib E, Tinturier F, Slama M,
Dupont H. The passive leg-raising manevre cannot accurately predict fluid responsiveness in
patients with intra-abdominal hypertension. Crit Care Med. 2010; 38(9): 1824-1829.
44. Pelosi P, Calzia E, Asfar P. It's time to measure intra-abdominal pressure to optimize
hemodynamics. Intensive Care Med 2007; 33(1): 163-171.
45. Cheatham ML. Nonoperative management of intraabdominal hypertension and abdominal
compartment syndrome. World J Surg. 2009; 33(6): 1116-1122.
46. Oda S, Hirasawa H, Shiga H, Matsuda K, Nakamura M, Watanabe E, Moriguchi T. Management
of intra-abdominal hypertension in patients with severe acute pancreatitis with continuous
haemofiltration using a polymethyl methacrylate membrane haemofilter. Ther Apher Dial. 2005;
9(4): 355-361.
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Correspondence to: Voichia Mogo, MD, PhD, Professor of Endocrinology, Clinic of Endocrinology,
St. Spiridon Hospital Iai, Independenei str. No. 1, 700111, Iai, Romania*
INTRODUCTION
Radical pelvic surgery is an important cause of iatrogenic erectile dysfunction
[1]. Most date in literature deal with erectile dysfunction after radical prostatectomy, but
date on sexual consequences of colonic and rectal surgery are also available.
Radical prostatectomy remains standard therapy for localized prostate cancer
[2]. Erectile dysfunction is one of the most important issue following radical
prostatectomy with significant negative impact on health-related quality of life [3,4].
Occurrence of sexual dysfunction and its recovery after radical prostatectomy
dependens of surgical procedure the ability to perform a nerve sparing surgery and
previous sexual function of the patients [5].
*
received date: 09.06.2011
accepted date: 27.06.2011
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Doppler duplex penile ultrasonography may have predictive value for sexual
function recovery. Ohebshalom [16] demonstrated by using this method the occurrence
of up to 71% abnormal penile hemodynamic after prostatic surgery and some cases with
venous leak, as well as a strong correlation between erectile function scores domains
and abnormal findings during Doppler duplex penile ultrasonography.
Clinical predictive factors for erectile function recovery after radical
prostatectomy may be the following [17]:
o Preoperative factors:
- Young age of the patient and younger partner results in stimulating sexual
interest and desire.
- Good preoperative sexual function: patients with good preoperative sexual
function may be the best candidates for nerve-sparing radical prostatectomy
with good recovery prognosis. Those who already have sexual dysfunction
and use phosphodiesterase type 5 inhibitors may develop worse sexual
function irrespective of the surgical technique.
- Comorbidities: patients with diabetes, arterial hypertension, ischemic hearth
disease, smokers or with hypercholesterolemia may already have sexual
dysfunction.
o Intraoperative factors:
- Preservation of both neuro-vascular bundles that are neuro-vascular
networks more complex that previously anticipated by classic anatomy.
- Preservation of accessory pudendal artery if present.
- Surgeons experience is an independent predictive factor for postoperative
preservation of sexual function.
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CONCLUSIONS
Radical prostatectomy and colonic and rectal surgery are associated with
iatrogenic erectile dysfunction due to cavernous nerve injury which leads to reduced or
absent spontaneous erection, hypoxia, oxidative stress, apoptosis of cavernous smooth
muscle, fibrosis and venooclusive disease.
The prevalence of iatrogenic ED depends of type of surgery, autonomic nerve-
sparing abilities, and sexual function before surgery.
Postoperative rehabilitation of sexual function program must start immediately
after surgery in order to induce erections with adequate blood and oxygen supply to
prevent cavernous muscle apoptosis and fibrosis and to increase future ability to
perform a good sexual function.
First line therapy in rehabilitation programs are PDE 5 inhibitors, intracavernous
erectogenic drugs administration and vacuum constriction devices.
Other options such as antioxidants, sartans, atorvastatin and geen therapy are in
trial.
BIBLIOGRAPHY
1. Becher EF, Toblli JE, Castronuovo C, Nolazco C, Rosenfeld C, Grosman H, Vasquez E, Mazza
ON. Expression of caveolin-1 in penile cavernosal tissue in a denervated animal model after
treatment with sildenafil citrate. J Sex Med. 2009; 6(6): 1587-1593.
2. Moghelli A. Erectile dysfunction following prostatectomy:prevention and treatment. Nat Rev
Urol. 2009; 6(8): 415-427.
3. Hatzimouratidis K, Burnett AL, Hatzichristou D, Mc Cullogh AR, Montorsi F, Mulhall JP.
Phosphodiesterasis 5 inhibitors in prostatectomy erectile dysfunction: a critical analysis of the
basic science rationale and clinical application. Eur Urol. 2009; 55(2): 334-347.
4. Nandipanti KC, Raina R, Agarwal A, Zippe CD. Erectile dysfunction following radical
retropubic prostatectomy: epidemiology, pathophysiology and pharmacological management.
Drugs Aging. 2006; 23(2): 101-117.
5. Lehrfeld T, Lee DI. The role of vacuum erection devices in penile rehabilitation after radical
prostatectomy. Int J Impot Res. 2009; 21(3): 158-164.
6. Brewer ME, Kim ED. Penile rehabilitation therapy with PDE 5 inhibitors following radical
prostatectomy: proceed with caution. Adv Urol. 2009:852437.
7. Raina R, Pahlajani G, Agarwal A, Zippe CD. Early penile rehabilitation following radical
prostatectomy.Cleveland clinic experience. Int J Impot Res. 2008; 20(2): 121-126.
8. Story M. Sexual dysfunction in men after surgery of colorectal carcinoma.New developments
in prevention and therapy. Rozhl Chir. 2009; 88(6): 320-325.
9. Lagoda G, Jin L, Lehrfeld IJ, Liu T, Burnett AL. FK 506 and sildenafil promote erectile
function recovery after cavernous nerve injury through antioxidative mechanisms. J Sex Med.
2007; 4(4 Pt 1): 908-916.
10. Khera M. Androgens and erectile function: a case of early androgen use in post prostatectomy
hypogonadal men. J Sex Med. 2009; 6 Suppl 3: 234-238.
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11. van der Horst C, Martinez-Portillo FJ, Jneman KP. Pathophysiology and rehabilitation of
erectile dysfunction after nerve-sparing radical prostatectomy. Urologe A. 2005; 44(6): 667-673.
12. Barr C, Tholouzan M. Nerve-sparing open radical prostatectomy with extracapsular dissection.
Prog.Urol. 2009; 19 suppl. 4: S177-178.
13. Walsh PC, Schlegel PN. Radical pelvic surgery with preservation of sexual function. Ann Surg.
1988; 208(4): 391-400.
14. Heriot AG, Tekkis PP, Fazio VW, Neary P, Lavery IG. Adjuvant radiotherapy is associated with
increased sexual dysfunction in male patients undergoing resection for rectal cancer. Ann Surg.
2005; 242(4): 502-510.
15. Bannowsky A, Schultze H, van der Horst C, Stubinger JH, Portillo FJ, Junemann KP. Erectile
function after nerve-sparing radical prostatectomy. Nocturnal early erection as parameter of
postoperative organic erectile integrity. Urologe A. 2005; 44(5): 523-526.
16. Ohebshalom M, Parker M, Waters B, Flanagan R, Mulhall JP. Erectile hemodynamic statis after
radical prostatectomy correlates with erectile function outcome. BJU Int. 2008; 102(5): 592-596.
17. Briganti A, Capitanio U, Chun FK, Karakiewicz PI, Salonia A, Bianchi M, Cestari A, Guazzoni
G, Rigatti P, Montorsi F. Prediction of sexual function after radical prostaectomy. Cancer. 2009;
115(13 Suppl): 3150-3159.
18. Weistein M, Roberts M. Sexual potency following surgery for rectal carcinoma. A follow-up
study of 44 patients. Ann.Surg. 1977; 185(3): 295-300.
19. Keating JP. Sexual function after rectal excision. ANZ Surg 2004; 74(4): 248-259.
20. Kim NK, Aahn TW, Park JK, Lee KY, Lee WH, Sohn SK, Min JS. Assessment of sexual and
voiding function after total mesorectal excision with pelvic autonomic nerve preservation in
males with rectal cancer. Dis.Colon Rectum 2002; 45(19): 1178-1185.
21. Kyo K, Sameshima S, Takahashi M, Furogari T, Sawada T. Impact of autonomic nerve
preservation and lateral node dissection on male urogenital function after total mesorectal
excision for lower rectal cancer. World J.Surg. 2006; 30(6): 1014-1019.
22. Pietrangeli A, Pugliese P, Perrone M, Sperduti I, Cosimelli M, Jandolo B. Sexual dysfunction
following urgery for rectal cancer a clinical and neurophysiological study. J Exp Clin Cancer
Res. 2009; 28: 128.
23. Maurer CA, ZGraggen K, Renzulli P, Schilling MK, Netzer P, Bchler MW. Total mezorectal
excision preserves male genital function comared with conventional rectal cancer surgery. Br. J.
Surg. 2001; 88(11): 1501-1505.
24. Liang JT, Lai HS, Lee PH. Laparoscopic pelvic autonomic nerve-sparing surgery for patients
with lower rectal cancer after chemoradiation therapy. Ann Surg Oncol 2007; 14(4): 1285-1285.
25. Liang JT, Lai HS, Lee PH, Chang KJ. Laparoscopic pelvic autonomic nerve-preserving surgery
for sigmoid colon cancer. Ann Surg Oncol 2008; 15(6): 1609-1616.
26. Mc Cullogh AR, Levine A, Padma Hanthan H. Returnal of nocturnal erection and erectile
function after bilateral nerve-sparing radical prostatectomy in men treated nightly with sildenafil
citrate: Subnalysis of longitudinal randomized double-blind placebo-controlled trial. J Sex Med.
2008; 5(2): 476-484.
27. Raina R, Levine MM, Agarwal A, Sharma R, Goyal KK, Montaque DK, Klein E, Zippe CD.
Long-term effect of sildenafil citrate on erectile dysfunction after radical prostatectomy: 3 year
follow-up. Urology 2003; 62(1): 110-115.
28. Lee DJ, Cheetam P, Badari KK. Penile rehabilitation protocol after robot-assited radical
prostatectomy: assessment of compliance with phosphodiesterase type 5 inhibitors therapy and
effect on early potency. BJU 2010; 105(3): 382-388.
29. Dinelli N, Salinitri G, Pomara G, Menchini Fabris F, Morelli G, Selli C. Role of pharmacologic
rehabilitation in the recovery of sexual function following radical prostatectomy. Minerva Urol
Nefrol. 2005; 57(4): 325-329.
30. Yuan J, Hoang AN, Romero CA, Lin H, Dai Y, Wang R. Vacuum therapy in erectile
dysfunction science and clinical evidence. Int J Impot Res. 2010; 22(4): 211-219.
31. Zippe CD, Pahlajani G. Penile rehabilitation following radical prostatectomy: role of early
intervention and chronic therapy.Urol Chir North Amer. 2007; 34(4): 601-618.
32. Morgentaler A. Testosterone therapy for men at risk for or history of prostate cancer. Curr Treat
Options Oncol. 2006; 7(15): 363-369.
33. Sezen SF, Lagoda G, Burnett AL. Role of immunophylins in recovery of erectile function in the
cavernous nerve injury. J Sex Med. 2009; 6(suppl. 3); 340-346.
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34. Cangueven O, Lagoda G, Sezen SF, Burnett AL. Losartan preserves erectile function after
bilateral cavernous nerve injury via antifibrotic mechanisms in male rat. J Urol. 2009; 18(6):
2816-2822.
35. Hong SK, Han BK, Jeong SJ, Byun SS, Lee SE. Effect of statin therapy on early return of
potency after nerve sparing radical retropubic prostatectomy. J Urol. 2007; 178(2): 613-616.
36. Burnett AL, Althof ME, Bivalaqua TJ. Erithropoetin promotes erection recovery after nerve-
sparing radical retropubic prostatectomy. A retrospective analysis. J Sex Med. 2008; 5(10):
2392-2398.
37. Yuan J, Wesney OL, Ruan KH, Wang R. A new strategy, super enzyme therapy in penile
rehabilitation. J Sex Med. 2009; 6(suppl. 3): 328-333.
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Coresponden: Dr. Lili-Gabriela Lozneanu, medic primar chirurgie general, doctorand Universitatea de
Medicin i Farmacie Gr.T.Popa Iasi, Clinica I Chirurgie, Sp. Sf. Spiridon, str. Independenei, nr. 1,
700111, e-mail: lili_lozneanu@yahoo.com*.
INTRODUCERE
Tratamentul cancerului rectal s-a mbuntit semnificativ de-a lungul anilor,
obiectivul primordial i constant fiind o mai bun calitate a vietii (QOL), prin coborarea
limitelor de rezecie i conservarea aparatului sfincterian, n condiii de securitate
oncologic. Cu toate acestea, recurena local (LR) rmne o problem major i cu un
prognostic rezervat n tratamentul cancerului rectal, fiind rareori curabil, iar
simptomatologia, dificil de paliat.
Ea este definit ca recurena n patul tumoral, ganglionii regionali, structurile
adiacente, anastomoza, pelvisul, perineul i cicatricile postoperatorii. Incidena raportat
a acesteia dup rezecia potenial curativ variaz larg n literatura de specialitate intre
5% i 45% [1-4]. Aceast variaie considerabil n serii diferite este determinat
probabil de calitatea diferit a actului chirurgical, rate mai mari ale incidenei LR fiind
asociate cu procedeele chirurgicale convenionale de excizie a rectului, prin blunt
digital dissection, nestandardizate.
*
received date: 07.06.2011
accepted date: 29.07.2011
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MATERIAL SI METOD
Am efectuat un studiu prospectiv pe o perioad de 7 ani (ianuarie 2004-
decembrie 2010). Au fost inclui n studiu 23 de pacieni consecutivi cu
adenocarcinoame rectale mijlocii sau superioare care au beneficiat de rezecie anterioar
cu TME n Clinica I-a Chirurgie Iai, de ctre o singur echip operatorie, cu acelai
chirurg operator. Recrutarea pacienilor s-a efectuat imediat dup intervenia
chirurgical. Urmrirea pacienilor s-a realizat pe o perioad medie de 30 de luni, fiind
cunoscut i acceptat faptul c majoritatea recidivelor locale apar n primii 2 ani dup
intervenie.
Criteriile de includere n lot au fost:
- rezecie anterioar de rect cu TME i anastomoz colo-rectal sau colo-
supraanal, efectuat de acelai chirurg operator;
- diagnostic histopatologic de adenocarcinom rectal;
- absena MTS la distan documentat pre- sau intraoperator.
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REZULTATE
n intervalul studiat (01.01.2004 - 31.12.2010) s-au efectuat 23 de rezecii
anterioare de rect cu TME de ctre acelai chirurg operator (Fig. 1), la pacieni cu
cancere rectale mijlocii i superioare. 14 (60,86%) au fost brbai i 9 (39,13%) femei.
Vrsta medie a fost 62 ani (extreme 40-78 ani). Localizarea tumorii a fost rectul
mijlociu (5-10 cm de marginea anal) la 15 pacieni (65,21%) i rectul superior (>10 cm
de marginea anal) la 8 pacieni (34,78%). Distana medie a tumorii fa de marginea
anal a fost 8 cm (extreme 3-14 cm).
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Anastomoza s-a efectuat mecanic n toate cele 23 cazuri. S-a folosit stapler
circular EEA 31 pentru anastomoz i dou staplere TA 55 pentru nchiderea rectului
(Fig. 2).
n 15 cazuri (65,21%) anastomoza a fost colo-supraanal, iar n 8 cazuri (34,78
%) s-a realizat o anastomoz colo-rectal. Un pacient cu rezecie potenial curativ a
prezentat margini pozitive la examenul histopatologic i a beneficiat ulterior de rezecie
abdomino-perineal, rmnnd bine 3 ani dupa intervenie. S-a efectuat lavajul bontului
rectal cu soluie tumoricid. n majoritatea cazurilor (82,60% - 19 cazuri) s-a efectuat o
stomie de defuncionalizare, chirurgul operator avnd preferin pentru ileostomia pe
baghet, practicat n 17 cazuri (73,91%). Colostomia de protecie s-a efectuat n 2
cazuri (8,69%) pe colonul transvers.
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Fig. 3 Cancer rectal ampular mijlociu aspect IRM (stnga), aspecte intraoperatorii -
disecie lateral (dreapta).
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DISCUII
Rezecia anterioar de rect a devenit opiunea preferat de tratament n cancerul
rectal, nlocuind rezecia abdomino-perineal descris de Miles. Rolul TME n
prognosticul pacienilor este esenial i depinde de calitatea actului chirurgical. Excizia
trebuie s se realizeze n planul fasciei mezorectale prin sharp dissection pstrnd
intact mezorectul. Aceast tehnic reduce rata LR sub 10% i permite o supravieuire pe
termen lung n 2/3 din totalul pacienilor.
Cancerele rectale din treimea mijlocie i inferioar a rectului trebuie tratate cu
TME pn la planeul ridictorilor anali, iar cele din 1/3 superioar i jonciunea
rectosigmoidian sunt tratate corespunzator prin rezecie parial de mezorect (PME)
pn la 5 cm sub limita inferioar a tumorii.
Limfadenectomia lateral pelvin extins nu aduce beneficii suplimentare n
ceea ce priveste supravieuirea [6,9]. Conceptul de excizie mezorectal - ridicarea n
bloc a rectului mpreun cu toate esuturile adiacente nvelite de fascia visceral (esut
adipos, ganglioni limfatici i vase limfatice) prin sharp dissection ntr-un plan
anatomic adecvat - este astzi acceptat de majoritatea chirurgilor colo-rectali ca fiind
esenial n reducerea la minimum a posibilitii de recuren.
Postulat de catre Heald n urma cu dou decade, TME combinat cu RT
preoperatorie a permis n prezent scderea ratei de LR la 4% la pacienii cu rezecii
curative [2,3]. nsuirea tehnicii corecte este capital n obinerea rezultatelor scontate.
Greelile de tehnic ce afecteaz securitatea oncologica sunt, probabil cea mai
important cauz de recidiv local.
Frecvena recidivelor este mai mare n prima parte a curbei de nvare care este
necesar pentru a deprinde o tehnic corecta de TME n tratamentul cancerului rectal.
Numrul interveniilor necesare a fi practicate pn la obtinerea unei TME performante
variaz n funcie de nivelul de pregtire a chirurgului [7].
Standardizarea tehnicii de disecie este imperios necesar pentru a minimaliza
rolul chirurgului ca factor n recurena local a cancerului rectal [2,12].
Dificultile tehnice ce pot apare n cursul TME i care pot fi depite prin
training pot fi sistematizate dup cum urmeaz:
- posterior: este esenial de intrat n pelvis n planul corect, anterior i medial de
nervii hipogastrici; planul este uor de identificat; disecia mezorectului pe
planul ridictorilor poate fi incomplet; vizibilitate; ghiduri de lumin; Sharp
dissection; Tissue sealig: CIND.
- anterior: vizualizarea veziculelor este eseniala, mezorect subire care nu permite
erori de tehnic; risc mare de margini circumfereniale pozitive.
- lateral: cel mai dificil punct, risc mare de compromitere a CRM; riscuri nelegate
de securitatea oncologic.
Este esenial s fie cunoscute unele gesturi minore de prevenire a nsmnrii
pelvine: rectul trebuie nchis nainte de transsecie, pentru a preveni riscul de
nsmnare pelvin cu celule flotante din lumenul rectal, dup manipulare tumoral;
splarea bontului rectal cu soluie tumoricid, pentru a evita riscul de nsmnare pe
linia de TA cu celule flotante.
Dac efectuarea unui double stapling este ideal, standardul actual este de a
practica n toate cazurile triple stapling.
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CONCLUZII
Recidivele pelvine se datoreaz unor greeli de tehnic chirurgical. O mare
parte se pot preveni prin perfectarea acurateei diseciei i prevenirea nsmnrii
tumorale prin deschiderea inadecvat a rectului.
nelegerea planului corect de disecie reprezint cheia pentru o TME bun, care
va conduce la un rezultat oncologic mai bun i o rat mai mic a complicaiilor. Exist o
curb de nvare i rezultatele difer major dup nsuirea corect a tehnicii .
Combinnd stabilirea adecvat a deciziei de tratament cu o tehnic chirurgical
optim, chirurgul poate oferi pacientului cu cancer rectal rezecabil ansa de a evita LR,
o QOL mbuntit i, n final, o supravieuire mai bun.
BIBLIOGRAFIE
1. Mac Farlane JK, Ryall RD, Heald RJ. Mesorectal excision for rectal cancer. Lancet 1993;
341(8843): 457-460.
2. Heald RJ, Husband EM, Ryall RD. The mesorectum in rectal cancer surgery - the clue to pelvic
recurrence? Br J Surg 1982; 69(10): 613-616.
3. Enker WE, Thaler HT, Cranor ML, Polyak T. Total mesorectal excision in the operative
treatment of carcinoma of the rectum. J Am Coll Surg 1995; 181(4): 335-346.
4. Quirke P, Durdey P, Dixon MF, Williams NS. Local recurrence of rectal adenocarcinoma due to
inadequate surgical resection. Histopathological study of lateral tumor spread and surgical
excision. Lancet 1986; 2(8514): 996-999.
5. Paty PhB, Enker WE, Cohen AM, Lawers GY. Treatment of rectal cancer by low anterior
resection with coloanal anastomosis. Annals of Surgery 1994; 219(4): 365-372.
6. Maughan NJ, QuirkeP. Modern management of colorectal cancer - a pathologists view. Scand J
Surg 2003; 92(1): 11-19.
7. Hermanek P, Mansmann U, Staimmer DS, Riedl S, Hermanek P. The German experience: The
surgeon as a prognostic factor in colon and rectal cancer surgery. Surg Oncol Clin North Am
2000; 9(1): 33-49.
8. Oh SY, Kim YB, Paek OJ, Suh KW. Does total mesorectal excision require a learning curve?
Analysis from the database of a single surgeons experience. World J.Surg 2011; 35(5):
1130-1136.
9. Nagtegaal ID, van de Velde CJ, Marijnen CA, van Krieken JH, Quirke P; Dutch Colorectal
Cancer Group; Pathology Review Committee. Low rectal cancer: A call for a change of
approach in abdominoperineal resection. Journal of Clinical Oncology 2005; 23(36): 9257-9264.
10. Kapiteijn E, Marijnen CA, Nagtegaal ID, Putter H, Steup WH, Wiggers T, Rutten HJ, Pahlman
L, Glimelius B, van Krieken JH, Leer JW, van de Velde CJ; Dutch Colorectal Cancer Group.
Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer.
N Engl J Med 2001; 345(9): 638-646.
11. Law CC, Fu YT, Chan TM. Adjuvant therapy for rectal cancer in the era of total mesorectal
excision. J HK Coll Radiol. 2006; 9: 3-14.
12. Heald RJ. Surgical management of rectal cancer: a multidisciplinary approach to technical and
technological advances. Br J Rad 2005; 78 Spec No 2: S128-130.
13. Sauer R, Becker H, Hohenberger W, Rdel C, Wittekind C, Fietkau R, Martus P, Tschmelitsch J,
Hager E, Hess CF, Karstens JH, Liersch T, Schmidberger H, Raab R; German Rectal Cancer
Study Group. Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J
Med 2004; 351(17): 1731-40.
14. Mc Ardle CS, Hole D. Impact of variability among surgeons on postoperative morbidity and
mortality and ultimate survival. BMJ 1991; 302(6791): 1501-1505.
15. Choi JS, Kim SJ, Kim YI, Min JS. Nodal metastasis in the distal mesorectum:need for total
mesorectal excision of rectal cancer.Yonsei Med J 1996; 37(4): 243-250.
16. Marijnen CA, Nagtegaal ID, Kapiteijn E, Kranenbarg EK, Noordijk EM, van Krieken JH, van de
Velde CJ, Leer JW; Cooperative investigators of the Dutch Colerectal Cancer Group.
Radiotherapy does not compensate for positive resection margins in rectal cancer patients. Int J
Radial Oncol Biol Phys 2003; 55(5): 1311-1320.
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17. Nagtegaal ID, Marijnen CA, Kranenbarg EK, van de Velde CJ, van Krieken JH; Pathology
Review Committee; Cooperative Clinical Investigators. Circumferential margin involvement is
still an important predictor of local recurrence in rectal carcinoma:not one millimeter but two
millimeters is the limit. Am J Surg Pathol 2002; 26(3): 350-357.
18. Chapuis PH, Lin BP, Chan C, Dent OF, Bokey EL. Risk factors for tumour present in a
circumferential line of resection after excision of rectal cancer. Br J Surg. 2006; 93(7): 860-865.
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Coresponden: Dr. Victor-Gabriel Rugin, Universitatea de Medicin i Farmacie Gr.T. Popa Iai,
Clinica IV Obstetric-Ginecologie, Obstetric Ginecologie Cuza Vod Iai, e-mail: dr.victorrugina
@gmail.com*.
INTRODUCERE
Statusul histologic al limfoganglionilor axilari reprezint factorul de prognostic
major al supravieuirii pacientelor diagnosticate cu cancer mamar, diagnosticarea
corect a invaziei tumorale fiind esenial n vederea stabilirii indicaiilor, etapizrii i
prognosticului strategiilor terapeutice [1]. Actualmente, disecia axilar, metoda
standard de identificare a invaziei limfoganglionare se realizeaz sub anestezie general
i poate fi invalidant ntr-un numr mic, dar semnificativ, de cazuri, cu o rat maxim a
complicaiilor imediate de 20%, iar a complicaiilor cronice, de tipul limfedemului
braului, de 20-30% [2,3].
Biopsia limfoganglionului santinel s-a impus n ultimii ani drept o alternativ la
disecia axilar la pacientele cu cancer mamar invaziv. Conceptul de limfoganglion
santinel se bazeaz pe teoria diseminrii limfatice a cancerului mamar, statusul primei
staii limfatice avnd valoare prognostic n progresia metastatic.
Termenul de limfoganglion santinel a fost introdus n 1977 de Ramn Cabaas
care a demonstrat c analiza limfoganglionilor poate fi utilizat pentru decelarea primei
staii limfoganglionare invadate metastatic n cancerul penian [4].
*
received date: 21.05.2011
accepted date: 22.07.2011
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MATERIAL I METOD
Lotul de studiu a inclus 54 de paciente diagnosticate cu cancer mamar n stadiile
clinice T1Nx i T2Nx, n Clinica a IV-a, Spitalul Clinic de Obstetric Ginecologie Cuza
Vod Iai, n perioada 2000-2010. Protocolul studiului a fost realizat respectnd
principiile de etic a cercetrii medicale, n baza consimmntului informat al
pacientelor. Metoda a fost aplicat la cazurile care au prezentat tumori cu dimensiuni de
maxim 5 cm (Fig. 1). Au fost excluse pacientele cu cancer local avansat sau tumori
multifocale.
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REZULTATE
Din totalul celor 54 de paciente incluse iniial n studiu, dou cazuri au prezentat
tumori nepalpabile, iar un caz a fost diagnosticat drept carcinom ductal in situ, motive
pentru care au fost excluse din lot. n 5 cazuri nu s-a reuit identificarea
limfoganglionului santinel. Evaluarea histopatologic a limfoganglionilor santinel a
fost realizat n 46 de cazuri, ale cror caracteristici sunt sintetizate n Tabel 1.
Tabel 1
Caracteristicile clinice i patologice ale pacientelor evaluabile
Parametru Valoare
Vrst (medie i valori extreme) 59 ani (30-89 ani)
Stadiul tumoral
T1 27 cazuri (58,7%)
T2 19 cazuri (41,3%)
Localizare
Cadranele externe 24 cazuri (52,17%)
Cadranele interne 10 cazuri (21,74%)
Unirea cadranelor superioare 7 cazuri (15,22%)
Unirea cadranelor inferioare 3 cazuri (6,52%)
Retroareolar 2 (4,34%)
Diagnostic histopatologic
Carcinom ductal invaziv 38 cazuri (82,6%)
Carcinom lobular invaziv 4 cazuri (8,69%)
Altele 4 cazuri (8,69%)
Diagnosticul histopatologic al limfoganglionului
santinel
Absena invaziei metastatice 34 cazuri (73,91%)
Prezena invaziei metastatice 12 cazuri (26,08%)
Statusul axilar
Axil cu limfoganglioni negativi 31 cazuri (67,39%)
Axil cu limfoganglioni invadai metastatic 15 cazuri (32,61%)
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Tabel 2
Rezultatele identificrii limfoganglionului santinel
Rata de identificare 41 cazuri (89,13%)
Cazuri evaluabile 46
Rezultate adevrat pozitive (AP) 12 cazuri (26,08%)
Rezultate fals negative (FN) 2 cazuri (4,35%)
Rezultate adevrat negative (AN) 32 cazuri (69,57%)
Rata rezultatelor fals negative (FN/AP+FN) 18%
Sensibilitate (AP/AP+FN) 82%
Valoarea predictiv pozitiv (AP/AP+FP) 100%
Valoarea predictiv negativ (AN/AN+FN) 93,93%
DISCUII
Limfoganglionii santinel sunt definii ca limfoganglioni cu drenaj limfatic
direct al tumorii primare. Identificarea i evaluarea lor permite decelarea situsurilor de
metastazare regional la nivelul cror pot fi prezente metastaze oculte. Statusul
limfoganglionului santinel certific statusul limfoganglionilor axilari, acest procedeu
reprezentnd o alternativ pentru disecia axilar, scutind pacientele de morbiditatea
asociat acesteia [11].
Selecia adecvat a cazurilor reprezint un pas important n diagnostic.
Detectarea limfoganglionului santinel utilizeaz n general colorant albastru
vital (izosulfan, Lymphazurin 1%), 5 ml, care se injecteaz peritumoral sau la nivelul
patului tumoral. Exist diferite opinii potrivit crora cantitatea necesar de colorant
pentru a obine rezultate pertinente este diferit, variind de la 2 ml pn la 3-5 ml.
Volumul de colorant pare a fi dependent de distana tumor-axil i de mrimea tumorii.
La pacientele cu sni voluminoi pot fi necesare cantiti mai mari de colorant [12,13].
n cazul tumorilor situate n cadranele interne, limfoscintigrafia preoperatorie pune n
eviden drenajul limfatic. La aproximativ 5 minute de la injectare se practic incizia
axilar i se urmrete traiectul limfatic impregnat n albastru. Se pot identifica mai
muli limfoganglioni sau nici unul (tumori n cadranele interne ce dreneaz n lanul
mamar intern). Studii realizate n cazul colorrii sau radioactivitii mai multor
limfoganglioni demonstreaz c, n vederea unui examen histologic pertinent, trebuie
extirpai i analizai toi aceti limfoganglioni, pacientele care prezint invazia mai
multor limfoganglioni santinel avnd risc crescut de metastazare la nivelul altor
limfoganglioni axilari [14-16].
Metoda este destul de fiabil, dar necesit timp i experien adecvat.
Avantajele metodei sunt determinate de evitarea radioactivitii, simplitate i cost
sczut.
n evaluarea histopatologic, cele mai recente probleme legate de
limfoganglionul santinel privesc micrometastazele (0,2-2,0 mm) i
submicrometastazele (<0,2 mm) la acest nivel, decelabile prin examen histopatologic,
completat de examen imunohistochimic.
Implicaiile clinice ale acestor micrometastaze sunt necunoscute. Exist
posibilitatea ca mai muli limfoganglioni s fie invadai? Este util disecia axilar n
cazurile cu micrometastaze n limfoganglionul santinel?
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CONCLUZII
Introducerea n practic a evalurii limfoganglionului santinel a determinat
scderea frecvenei diseciei axilare n cazul pacientelor cu tumori n stadiile I i II,
pentru care chirurgia conservatoare este la fel de eficient ca mastectomia, fiind
preferabil acesteia deoarece este mai puin mutilant.
BIBLIOGRAFIE
1. Pricop M. Chirurgie ginecologic. Puncte de vedere. Institutul European, 2006.
2. Ivens D, Hoe A L, Podd TJ et al. Assessment of morbidity from complete axillary nodes
dissection. Br J Cancer 1992; 66(1): 136-138.
3. Petrek JA, Pressman PI, Smith RA. Lymphedema: current issues in research and management.
CA Cancer J Clin 2000; 50(5): 292-307.
4. Cabaas R. An approach for the treatment of penile carcinoma. Cancer 1977; 39(2): 456-466.
5. Morton DL, Wen DR, Wong JH et al. Technical details of intraoperative lymphatic mapping for
early melanoma. Arch Surg 1992; 127(4): 392-399.
6. Krag DN, Weaver DL, Alex JC, Fairbank JT. Surgical resection and radiolocalization of the
sentinel lymph node in breast cancer using a gamma probe. Surg Oncol 1993; 2(6): 335-339.
7. Giuliano AE, Kirgan DM, Guenther JM. Lymphatic mapping and sentinel lymphadenectomy for
breast cancer. Ann Surg 1994; 220(3): 391-401.
8. Albertini JJ, Lyman GH, Cox C et al. Lymphatic mapping and sentinel node biopsy in the patient
with breast cancer. JAMA 1996; 276(22): 1818-1822.
9. Boolbol SK, Borgen PI. Sentinel lymph node biopsy: an American perspective. Breast 2001;
10(4): 287-290.
10. Borgstein PJ, Meijer S, Pijpers R. Intradermal blue dye to identify sentinel lymph node in breast
cancer. Lancet 1997; 349(9066): 1668-1669.
11. Veronesi U, Paganelli G, Galimberti V et al. Sentinel node biopsy to avoid axillary node
dissection in breast cancer with clinically negative lymph nodes. Lancet 1997; 349(9069):
1864-1867.
12. Treseler PA, Tauchi PS. Pathologic analysis of the sentinel node. Surg Clin N Am 2000; 80(6):
1695-1719.
13. Van der Ent FW, Kengen RA, van der Pol HA et al. Halsted revisited: Internal mammary
sentinel lymph node biopsy in breast cancer. Ann Surg 2001; 234(1): 79-84.
14. Chua B, Ung O, Taylor et al. Treatment implications of a positive sentinel node biopsy for
patient with early stage breast carcinoma. Cancer 2001; 92(7): 1769-1774.
15. Gemigani ML, Borgen PI. Is there a role for selective axillary dissections in breast cancer?
World J Surg 2001; 25(6): 809-818.
16. Wong SL, Edwards MS, Chao C et al. Sentinel lymph node biopsy for breast cancer: impact of
number of sentinel lymph nodes removed on false negative rate. J Am Coll Surg 2001; 192(6):
684-691.
17. Cody HS 3rd, Borgen PI. State-of-the-art approaches to sentinel node biopsy for breast cancer:
study design, patient selection, technique, and quality control at Memorial Sloan-Kettering
Cancer Center. Surg Oncol 1999; 8(2): 85-91.
18. Giuliano AE, Jones RC, Brennan M, Statman R. Sentinel lymphadenectomy in breast cancer. J
Clin Oncol 1997; 15(6): 2345-2350.
19. Nahrig J, Richter T, Kowolik J et al. Comparison of different histopathological methods for the
examination of sentinel lymph nodes in breast cancer. Anticancer 2000; 20(3B): 2209-2212.
20. Moore KH, Thaler HT, Tan LK et al. Immunohistochemically detected tumor cells in the
sentinel lymph nodes of patients with breast carcinoma. Biologic metastasis or procedural
artifact? Cancer 2004; 100(5): 929-934.
21. Carter BA, Jensen RA, Simpson JF et al. Benign transport of breast epithelium into axillary
lymph nodes after biopsy. Am J Clin Pathol 2000; 113(2): 259-265.
22. Cox CE, Yeatman T, Salud CJ, Bass SS. Significance of sentinel node micrometastasis. Cancer
Control 1999; 6(6): 601-605.
23. Fisher B. Lumpectomy versus quadrantectomy for breast conservation: a critical appraisal. Eur J
Canc 1995; 31A(10): 1567-1569.
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Coresponden: Conf. Dr. Sorin Simion / Asist. Univ. Drd. Cosmin Popa, Clinica de Chirurgie General,
Spitalul Clinic Colentina, oseaua tefan cel Mare nr. 19-21, Sector 2, 020125, Bucureti, Romnia; e-
mail dr.cosminpopa@yahoo.com*
INTRODUCERE
Aproximativ 60% din pacienii cu cancere colorectale vor dezvolta metastaze
hepatice pe parcursul evoluiei bolii, iar boala metastatic va rmne la nivelul ficatului
n 30% din cazuri. Pentru 80-90% din pacienii cu metastaze hepatice de origine
colorectal, care nu se preteaz la rezecie hepatic sau termoablaie, prognosticul este
grav [1]. HAI pare o alegere logic pentru aceti pacieni deoarece:
- boala metastatic este cantonat la nivel hepatic
- metastazele hepatice ale cancerelor colo-rectale sunt perfuzate mai ales de
reeaua arterial, pe cnd parenchimul este perfuzat preponderent de sistemul
port [2]
- metastazele hepatice ale cancerelor colo-rectale vor fi expuse la concetraii mari
de substan activ, evitnd efectele de traversare a substanei prin parenchimul
hepatic i efectele sistemice. [3]
*
received date: 18.04.2011
accepted date: 24.05.2011
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MATERIAL I METOD
S-a efectuat un studiu retrospectiv care a cuprins pacienii cu neoplasm colo-
rectal tratai n Clinica I Chirurgie General, Spitalul Clinic Colentina, n perioada
ian. 2008-ian. 2010. n aceast perioad au fost tratai 36 pacieni cu metastaze hepatice,
sincrone sau metacrone, nerezecabile.
Chimioterapia intraarterial s-a administrat la 14 pacieni cu metastaze hepatice
de origine colorectal nerezecabile, prin colaborare cu Departamentul de Angiografie al
Spitalului Clinic de Urgen Floreasca. 22 de pacieni au primit doar tratament
sistemic chimioterapic cu Oxaliplatin 150mg, 5FU 2500mg i Calciu folinat 150 mg.
S-a demonstrat c utilizarea HAI cu 5FU, Farmarubicin, Iomeron, n asociere cu
un regim sistemic de 4 cure cu Oxaliplatin i 5FU a dat rspuns pozitiv n 64% din
cazuri. Mai mult, rspunsul tumorii la terapie a permis rezecia curativ ulterioar n
18% din cazuri. OS a fost de 20 de luni iar durata de supravieuire fr boal (PFS) de
11 luni.
Criteriile de includere au fost: tumor colo-rectal confirmat anatomo-
patologic rezecat cu viz oncologic; metastaze hepatice ce ocup sub 50% din
volumul hepatic care nu se pot direciona spre rezecie sau termoablaie; rezerv
medular viabil (Hb peste 10 g/dl, WBC peste 1500 / mmc, trombocite peste 100000 /
mmc), funcie hepatic bun (bilirubina sub x2 limita superioar, transaminaze sub x3
limita superioar) i absena metastazelor extrahepatice.
n ceea ce privete tehnica HAI, am utilizat un cateter intrahepatic arterial Cobra
5 Fr care se implanteaz prin angiografie hepatic, percutan, pe traiectul arterei
femurale. Dup cateterizare s-a verificat fluxul de citostatic spre metastaze prin
introducerea de colorant (albastru de metilen 1%) n cateter, cu colorarea vizibil a
diseminrilor secundare hepatice. Pacienii au beneficiat de asociere chimioterapie
intraarterial cu chimioterapie sistemic. Avantajul semnificativ const n obinerea
unor concentraii mult superioare la nivelul tumorilor, deoarece chimioterapicul se
distribuie aproape exclusiv la nivelul acestora, n timp ce restul esutului hepatic nu este
vizat de chimioterapia regional.
Substanele active utilizate au fost 5FU 750mg, Farmarubicin 60 mg i Iomeron
6 ml combinat cu 4 doze de Oxaliplatin 150mg i bolus 5FU 2500mg. Tratamentul se
repet la fiecare 30 de zile pn cnd progresia bolii, toxicitatea sau probleme de
administrare duc la sistarea tratamentului. Doza de 5FU se reduce la 75% dac apar
neutropenie, trombopenie, febr sau infecie, diaree. Doza de Oxaliplatin se reduce la
85% n caz de trombocitopenie, parestezie permanent de intensitate medie, vrsturi
severe n ciuda tratamentului specific. Dozele de 5FU i Oxaliplatin se mai reduc cu
15% n caz de toxicitate dup prima ajustare. Oxaliplatinul se elimin dac exist
disestezie permanent asociat paresteziei.
Urmrirea pacienilor s-a fcut prin examen clinic, hemoleucogram, profilul
biochimiei hepatice, efectuate nainte de fiecare edin de chimioterapie.
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REZULTATE
Au fost inclui n studiu 36 de pacieni. Au predominat cancerele colice cu
metastaze hepatice sincrone (34,94%). n medie, metastazele au ocupat 35% din
volumul ficatului (1050%). Toi pacienii au primit nainte cel puin o cur de
chimioterapie de tip 5FU / Oxaliplatin (n medie 2 cure; 1-5 cure), iar regimurile iniiale
au fost de tip 5FU la care s-a nregistrat lipsa rspunsului n 86% din cazuri. Progresia
bolii a fost principala expresie a lipsei de rspuns. La pacienii cu rspuns parial ideea
de introducere n studiu a fost determinat de reaciile adverse la chimioterapie sau
posibilitatea de reducere rapid a volumului metastatic n vederea unei poteniale
rezecii chirurgicale.
Fezabilitatea tratamentului i tolerana
Au fost efectuate n total, 84 de edine de chimioterapie intrahepatic (media de
6, ntre 1 i 8). Incidentele la efectuarea metodei au aprut la 30% din cazuri: perfuzarea
extrahepatic i migrarea vrfului cateterului n cursul procedurii, dar care nu au
determinat ntreruperea tratamentului. La 6 pacieni doza de Farmarubicin a trebuit s
fie redus din cauza toxicitii hepatice (3 cazuri), neurotoxicitii (1 caz) sau ambele (2
cazuri). Tratamentul a fost ntrerupt datorit toxicitii, progresiei bolii, rezeciei
chirurgicale sau ablaiei prin radiofrecven.
Toxicitatea a fost n general medie. Cele mai frecvente (peste 10%) efecte
adverse importante au fost neutropenia, neuropatia periferic cumulativ la Oxaliplatin,
durerea abdominal.
Rspunsul la tratament i supravieuirea
Un pacient din 14 a primit sub 4 edine de chimioperfuzie din cauza alergiei
severe la farmarubicin. Acesta nu a fost msurabil pentru rspunsul tumoral. Din cei 13
la care s-a putut evalua rspunsul, 7 (57%) au avut rspuns parial, 4 (28,6%) au
prezentat stabilizarea bolii, iar la 2 (14,3%) s-a nregistrat progresia bolii. Practic
controlul bolii s-a realizat la 11 de pacieni. Per total, rata de rspuns total cu intenie
curativ a fost de 78,6%. Cei 11 de respondeni au euat la tratamentul sistemic
chimioterapic cu 2 cure n medie (1-3 cure). Progresia bolii sub chimioterapie a fost
observat 14,3% din cazuri.
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60
50
40
Iniial
diam etru
mm 30
evaluare
20 3 luni
evaluare
10 6 luni
0
1 2 3 4 5 6 7
DISCUII
Principalul rezultat al acestui studiu este c perfuzia arterial hepatic cu 5FU,
Farmarubicin, Iomeron i administrarea i.v. de 5FU i Oxaliplatin a produs o rat de
rspuns cu intenie curativ de 21% (posibilitate de rezecie chirurgical sau
termoablaie).
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CONCLUZII
Administrarea chimioterapiei prin perfuzie arterial hepatic este eficient i
bine tolerat pentru metastazele hepatice nerezecabile ale cancerelor colo-rectale.
Procedura de implantare a cateterului pe cale femural este fezabil i face
administrarea puin invaziv pentru tratamentele paliative i chiar neoadjuvante.
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7. Rougier P, Laplanche A, Huguier M, Hay JM, Ollivier JM, Escat J, Salmon J, Julien J, Gallot D.
Hepatic arterial infusion of floxuridine in patients with liver metastases from colorectal
carcinoma: long-term results of a prospective randomized trial. Journal of Clinical Oncology.
1992; 10: 1112-1118.
8. Kemeny N, Gonen M, Sullivan D et al. Phase I study of hepatic arterial infusion of floxuridine
and dexamethasone with systemic irinotecan for unresectable hepatic metastases from colorectal
cancer. J Clin Oncol 2001; 19: 2687-2695
9. Kemeny NE, Niedywiecki D,. Hollis DR, Leny HJ, Warren RS, Naughton MJ, Weeks JC,
Sigurdson ER, Herndon JE 2nd, Zhang C, Mayer RJ. Hepatic arterial infusion versus systemic
therapy for hepatic metastases from colorectal cancer: a randomised trial of efficacy, quality of
life, and molecular markers. J Clin Oncol. 2006; 24(9): 1395-1403.
10. Kemeny N, Jarnagin W, Paty P et al. Phase I trial of systemic oxaliplatin combination
chemotherapy with hepatic arterial infusion in patients with unresectable liver metastases from
colorectal cancer. J Clin Oncol 2005; 23: 4888-4896.
11. Ilina Diana, Mintioan Corina, Crbineanu A, Miclu Codrua, Ilina R, Nicola T. Chimioterapia
intaraarterial intrahepatic pentru metastaze hepatice ale cancerului colorectal J Chir. 2008;
4(2): 90-93.
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Coresponden: Dr. Gabriela Blan, doctorand Universitatea de Medicin i Farmacie Gr. T. Popa Iai,
Clinica de Gastroenterologie, Spitalul Judeean de Urgen Sf. Ap. Andrei Galai, Str. Brilei nr. 177,
800578. Tel.: 0236 301111, 0236 301112. Fax : 0236 461000, e-mail: gabrielamedicine@yahoo.com*.
INTRODUCERE
Herniile peretelui abdominal sunt frecvent ntlnite la bolnavii cu ciroz hepatic
(CH) complicat cu ascit, hernia ombilical aprnd n peste 20% din cazuri [1].
Factorii care contribuie la formarea herniei ombilicale la aceti pacieni sunt: creterea
presiunii intra-abdominale prin formarea ascitei, slbirea fasciei i a musculaturii
peretelui abdominal, consecin a statusului nutriional precar i repermeabilizarea venei
ombilicale cu lrgirea defectului preexistent al fasciei supraombilicale datorit
hipertensiunii portale [2,3].
Herniile pot atinge dimensiuni impresionante prin mrirea defectului
aponevrotic i a sacului herniar la bolnavii cirotici, n special la cei cu ascit sub
tensiune [4]. Distensia rapid a esuturilor provoac leziuni ischemice, ruptura
nveliurilor herniare, scurgerea lichidului de ascit, hipotensiune i dezvoltarea
peritonitei bacteriene secundare.
*
received date: 18.05.2011
accepted date: 24.07.2011
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MATERIAL I METOD
n perioada 1 ianuarie 2007 31 decembrie 2007 au fost internai n Clinica de
Gastroenterologie a Spitalului Clinic Judeean de Urgen Sfntul Apostol Andrei
Galai, 122 bolnavi diagnosticai cu ciroz hepatic i ascit, monitorizai pe o perioad
de 36 de luni. Din ntreg lotul doar 31 bolnavi au fost selectai pentru studiul prospectiv,
prezentnd pe lng CH cu ascit diagnosticat pe baza datelor clinice, biochimice,
ecografice, histopatologice i hernie ombilical.
Consimmntul informat scris a fost obinut de la toi pacienii. Severitatea cirozei
hepatice s-a apreciat folosind scorurile Child-Pugh i MELD (model for end-stage liver
disease) calculate la nceperea studiului. Scorul MELD s-a calculat utiliznd formula:
9,57 x log e (creatinina, mg/dl) + 3,78 x log e (bilirubina, mg/dl) + 11,2 x log e (INR) +
6,43 [11].
n funcie de managementul herniei ombilicale s-au identificat dou grupuri de
pacieni: bolnavi care au fost tratai iniial conservator i bolnavi care au beneficiat de
intervenie chirurgical electiv.
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REZULTATE
Studiul a inclus 31 bolnavi (17 brbai i 14 femei) cu ciroz hepatic complicat cu
ascit i hernie ombilical. Caracteristicile demografice i clinice ale cazurilor selectate la
momentul includerii n studiu sunt prezentate n Tabel 1. Vrsta medie a fost 58,0310,39
ani, iar sexul masculin a fost predominant (54,84%). Consumul de alcool a reprezentat
cauza cea mai frecvent a CH (67,74%), urmat de infecia cu virus hepatitic C (29,03%),
virus hepatitic B (19,35%) i virus hepatitic D (3,23%). Etiologia CH a fost: alcool 17
cazuri, alcool + VHC 4 cazuri, VHB 5 cazuri, VHC 5 cazuri, VBH + VHD 1 caz) (Fig. 1).
Din punct de vedere al clasificrii Child-Pugh, a predominat clasa Child B (64,52%),
urmat de Child C (35,48%); nici un bolnav nu s-a situat n clasa Child A. Valoarea medie
a scorului MELD a fost 13,33,59. Toi pacienii au prezentat ascit moderat sau sever.
Tabel 1
Caracteristicile lotului studiat
Vrsta (ani) 58,0310,39
Brbai/Femei 17/14
Cauza cirozei, n (%)
Consum de alcool 21 (67,74)
Virus hepatitic C 9 (29,03)
Virus hepatitic B 6 (19,35)
Virus hepatitic D 1 (3,23)
Clasa Child-Pugh (media DS) 9,55 1,8
Scorul Child-Pugh, n (%)
Clasa Child B 20 (64,52)
Clasa Child C 11 (35,48)
Scorul MELD 13,3 3,59
Manifestri clinice, n (%)
Antecedente de hematemez 8 (25,8)
Icter 18 (58,06)
Edeme 17 (54,83)
Circulaie colateral 26 (83,87)
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60% 54.83%
40%
20% 16.12% 16.12% 12.90%
0% 3.22%
D
l
C
o
VH
VH
VH
VH
co
l+
al
H+
o
VB
co
al
Tabel 2
Caracteristicile demografice ale grupurilor studiate
Intervenie chirurgical electiv a herniei Tratament conservator
Numr 8 23
Raport brbai:femei 1:3 1,87:1
Vrsta medie (ani) 57,5 58,22
Scorul MELD mediu 10,81 13,75
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Tabel 3
Morbiditatea postoperatorie
Complicaii postoperatorii Numr pacieni
Infecia plgii 1 (12,5%)
Fistul ascitic 2 (25%)
Peritonit bacterian secundar 2 (25%)
Ascit sub tensiune 3 (37,5%)
Insuficien hepatic 2 (25%)
DISCUII
Scopul studiului prospectiv a fost de a evalua managementul herniei ombilicale la
bolnavii cu ciroz hepatic complicat cu ascit n Clinica de Gastroenterologie din
Spitalul Judeean Galai. Ratele morbiditii i mortalitii au fost semnificativ mai mari la
bolnavii tratai iniial conservator, comparativ cu pacienii operai electiv, aspect ce ar
putea fi argumentat prin selecia adecvat a subiecilor candidai pentru tratamentul
chirurgical n funcie de severitatea hepatopatiei. Principalii factorii care intervin n
stabilirea indicaiei de chirurgie electiv includ severitatea simptomelor, gradul
disfunciei hepatice, controlul ascitei i prezena coagulopatiei. Cu toate acestea, scorul
MELD, ca indicator al severitii cirozei hepatice nu a prezentat diferene ntre cele
dou grupuri.
Managementul ascitei prin utilizarea diureticelor i a dietei hiposodate,
corectarea coagulopatiei i antibioterapia au contribuit la succesul interveniilor
chirurgicale elective ale bolnavilor cirotici cu ascit i hernie ombilical. Studii recente
au evideniat eficiena asocierii tratamentului chirurgical al herniilor ombilicale cu
realizarea unui unt peritoneo-venos sau unt porto-sistemic transjugular intrahepatic
pentru controlul hipertensiunii portale [12,13].
Anestezia general poate contribui la agravarea cirozei hepatice [6], acesta fiind
motivul pentru care pacienii acestui studiu au fost operai sub anestezie regional pentru a
asigura injuria hepatic minim.
Datele recent publicate indic faptul c ratele morbiditii i mortalitii n
chirurgia reparatorie electiv a herniilor ombilicale la bolnavii cu ciroz hepatic sunt
semnificativ mai reduse fa de interveniile reparatorii de urgen [7,13], susinnd
aceast indicaie la cazurile bine selecionate, dup pregtire preoperatorie adecvat
[14].
Rata complicaiilor n grupul tratat electiv i n cel tratat conservator (25% fa
de 56,52%) a nregistrat diferene statistic semnificative, p = 0,001, n timp ce scorul
MELD a fost comparabil n cele 2 grupuri (10,81 versus 13,75, p>0,05).
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CONCLUZII
Hernia ombilical complicat la bolnavii cirotici cu ascit poate fi tratat
chirurgical, cu o rat minim a morbiditii i inciden redus a recidivei n cazuri atent
selecionate.
Controlul preoperator al ascitei deine rolul important n obinerea succesului
terapeutic.
BIBLIOGRAFIE
1. Telem DA, Schiano T, Divino CM. Complicated hernia presentation in patients with advanced
cirrhosis and refractory ascites: Management and outcome. Surgery 2010; 148(3): 538-543.
2. Hung TH, Hsiao FT, Tseng CW. Umbilical Hernia due to Enlarged Paraumbilical Vein, Clin
Gastroenterol Hepatol. 2011 Mar 11. [Epub ahead of print].
3. Shlomovitz E, Quan D, Etemad-Rezai R, et al. Association of recanalization of the left umbilical
vein with umbilical hernia in patients with liver disease. Liver Transpl 2005; 11: 1298-1299.
4. Andraus W, Sepulveda A, Pinheiro RSN, Teixeira AR, DAlbuquerque LAC. Management of
Uncommon Hernias in Cirrhotic Patients. Transplant Proc 2010; 42(5): 1724-1728.
5. Ginsburg BY, Sharma AN. Spontaneous rupture of an umbilical hernia with evisceration. J
Emerg Med 2006; 30: 155-157.
6. Hansen JB, Thulstrup AM, Vilstup H, Sorensen HT. Danish nationwide cohort study of
postoperative death in patients with liver cirrhosis undergoing hernia repair. Br J Surg 2002; 89:
805-806.
7. Marsman HA, Heisterkamp J, Halm JA, et al: Management in patients with liver cirrhosis and an
umbilical hernia. Surgery 2007; 142: 372-375.
8. Park JK, Lee SH, Yoon WJ, et al. Evaluation of hernia repair operation in Child-Turcotte-Pugh
class C cirrhosis and refractory ascites. J Gastroenterol Hepatol 2007; 22: 377-382.
9. Belghiti J, Desgrandchamps F, Farges O, Fkt F. Herniorrhaphy and concomitant
peritoneovenous shunting in cirrhotic patients with umbilical hernia. World J Surg 1990; 14:
242-246.
10. Douard R, Lentschener C, Ozier Y, Dousset B. Operative risks of digestive surgery in cirrhotic
patients. Gastroenterol Clin Biol 2009; 3: 555-564.
11. Kamath PS, Wiesner RH, Malinchoc M, Kremers W, Therneau TM, Kosberg CL, et al. A model
to predict survival in patients with end-stage liver disease. Hepatology 2001; 33: 464-470.
12. Rossle M, Ochs A, Gulberg V, Siegerstetter V, Holl J, Deibert P, et al. A comparison of
paracentesis and transjugular intrahepatic portosystemic shunting in patients with ascites. N Engl
J Med 2000; 342: 1701-1707.
13. Fagan SP, Awad SS, Berger DH. Management of complicated umbilical hernias in patients with
end-stage liver disease and refractory ascites. Surgery 2004; 135: 679-682.
14. McKay A, Dixon E, BGathe O, Sutherland F. Umbilical hernia repair in the presence of cirrhosis
and ascites: results of a survey and review of the literature. Hernia 2009; 13(5): 461-468.
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Coresponden: Dr. Otilia Boiteanu, medic primar ATI, doctorand Universitatea de Medicin i
Farmacie Gr. T. Popa Iai, e-mail: otilia.boisteanu@yahoo.com*.
INTRODUCERE
Utilizarea sedrii este o practic curent n stomatologie i chirurgia oro-maxilo-
facial de ambulator. Perrot i colaboratorii raportau nc din 2003 c majoritatea
interveniilor de chirurgie oral i maxilo-facial de ambulator se realizeaz folosind
sedarea (diferite grade) asociat anesteziei locale [1]. De cele mai multe ori sala de
operaie reprezint un mediu "ostil" pentru pacient i de aceea anxietatea, teama,
agitaia, durerea sunt cele mai neplcute impresii nregistrate de acesta [2,3]. Scopul
terapeutic al sedrii farmacologice l constituie asigurarea confortului pacientului,
realizarea amneziei evenimentelor traumatizante i asigurarea unei bune analgezii,
deoarece la rndul ei durerea creeaz disconfort i favorizeaz anxietatea.
*
received date: 07.04.2011
accepted date: 24.06.2011
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MATERIAL I METOD
Studiul s-a desfurat pe un lot de 65 pacieni care au fost rezolvai n Clinica de
chirurgie oro-maxilo-facial, Spitalul clinic judeean de urgene "Sf. Spiridon" Iai, n
condiii de ambulator. Pacienii au fost programai i supui unor intervenii de chirurgie
oro-maxilo-facial efectuate cu asistare anestezic monitorizat (AAM) anestezie
loco-regional cu sedare i analgezie intravenoas. Interveniile chirurgicale efectuate
au ndeplinit criteriile chirurgiei ambulatorii: durata scurt (aprox. 1-2 ore), cu risc
sczut din punct de vedere respirator i hemoragic i care nu implic handicap important
n postoperator. Interveniile chirurgicale efectuate au fost de mic/medie amploare:
extracii dentare, odontectomii, rezecii apicale, chistectomii pe 1-2 dini, amputaii
radiculare, premolarizri, extirpri tumori benigne de mici dimensiuni ale prilor moi
orale i extraorale, incizia abceselor periosoase, biopsii ganglionare, suprimarea
materialului de osteosintez, lipostructura. Alegerea tehnicii anestezice s-a fcut n
funcie de necesitile chirurgicale, considerentele anestezice, starea pacientului i
preferinele sale. Includerea pacienilor in studiu s-a fcut pe baza consimmntului
scris informat al acestora. Selecia pacienilor rezolvai cu anestezie loco-regional i
sedare (AAM) n condiii de ambulator s-a fcut innd cont de criteriile sociale i
medicale care se impun n chirurgia de o zi. Au fost admii pentru chirurgia de o zi
(chirurgia ambulatorie) pacienii din clasa ASA I, II i compensai ASA III. Pacienii
din clasa ASA III au fost admii n urma unui acord cu medicul chirurg. Pacienii
selectai au fost mprii n dou loturi: Lotul M (cei crora li s-a administrat
midazolam) i Lotul P (cei crora li s-a administrat propofol). Toi pacienii au fost
evaluai din punct de vedere clinic i paraclinic, conform protocoalelor emise de ASA,
ACC, AHA, asemntor anesteziei generale. Examenul preanestezic s-a efectuat n
condiii de ambulator, ceea ce a scurtat timpul de edere a pacienilor n spital i a
constat ntr-o anamnez amnunit, un examen clinic riguros pe sisteme i aparate i o
serie de investigaii paraclinice. n funcie de amploarea interveniei i de terenul
pacientului, examenul preanestezic a fost fcut:
cu cteva zile nainte de operaie n cazul pacienilor din clasa ASA III -
compensai;
cu o zi nainte de operaie n cazul pacienilor din clasa ASA II;
n ziua interveniei n cazul pacienilor sntoi clasa de risc ASA I, dar acetia
au fost informai n prealabil de posibilitatea operaiei n aceeai zi.
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REZULTATE I DISCUII
Caracteristicile pacienilor luai n studiu (vrsta, greutatea, nlimea, sexul)
sunt prezentate n Tabel 1.
Tabel 1
Caracteristicile pacienilor din ambele loturi
Variabile Lotul M - Midazolam Lotul P - Propofol
(n = 31) (n = 34)
Vrsta (ani) Medie 45 40
Limite 19 -71 17 - 64
Greutate (kg) Medie 53 55
Limite 40 66 44 66
nlime (cm) Medie 156 161
Limite 142 170 150 173
Sex / 14/17 13/21
Tabel 2
Durata spitalizrii, durata tratamentului chirurgical, timpul de trezire i timpul de externare n cazul
sedrii cu Midazolam i Propofol
Variabile Lotul M - Midazolam Lotul P - Propofol
(n = 31) (n = 34)
Mediu 145 113
Durata spitalizrii (min)
Limite 101 293 67 254
Durata tratamentului Mediu 33 38
chirurgical (min) Limite 10 100 10 80
Mediu 55 18
Timpul de trezire (min)
Limite 20 175 10 140
Mediu 80 52
Timpul de externare (min)
Limite 57 - 198 40 - 184
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CONCLUZII
Tehnicile de sedare utiliznd ageni anestezici cu debut rapid al aciunii i cu
durat scurt de aciune sunt sigure i eficiente n cazul chirurgiei oro-maxilo-faciale de
ambulator. Studiul efectuat relev c propofolul i midazolamul se pot utiliza cu succes
pentru sedarea pacienilor n cursul tehnicilor de anestezie loco-regional, oferind efecte
anxiolitice, hipnotice/sedative i amnestice i care conduc la externarea pacienilor n
condiii de siguran, innd cont de caracterul ambulator al interveniilor.
BIBLIOGRAFIE
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Coresponden: Dr. Valeriu urlin, Address: Calea Bucureti A8b 3/10, 200484, Craiova, Dolj, Romania,
Tel: 0040740182346, e-mail: vsurlin@gmail.com*.
INTRODUCERE
O intervenie chirurgical major, precum artroplastia total de genunchi (ATG),
este asociat cu un rspuns complex neurohormonal, imunologic i metabolic, imediat
dup incizie. Este cunoscut faptul c magnitudinea acestui rspuns este proportional cu
amploarea injuriei tisulare, timpul total operator, pierderile de snge, alegerea tehnicii
anestezice, durerea postoperatorie. Intervenia chirurgical reprezint rspunsul
inflamator adiional, declanarea rspunsului postagresiv aparinnd afeciunii iniiale,
locale, de cauz divers (osteoartrite, traumatisme, etc.), existnd o corelaie strns
ntre severitatea agresiunii primare i magnitudinea SIRS/CARS [1].
*
received date: 08.03.2011
accepted date: 12.07.2011
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MATERIAL I METOD
Au fost selecionai pentru acest studiu prospectiv 18 pacieni cu diagnostic de
osteoartrit primar, dintre pacienii operai n clinica de Ortopedie i Traumatologie n
perioada 2009-2010.
Criteriile de includere ale acestor pacieni au fost reprezentate de absena:
tratamentelor cu opioizi, steroizi, antibiotice, artrit reumatoid sau alte boli
imunologice, boli hepatice, diabet zaharat, istoric de alergii medicamentoase, index de
mas corporal (BMI)>40, cancer, afeciuni vasculare, transfuzii de snge intraoperator,
complicaii intraoperatorii de cauz chirurgical.
Acetia au fost mprii aleator n dou loturi: lotul A (abord parapatelar intern -
API)- 8 pacieni i lotul B (abord subvastus medialis - ASM) 10 pacieni.
A fost stabilit un protocol standard de management perioperator adaptat
interveniei chirurgicale. Astfel, toi pacienii au primit anestezie rahidian (AR):
levobupivacain 0,5% 15 mg + Fentanyl 15-20 g (bloc motor cuantificat prin scor
Bromage modificat) + sedare vigil i.v.: Propofol 0,5 mg/kgcorp.
De asemenea, administrarea fluidelor intraoperator a fost standardizat: soluie
salin 0,9% (4,5-5ml/Kg/h) i coloid (Voluven 7-8 ml/kg/h), cu supliment de coloid
n funcie de pierderile sanguine. Administrarea preoperator de ketorolac 15 mg.
Din sngele periferic, preoperator, intraoperator dup efectuarea implantului i
postoperator la 24 ore, au fost determinate: interleukina-6 (IL-6), determinat folosind
PeliKine huIL-6 ELISA kit care este un test de dozare enzimatic de tip sandwich
n care anticorpii monoclonali anti-huIL-6 au fost preacoperii cu godeuri de polistiren
(valorile IL-6 n serul proaspt i plasma individului sntos este <10 pg/ml); proteina C
reactiv (PRC), determinat prin metoda latex-imunoturbidimetrie; valoare de referin
<0.5 mg/dL; cortizolul seric: determinare prin metoda imunohistochimic cu detecie
prin electrochemiluminiscen (ECLIA) (valori de referin: dimineaa orele 7-10: 171-
536 nmol/L; dup-amiaza orele 16-20: 64-327 nmol/L; dup stimulare: cretere >20
mg/dL (>552 nmol/L) sau o cretere de cel puin 3x fa de nivelul bazal; dup supresie:
<5 mg/dL (<138 nmol/L) sau <50% fa de nivelul bazal (ora 8 a.m.).
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REZULTATE
Caracteristicile pacienilor din lotul studiat sunt redate comparativ n Tabel 1, iar
parametrii nregistrai n cursul interveniei chirurgicale sunt redai n Tabel 2
Tabel 1
Caracteristicile pacienilor studiai
Parametri Lotul A (API) Lotul B (ASM)
Vrst 64,4 ani 65,2 ani
Sex F/B 6/2 7/3
BMI 27 29,5
ASA II/III 6/2 7/3
Tabel 2
Parametri legai de intervenia chirurgical.
Parametri API ASM
Lungimea inciziei (mm) 130-140 130-140
Durata interveniei (min.) 8015 8515
Pierderi de snge (ml) 15050 450120
Necesar efedrin (mg) 105 155
Necesar transfuzii (uniti CBC II) 2,7 1,62
p8
p9
p7
p6 p7
p5
p4 p5
p3
p3
p2
p1 p1
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DISCUII
Abordul subvastus n artroplastia total de genunchi respect aparatul extensor
al genunchiului, prin faptul c incizia la nivelul capsulei articulare se face mai intern de
muschiul vast medial, pe care l respect n totalitate, spre deosebire de cel parapatelar
intern care incizeaz tendonul cvadricepsului. Practic, deosebirea de tehnic ntre cele
dou aborduri se rezum la dou aspecte: distrucia muscular i incizia diferit la
nivelul capsulei articulare i a sinovialei.
Rspunsul caracteristic care urmeaz stresului chirurgical, implic creterea
circulaiei hormonilor de stress (cortizol i catecolamine), sinteza i eliberarea diferiilor
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CONCLUZII
Rspunsul postagresiv inflamator i neuroendocrin n ATG este influenat de
tehnica chirurgical utilizat, fiind diminuat n abordul subvastus medial fa de
parapatelar intern. Dei mrimea inciziei este aceeai, conservarea unor esuturi
profunde (muchi, tendoane), ca i utilizarea doar temporar a tourniquet-ului i
necesarul transfuzional mai sczut, pot fi posibile explicaii.
Rspunsul sistemic nu se coreleaz cu rspunsul local, acesta din urm fiind
mult mai crescut dar care pstreaz acelai pattern corelat cu tehnica chirurgical.
Anestezia spinal potenat i.v. influeneaz modularea rspunsului endocrin, iar
administrarea de ketorolac preoperator ar putea influena rspunsul inflamator n ATG.
Experiena chirurgului operator i variaiile anatomice locale individuale pot
influena distrucia tisular i implicit gradul rspunsului inflamator local i sistemic.
BIBLIOGRAFIE
1. Giannoudis P. Current concepts of the inflammatory response after major trauma: an update.
Injury. 2003; 34(6): 397-404.
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2. Heinrich PC, Castell JV, Andus T. Interleukin-6 and the acute phase response, Biochem J. 1990;
265: 621-636.
3. Eriksson S, Olander B, Pira U, Gronstom L. White blood cell count, leucocyte elastase activity,
and serum concentrations of interleukin-6 and C-reactive protein after open appendectomy. Eur
J Surg. 1997; 163(2): 123-127.
4. Kishimoto T. The biology of interleukin-6. Blood. 1989; 74(1): 1-10.
5. Walther Z, May LT, Sehgal PB. Transcriptional regulation of the interferon-beta 2/B cell
differentiation factor BSF-2/hepatocyte-stimulating factor gene in human fibroblasts by other
cytokines. J Immunol 1988; 140(3): 974-977.
6. Niskanen RO, Korkala O, Pammo H. Serum C-reactive protein levels after total hip and knee
arthroplasty. J Bone Joint Surg Br 1996, 78(3): 431-433.
7. Kugisaki H, Sonohata M, Komine M, Tsunoda K, Someya S, Honke H, Mawatari M,
Hotokebuchi T. Serum concentrations of interleukin-6 in patients following unilateral versus
bilateral total knee arthroplasty. J Orthop Sci 2009; 14(4): 437-442.
8. Kragsbjerg P, Holmberg H, Vikerfors T. Serum concentrations of interleukin-6, tumour necrosis
factor-alpha, and C-reactive protein in patients undergoing major operations. Eur J Surg 1995;
161(1): 17-22.
9. Baigrie RJ, Lamont PM, Kwiatowski D. Sistemic cyrokine response after major surgery. Br J
Surg 1992; 79(8): 757-760.
10. Cruickshank AM, Fraser WD, Burns HJ, Van Damme J, Shenkin A. Response of serum
interleukin-6 in patients undergoing elective surgey of varying severity. Clin Sci 1990; 79:
218-222.
11. Ydy LR, Slhessarenko N, de Aguilar-Nascimento JE. Effect of perioperative allogenic red blood
cell transfusion on the immune-inflammatory response after colorectal cancer resection. World J
Surg 2007; 31(10): 2044-2051.
12. Bottner F, Sheth N, Chimento G, Sculco T. Cytokine levels after transfusion of wash wound
drainage in total knee arthroplasty. J Knee Surg 2003; 16(2): 93-97.
13. Nezu Y, Nezu Y, Shigihara K, Harada Y, Yogo T, Hara Y, Tagawa M. Effects of small intestinal
ischemia and reperfusion on expression of tumour necrosis factor-alpha and interleukin-6
messenger RNAs in the jejunum, liver, and lungs of dogs. Am J Vet Res 2008; 69: 512-518.
14. Bjornsson GL, Thorsteinsson L, Gudmundsson KO, Jonsson Jr H, Gudmundsson S,
Gudbjornsson B. Inflammatory cytokines in relation to adrenal response following total hip
replacement. Scandinavian Journal of Immunology 2007; 85(1): 99-105.
15. Naitoh Y, Fukata J, Tomigata T, et al. Interleukin-6 stimulates the secretion of
adrenocorticotrophic hormone in conscious freely moving rats. Biochem Biophys Res Commun
1988, 155: 1459-1463.
16. Wagge A, Slupphauge G, Shalaby R. Glucocorticoids inhibit the production of IL-6 from
monocytes, endothelial cells and fibroblasts. Eur J Immunol 1990; 20(11): 2439-2443.
17. Moore CM, Desborough JP, Powell JP, Powell H, Burring JM, Hall GM. Effects of extradural
anaesthesia on interleukin-6 and acute phase response to surgery. Br J Anaesth 1994; 72(3):
272-279.
18. Crozier TA, Muller JE, Quittkat D, Sydow M, Wuttke W, Kettler D. Effect of anaesthesia on the
cytokine responses to abdominal surgery. Br J Anaesth 1994; 72(3): 280-285.
19. Hall GM, Peerbhoy D, Shenkin A, Parker CJR, Salmon P. Relationship of the functional
recovery after hip arthroplasty to the neuroendocrine and inflammatory responses. Br J Anaesth
2001; 87(4): 537-542.
20. Maury CPJ, Teppo AM, Raunio P. Control of the acute phase serum amyloid A and C-reactive
protein response: comparison of total replacement of the hip and knee. Eur J Clin Invest 1984;
14: 323-328.
21. White J, Kelly M, Dunsmuir R. C-reactive protein level after total hip and total knee
replacement. J Bone Joint Surg 1998; 80-B: 909-911.
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Coresponden: Dr. Mirela Ionescu, Spitalul Universitar de Urgent Elias, Bd. Mrti, Nr. 17, sector 2,
Bucureti; Tel/Fax 0040213161613; e-mail: mirela_ciocirlan@yahoo.com*
INTRODUCERE
Tromboza de ven port (TVP) este una din cele mai dramatice complicaii ce
poate surveni n evoluia cirozelor hepatice, neoplaziilor, a diverselor afeciuni
inflamatorii/infecioase sau consecutiv unor intervenii chirurgicale. Ciroza hepatic
este considerat o afeciune predispozant de majoritatea autorilor, citndu-se o
prevalen care variaz mult, ntre 5,2 i 26% [1,2]. Un studiu efectuat la pacienii
transplantai hepatic menioneaz o inciden general a TVP de 15,7%, dar aceasta este
de 34,8% la cei cu hepatocarcinom i doar de 7% la cei cu ciroz hepatic de cauz
autoimun [3].
Se consemneaz o cretere a incidenei i prevalenei TVP la cirotic n ultimele
dou decade, probabil datorit creterii performanei diagnostice, a mijloacelor tehnice
non-invazive de detecie: ultrasonografia Doppler, accesul la tomografie computerizat
(CT) i rezonan magnetic nuclear (RMN).
*
received date: 14.05.2011
accepted date: 12.07.2011
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MATERIAL I METOD
Am inclus n studiu toi pacienii cirotici internai n perioada Ianuarie 2008 -
Martie 2010 n Clinica de Gastroenterologie i Hepatologie Elias ce aveau ca diagnostic
de internare asociat tromboz de ven port.
Au fost excluse afeciunile hematologice specifice. Scorul Child-Pugh a fost
folosit pentru evaluarea severitii bolii hepatice [17].
Tromboza de ven port (parial/total) sau a ramurilor sale pre/intrahepatice a
fost diagnosticat pe baza ecografiei abdominale Doppler i confirmat prin examinare
CT sau/i RMN.
Diagnosticul HCC a fost stabilit n conformitate cu criteriile Barcelona, utiliznd
pentru diagnostic asocierea ntre una/dou examene imagistice diferite ce confirm o
leziune hipervascular la cirotic (ecografie Doppler, CT, RMN) i creterea AFP la
valori diagnostice [18]. Nici un pacient nu a avut confirmare histologic prin biopsie
hepatic. Clasificarea i evaluarea prognostic a HCC a fost fcut cu ajutorul scorului
CLIP (Cancer of the Liver Italian Program) [19].
Am cutat asocieri specifice ale mai multor parametri comparnd variabile
morfologice, biochimice i clinice la pacienii cirotici cu i fr hepatocarcinom asociat.
Variabilele numerice i non-numerice au fost comparate pentru cele dou grupuri,
identificndu-le pe acelea care ating semnificaia statistic, cu o probabilitate de eroare
mai mica de 5% (p<0.05). Pentru variabilele numerice s-a folosit testul U-Mann
Whitney, iar testul Fisher s-a utilizat pentru variabilele categorice. Pentru analiza
statistic s-a utilizat programul SPSS 11.0 (Statistical Package for the Social Sciences).
Colectarea datelor i analizarea lor s-a desfurat n conformitate cu principiile
eticii i confidenialitii medicale.
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REZULTATE
Am inclus 42 de pacieni cu TVP, 28 cu HCC i 14 pacieni fr neoplasm
hepatic asociat. Caracteristicile i diferenele ntre cele dou grupuri sunt prezentate n
Tabel 1.
Scorul Child C a fost semnificativ mai frecvent ntlnit la grupul de pacieni cu
HCC, 18/28 de pacieni (64,3%), comparativ cu 2/14 pacieni (14,3%) n grupul fr
HCC.
Tabel 1
Analiza comparativ ntre cele dou grupuri de pacieni, fr HCC i cu HCC asociat.
NS (nesemnificativ), pt. pts (pacient, pacieni)
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Aa cum era de prevzut, valorile AFP au fost semnificativ mai mari la grupul
cu HCC. 9/28 de pacieni cu HCC au avut valori ale AFP > 400 ng/ml i nici un pacient
din grupul fr HCC nu a avut valori ale AFP > 400 ng/ml.
Aminotransferazele serice (ALT i AST), ca i gammaglutamiltranspeptidaza
(GGT) au fost semnificativ mai mari la grupul cu HCC.
Consemnarea splenectomiei i a litiazei biliare veziculare a fost mai puin
ntlnit n grupul de pacieni cu HCC.
Pentru grupul de pacieni cu HCC, distribuia morfologiei hepatice i clasificarea
CLIP sunt prezentate n Fig. 1.
CLIP 6
Uninodular
10,7%
21,4%
Infiltrative CLIP 3
17,9%
Multinodular
42,9% CLIP 4
39,3%
Fig. 1 Aspectul morfologic al ficatului cirotic (stnga) i clasificarea CLIP (dreapta) pentru
pacienii din grupul HCC.
Nivelul ALT-lui a fost semnificativ mai mare la cei cu HCC multinodular sau
infiltrativ, n comparaie cu pacienii cu HCC uninodular (99 vs. 32 U/L, p = 0.002), la
fel, pentru valorile AST-lui (143 vs. 59 U/L, p = 0.004).
DISCUII
Cele dou grupuri au fost similare n ceea ce privete vrsta, distribuia pe sexe
i etiologia cirozei hepatice. Infecia cu virus hepatitic C (VHC) a fost cea mai frecvent
pentru ambele grupuri de pacieni. VHC este considerat de anumii autori un factor de
risc pentru apariia trombozei de ven port [2,6].
n lucrarea noastr am evideniat o diferen semnificativ ntre cele dou
grupuri de pacieni n ceea ce privete severitatea cirozei hepatice subiacente. Astfel,
scorul Child a fost C la 64,3% din pacienii cu cancer de ficat n comparaie cu doar
14,3% din cei fr HCC. Datele din literatur sugereaz c, n lipsa asocierii TVP,
37,8% din pacienii cu ciroz hepatic ce nu sunt monitorizai ecografic semestrial ating
scorul Child C n momentul diagnosticului HCC, n comparaie cu numai 12,5% din
pacienii ce sunt corect supravegheai ecografic [20]. Conform indicaiilor actuale,
apariia HCC la cirotic este monitorizat prin screening ecografic i dozarea AFP
semestrial [21].
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Cnd se asociaz TVP, 39,1% din pacienii cu ciroz hepatic sunt ncadrai n
clasa Child C [22].
Astfel, n studiul nostru, severitatea cirozei hepatice a fost mai mare dect cea
ateptat conform datelor din literatur pentru pacienii cu HCC, dar mai mic dect cea
menionat de ali autori, pentru grupul fr HCC. Acest lucru se poate datora n parte
unuia din aspectele care pot fi reproate studiului de fat, i anume a heterogenitii
grupului de studiu n ceea ce privete momentul diagnosticului HCC.
Am gsit diferene semnificative ntre nivelul enzimelor serice: AST, ALT, GGT
ntre cele dou grupuri de pacieni, iar nivelul fosfatazei alcaline (ALKP) a fost i el
aproape de semnificaia statistic. S-a demonstrat anterior c nivele ridicate persistent
ale ALT-lui sunt predictive pentru apariia HCC n ciroza hepatic cu VHC [23]; de
asemenea s-a demonstrat c valoarea ALT-lui crescut persistent este predictiv pentru
apariia HCC cu pattern multinodular [24]. Aceast ultim observaie este confirmat i
de studiul nostru, unde am identificat un nivel mediu al ALT-lui de trei ori mai mare la
cei cu HCC multinodular sau infiltrativ dect la pacienii cu HCC uninodular.
Deasemenea trebuie menionat c o ALKP crescut este predictiv pentru apariia HCC
la cei cu ciroz viral C [25].
Nu au existat diferene semnificative ntre grupurile HCC i non HCC n ceea ce
privete numrul de leucocite, trombocite sau ai parametrilor clasici ai coagulrii.
Acetia din urm nu se modific semnificativ la pacienii cirotici care dezvolt TVP
[26-28].
De asemenea nu au existat diferene privind frecvena encefalopatiei hepatice
sau a ascitei la cele dou grupuri. TVP poate agrava encefalopatia de la stadii
asimptomatice la cele simptomatice [29,30], n timp ce aproximativ 42% din pacieni
pot dezvolta ascit consecutiv instalrii TVP [1].
Prezenta unturilor intraabdominale spontane a fost egal consemnat n cele
dou grupuri, acestea fiind n acelai timp expresia condiiilor reologice locale ce
predispun la apariia trombozei [31-33].
Splenectomia poate fi o opiune terapeutic la ciroticii cu hipersplenism, n
special n cazurile cu trombocitopenie sever [34]. Pacienii splenectomizai prezint un
risc crescut de tromboz de ven splenic i ven port [35,36]. Trei dintre pacienii
inclui n studiu aveau un istoric de splenectomie, toi aparinnd grupului fr HCC.
Dei diferena era statistic semnificativ, cele 3 cazuri gsite nu pot fi considerate clinic
relevante.
n opinia noastr, identificarea litiazei biliare veziculare ca semnificativ mai
frecvent n grupul fr HCC este de asemenea clinic irelevant.
Grosimea peretelui veziculei biliare peste 8mm a fost menionat anterior ntr-un
studiu al nostru [37] ca fiind predictiv pentru apariia TVP la cirotic, nsa, n prezenta
lucrare, grosimea medie a peretelui vezical pentru pacienii inclui a fost de 5,4mm. Nu
au existat diferene semnificative ale acestui parametru ntre cele dou grupuri de
studiu.
Aa cum ne asteptam, nivelul AFP a fost mai mare n grupul de pacieni cu
HCC. S-a demonstrat anterior c nivelul AFP nu este predictiv pentru apariia TVP la
pacienii cu ciroz hepatic [37,38].
Scorul CLIP a fost destul de ridicat la pacienii notri, cu valori ntre 4 i 6 la
67,9% din cazuri, cu o supravieuire median prezis de 3,2 luni ntre 0 i 2 ani [19].
Studiul de fa nu a avut ca scop evaluarea supravieuirii.
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CONCLUZIE
Severitatea cirozei hepatice subjacente i nivelul enzimelor serice sunt
semnificativ mai mari la pacienii cu ciroz hepatic i tromboz de ven port care
asociaz HCC.
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Coresponden : Dr. Ionu opa, Spitalul Clinic de Urgene ,Sf. Spiridon seca exterioar Copou, Str.
Gen. Berthelot, nr.2, Iai, e-mail: ionuttopa@yahoo.com*.
INTRODUCERE
Zona II a tendoanelor flexoare ridic probleme dificile din punctul de vedere al
obinerii unui rezultat funcional optim.
n lipsa aplicrii unui protocol adecvat de reeducare precoce, cicatrizarea
extrinsec a tendoanelor flexoare va conduce ctre formarea de aderene i blocarea
tendonului n canalul osteofibros digital.
Numrul mare de protocoale din literatur pune terapeutul ntr-o postur dificil
de alegere i utilizare a lor. Acest studiu i propune s compare rezultatele aplicrii a 4
protocoale terapeutice, ncercnd s fac o evaluare complet a pacienilor privind
rezultatele dup TAM (Totale Active Motion), dinamometrul Jamar, bilanul de 100 de
puncte (reintegrarea n activitile socioprofesionale) i Minnesota Turning Test
(dexteritate).
Ierarhizarea protocoalelor terapeutice dup rezultatele funcionale poate conduce
ctre obinerea unui ghid de utilizare a lor.
*
received date: 12.03.2011
accepted date: 26.06.2011
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MATERIAL I METOD
Au fost luai n studiu 112 pacieni consecutivi care au prezentat leziuni ale
tendoanelor flexoare fr leziuni asociate. Dintre acetia 76 au fost brbai (68%) i 36
femei (32%) cu vrste cuprinse ntre 20 i 63 de ani, 59 (52,68%) de pacieni provenind
din mediul urban i 53 (47,32%) din mediul rural.
La toi pacienii s-a efectuat sutur primar tip Kessler modificat cu fir 3.0 sau
4.0 nylon neresorbabil n funcie de diametrul i gradul de dezvoltare al tendonului.
Studiul s-a desfurat pe o perioad de 32 de luni. Pacienii au fost luai n studiu
dup momentul prezentrii n tratament, respectiv pe perioade consecutive de 8 luni. n
fiecare perioad de studiu s-a aplicat un protocol terapeutic diferit:
- -n perioada mai 2008 - decembrie 2008 s-au prezentat un numr de 25 pacieni
care au urmat protocolul Kleinert modificat (cu modul palmar i scripetele de
traciune pe modul) (grupul Kleinert)
- -n perioada ianuarie 2009 - august 2009 s-au prezentat un numr de 26 pacieni
care au urmat protocolul Silfverskild i May (grupul Silfverkild)
- -n perioada septembrie 2009 aprilie 2010 s-au prezentat un numr de 30
pacieni care au urmat protocolul Strickland (grupul Strickland)
- -n perioada mai 2010 decembrie 2010 s-au prezentat un numr de 31 pacieni
care au urmat protocolul Gratton (grupul Gratton).
Pacienilor din grupurile Kleinert, Silfverskild i Gratton le-au fost introduse n
programul de reeducare funcional micrile de tenodez din protocolul Cooney [1].
A treia zi postoperator pacienilor din fiecare grup le-au fost aplicate ortezele
pentru nceperea programului de reeducare imediat postoperatorie i programul
specific fiecrui protocol.
n cadrul grupului Kleinert s-au aplicat orteze tip Kleinert modificate
individualizate, cu pumnul n 30 de flexie, articulaiile metacarpofalangiene (AMF) n
flexie 70, articulaiile interfalangiene (AIF) n poziie neutr i rezistena elastic pe
degetul operat dirijat la nivelul pliului palmar distal de flexie [2]. Pacienii au urmat
protocolul Kleinert [3,4] original i au efectuat n fiecare or 10 repetri de extensie
activ contra rezistenei elastice urmat de flexie pasiv a degetului operat asociate cu
10 micri de tenodez.
Pentru grupul Silfverskild s-au aplicat orteze cu pumnul n neutru, flexie AMF
50-70,rezistene elastice ataate pe toate cele 4 degete (four finger program). Pacienii
au efectuat n fiecare or 10 repetri extensie activ, flexie dinamic i flexie cu
contracie izometric (place-hold) n diferite poziii de flexie pentru 2-3 secunde [5]
asociate cu 10 micri de tenodez.
Pacienilor din grupul Strickland li s-au aplicat 2 orteze, una articulat pentru
exerciii i una dorsal de protecie cu pumnul n flexie 20 i AMF n flexie 50. Orteza
articulat a limitat extensia pumnului la 30 i permite flexia maxim. A fost permis
flexia total a degetelor, extensia AIF, dar extensia AMF a fost limitat la 60. Pacienii
au efectuat n fiecare or 15 repetri de flexie pasiv a AIF i AMF n orteza static
urmate de 25 de repetri de plasare-meninere a flexiei degetului pentru 5 secunde n
orteza de tenodez [6].
n cazurile grupului Gratton s-au aplicat orteze dorsale cu pumnul n flexie 20,
AMF n flexie 80-90 iar AIF n extensie. Orteza a fost mai lung cu 2 cm pentru a
mpiedica folosirea degetelor. La fiecare 4 ore fr orteze pacienii au efetuat cu toate
degetele 2 repetri de flexie pasiv, flexie activ, extensie activ i micri de tenodez.
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Tabel 1
Strickland a-2-a versiune
REZULTATE VALOARE COMPARATIV PROCENT
Excelent >132 75 100%
Bun 88 - 131 50 74%
Mediu 44 - 87 25 49%
Slab <44 < 25%
Tabel 2
Testul JAMAR
Rezultat Mna dominant Mna nedominant
Bun 80% fa de cea neafectat 60% fa de cea neafectat
Slab <80% fa de cea neafectat <80% fa de cea neafectat
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Bilanul de 100 de puncte. Acest test face parte din bilanul de 400 de puncte al
lui Chambon [11]. El obiectiveaz evoluia funciei minii i realizeaz o evaluare
cifrat a utilizrii minii lezate graie observrii a 57 de activiti curente. Noi am
utilizat doar bilanul pentru prizele monomanuale i deplasarea obiectelor, cotat cu 100
puncte (5 puncte per obiect). Acest bilan vizeaz s testeze capacitatea subiectului de a
prinde 20 de obiecte diferite de pe un plan de referin i s le transporte pe un plan mai
nalt. Proba este cronometrat i realizat mai nti cu mna sntoas i apoi cu cea
lezat.
Gesturile sunt realizate ntr-o msur normal avnd n vedere atingerea
timpilor. Obiectele nemutate n timpul menionat se scad cu cte 5 puncte din 100.
Datele obinute au fost centralizate n baze de date EXCEL i prelucrate cu
SPSS (Statistical Package for the Social Sciences) versiunea 17 pentru Windows.
Valoare semnificativ statistic a fost considerat pentru p < 0,05.
REZULTATE I DISCUII
Repartiia pe sexe n cadrul grupurilor a evideniat o pondere mai mare a sexului
masculin n fiecare grup (Tabel 3).
Tabel 3
Repartiia pe sexe n cadrul grupelor
Protocol Barbai Femei % Brbai % Femei
Kleinert 17 8 68% 32%
Silfverskild 16 10 62% 38%
Strickland 21 9 70% 30%
Gratton 22 9 71% 29%
Tabel 4
Repartiia cazurilor pe grupe dup mediul de provenien
Protocol Urban Rural % Urban % Rural
Kleinert 13 12 68% 32%
Silfverskild 14 12 62% 38%
Strickland 16 14 70% 30%
Gratton 16 15 71% 29%
Tabel 5
Distribuia cazurilor n grupe n funcie de vrsta pacienilor
Protocol 20-29 ani 30-39 ani 40-49 ani 50-59 ani peste 60 ani
Kleinert 7 7 7 3 1
Silfverskild 8 8 6 3 1
Stricland 9 8 8 3 2
Gratton 8 9 7 4 3
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60
50
40.68
38.6 37.77 38.73
40
30
ani
20
10
0
Kleinert Silfverskild Strickland Gratton
100%
80%
60%
40%
20%
0%
Kleinert Silfverskild Strickland Gratton
E+B M+S
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Tabel 7
Clasamentul dup testul JAMAR
Clasament Protocol Bun Slab
1 Strickland 30 pacieni 80% 20%
2 Gratton 31 pacieni 74% 26%
3 Silfverskold 26 pacieni 69% 31%
4 Kleinert 25 pacieni 60% 40%
Aceste rezultate au valori apropiate cu cele gsite de ali autori. Astfel Bal [18]
prezint o valoare bun n 71% din cazuri, Baktir [16] a obinut ntre 84-90% rezultate
bune comparnd cu mna sntoas, Evcik [15] a gsit valori bune la 67% , Chan [19] a
obinut rezultate bune la 72% dintre pacieni, Kitis [20] a raportat valori bune la 81%
cazuri.
Pentru a studia eficiena aplicrii scorului JAMAR comparativ cu scorul TAM
se analizeaz comparativ pe tipuri de protocoale, sensibilitatea i acurateea metodei de
evaluare.
n cazul pacienilor la care s-a aplicat protocolul Kleinert modificat rezultatele
bune la ambele tipuri de scoruri au o valoare predictiv pozitiv de 88,2%, diferen
semnificativ din punct de vedere statistic comparativ cu rspunsurile slabe (p=0,0006).
Pentru pacienii la care s-a aplicat protocolul Silfverskold rezultatele bune la ambele
tipuri de scoruri (JAMAR I TAM) au o valoare predictiv pozitiv de 90%, diferen
semnificativ din punct de vedere statistic comparativ cu rspunsurile slabe (p=0,002).
n cazurile la care s-a aplicat protocolul Strickland valoarea predictiv pozitiv a
rezultatelor bune la ambele tipuri de scoruri a fost de 92,3% (p=0,008), iar pentru
protocolul Gratton valoarea predictiv pozitiv a rezultatelor bune la ambele tipuri de
scoruri a fost de 91,3% (p=0,0002).
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1 .2
0 .8
sensibilitate
0 .6
0 .4 K+M T SM +M T
0 .2 STRICK G+M T
0
0 0 .2 0 .4 0 .6
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Tabel 9
Indicatori statistici ale valorilor ADL lot A1
Protocol
media min max SD err mediana CV% Q25 Q75
Lot A1
Kleinert 85 70 100 8,04 5,83 85 9,5 80 90
Silfverskold 90 70 100 7,21 5,71 90 8,0 90 95
Strickland 95 85 100 4,91 4,23 95 5,2 95 100
Gratton 90 75 100 6,32 5,45 90 7,0 88 95
Tabel 10
Indicatori statistici ale valorilor Minnesota lot A1
Protocol
media min max SD err mediana CV% Q25 Q75
Lot A1
Kleinert 8,01 6,2 9,2 0,97 0,91 8,20 12,1 7,2 8,8
Silfverskold 8,19 6,4 9,6 0,92 0,71 8,30 11,2 7,6 9,0
Strickland 8,39 6,6 9,8 0,86 0,76 8,30 10,3 7,9 9,2
Gratton 8,11 6,4 9,4 0,86 0,76 8,40 10,6 7,5 8,7
CONCLUZII
Succesul reeducrii funcionale a tendoanelor flexoare n zona 2 reprezint o
problem important pentru chirurg i kinetoterapeut, gsirea unei modaliti de alegere
(ierarhizare) a protocoalelor terapeutice putnd conduce ctre o mai bun reintegrare
socioprofesional a pacienilor.
Obinerea unei ierarhizri trebuie s in cont de toate aspectele refacerii
funcionalitii minii : mobilitate, for, evaluarea posibilitii reintegrrii n activitile
socio-profesionale i dexteritate.
n cazul leziunilor tendoanelor flexoare, fr asocierea altor elemente anatomice
(vase, nervi, oase), recomandarea noastr este s se utilizeze protocolul Strickland. n
cazul n care confecionarea ortezei articulate presupune dificulti, atunci putem
recomanda folosirea protocolului Silfverkild i May, urmat de Gratton i Kleinert,
asociate cu micri de tenodez.
BIBLIOGRAFIE
1. Cooney WP, Lin GT, An KN. Improved tendon excursion following flexor tendon repair. J
Hand Ther 1989, 2: 102-106.
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Coresponden: Dr. Maria Maxim, doctorand Universitatea de Medicina i Farmacie Gr. T. Popa, Iai;
Centrul de Gastroenterologie i Hepatologie Iai, Sp. Sf. Spiridon, str. Independentei nr. 1, 700111, e-
mail: rusumaria1975@yahoo.com*.
INTRODUCERE
Cancerul colorectal (CCR) este unul dintre cele mai frecvente diagnostice de
neoplazie pe plan mondial, devenind o adevrat problem de sntate public. n SUA
aceast maladie ocup locul trei ca inciden. n Europa este a doua cauz de deces prin
cancer, iar anual n lume se nregistreaz circa 1.000.000 de cazuri noi i peste 500.000
decese [1,2]. n Romnia s-a constatat n ultimele decenii o cretere marcant a
incidenei CCR (de la 8,98 %000 n 1982 pn la 26,8 %000 n 2007), att la brbai ct
i la femei [3].
Istoricul familial de CCR reprezint un factor de risc bine stabilit i unanim
acceptat pentru aceast boal malign, numeroase studii demonstrnd c prezena uneia
sau mai multor rude de gradul I cu CCR dubleaz riscul pentru aceast afeciune [4-8].
*
received date: 07.03.2011
accepted date: 12.06.2011
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MATERIAL I METOD
Am efectuat un studiu retroprospectiv n Institutul de Gastroenterologie i
Hepatologie (IGH) Iai n perioada noiembrie 2007-decembrie 2009. Au fost analizate
foile de observaie, examenul endoscopic i rezultatele examenului histopatologic ale
tuturor pacienilor cu CCR. Lotul de studiu a fost constituit din 460 pacieni
diagnosticai cu CCR. Vrsta medie a fost de 66,111,68 ani (28 - 87 ani). Pacienii au
fost evaluai n baza unor chestionare pentru obinerea informaiilor despre rudele de
grad I (prini, frai, surori, copii), precum i rudele de grad II i III (bunici, unchi,
mtui, veri). Analiza detaliat a datelor obinute din documentele studiate au inclus
urmtorii parametri: sexul, vrsta, mediul de provenien, localizarea tumorii, aspectele
anatomo-patologice, stadializarea i prezena leziunilor sincrone.
Analiza statistic a fost realizat prin intermediul soft-ului SPSS 13.0 (Statistical
Package for the Social Sciences). Datele au fost exprimate n termeni de valori medii
(valoare medie deviaie standard) i exprimri procentuale. Nivelul de semnificaie
statistic a fost stabilit la 0.05 pentru toate testele statistice.
Datele obinute fac parte dintr-un studiu mai amplu aflat n desfurare n IGH
Iai, studiu prospectiv ncepnd cu anul 2008, ce vizeaz oportunitatea unui program de
screening la rudele pacienilor diagnosticai cu CCR.
REZULTATE
Au fost inclui n studiu 460 pacieni diagnosticai cu CCR n IGH Iai n
perioada noiembrie 2007-decembrie 2009. Din ntreg lotul de studiu s-au detaat 3
subloturi: 1) 56 pacieni (12,2%) cu antecedente familiale de CCR; 2) 318 pacieni
(69,1%) fr istoric familial de CCR; 3) 86 pacieni ( 18,7%) cu antecedente heredo-
colaterale (AHC) neoplazice, altele dect cele de colon (Fig. 1). Majoritatea pacienilor
cu CCR (69,1%) nu prezentau antecedente familiale de aceasta boal i se ncadreaz n
grupul de cancer colorectal non-ereditar (sporadic) care reprezint 70-80% din
totalitatea CCR. Numai 12,2% dintre pacienii studiai au avut un istoric familial de
CCR.
12.2%
56 AHC colon
86 18.7%
AHC alte ne oplas m e
318 fr a AHC
69.1%
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35
32.1 31.4
30 cu istoric
25 26.1 familial
22.5 23.2 fr istoric
20
17.9 17.9
familial
%
15
10 9.8
8.2
5 5.4
3.5
2
0
30-39 40-49 50-59 60-69 70-79 80-89
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45
40 40.5
35 cu istoric
33
30 familial
25 fr istoric
23.2 26.8 26.8
familial
%
20
12.5
15 15.4
10 8.9
5 1.8 5.5
2.3 3.3
0
d
nt
t
c
al
rs
en
oi
ce
de
ct
ve
gm
nd
re
en
ns
ce
si
sc
tra
as
de
Tabel 2
Structura lotului dup forma endoscopic
Forma endoscopic Istoric familial de CCR (%) Fr istoric familial de CCR (%)
Infiltrativ 1,8 0,3
Vegetant-ulcerat 58,9 56,2
Stenozant 39,3 43,5
Tabel 3
Structura lotului dup stadializare
Stadiu Istoric familial de CCR (%) Fr istoric familial de CCR(%)
in situ 7,1 2,2
T1 1,8 2,2
T2 14,3 8,8
T3 48,2 45,3
T4 8,9 10,1
Inoperabili 19,7 31,4
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DISCUII
CCR reprezint una dintre principalele cauze de mortalitate i morbiditate din
lume, cu implicaii att n domeniul medical ct i n cel socio-economic. n Romnia
s-a nregistrat n ultimul deceniu o cretere semnificativ a incidenei CCR, n special n
rndul persoanelor cu vrsta sub 50 ani.
Istoricul familial este un factor de risc bine stabilit pentru CCR. Riscul familial
de CCR n prezena unei rude de gradul I este de 2-3 ori mai mare dect n populaia
general i crete de 3-4 ori n prezena a dou rude de gradul I cu CCR sau a unei rude
de gradul I diagnosticat pn la vrsta de 50 ani [4-8,11]. CCR familial se deosebete
de sindroamele ereditare cunoscute (sindromul Lynch, sindroamele polipozei
adenomatoase familiale), care au un model mendelian de transmitere i reprezint 15-
20% din toate cazurile de CCR [9,10,12].
n studiul nostru, 56 (12,2%) dintre pacieni au prezentat istoric familial de
CCR, iar dintre acestea 48 (85,7%) aveau rude de gradul I cu CCR.
Incidena CCR este sensibil mai ridicata la brbai dect la femei, indiferent de
prezena sau absena antecedentelor heredo-colaterale de aceast boal malign [13,14];
studiul nostru confirm datele epidemiologice din cercetrile anterioare, predominana
masculin fiind prezent att la pacienii cu istoric familial de CCR ct i la cei cu
cancer colorectal sporadic.
Vrsta avansat este, de asemenea, un alt factor de risc unanim acceptat pentru
CCR, cu o cretere exponeniala dup vrsta de 50 ani i cu dublarea numrului de
cazuri diagnosticate pentru fiecare decad de vrst [14,15]. n studiul nostru repartiia
pe grupe de vrsta este similar cu repartiia cazurilor de CCR din numeroase studii
naionale i internaionale [16-18]. Astfel, frecvena cea mai ridicat a CCR a fost la
pacienii cu vrsta cuprins ntre 70-79 ani pentru pacienii fr istoric familial,
comparativ cu grupa de vrst 50-59 ani la pacienii cu istoric familial de CCR. Fuchs i
col. [4] i Hemminki i col. [8] raporteaz o inciden mai ridicat a bolii la persoanele
tinere cu istoric familial de CCR dect la cele fr istoric familial.
n privina mediului de provenien am constatat o predominan net a cazurilor
provenite din mediul urban (~ 65 %), indiferent de prezena sau absena antecedentelor
familiale, ceea ce confirm datele din literatur [19,20].
Localizarea CCR a fost predominant la nivelul rectului i colonului sigmoid
(79%), n special la pacienii fr istoric familial, n timp ce la pacienii cu antecedente
heredo-colaterale de CCR mai mult de o treime (33,1%) din cazuri sunt localizate pe
poriunea proximal a colonului. Constatri similare n ceea ce privete localizarea CCR
pe colonul drept n proporie de 30%-40% la persoanele cu istoric pozitiv de CCR au
fost raportate de Bufill i col. [21] i Newcomb i col. [22]. n rile cu inciden sczut
a CCR predomin localizarea bolii la nivelul cecului i colonului ascendent, n timp ce
n rile cu inciden crescut par s predomine tumorile sigmoidiene i rectale [23,24].
Aspectul macroscopic al CCR a constituit alt particularitate, tumorile
prezentnd n majoritatea cazurilor forme cu caractere mixte. La pacienii din ambele
subloturi predomin formele vegetant-ulcerate; date similare au fost raportate de alte
studii din ar [25].
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Stadiul bolii este cel mai important factor prognostic, stadiile precoce (I i II)
avnd n general un prognostic favorabil, n contrast cu prognosticul nefavorabil pentru
stadiile avansate ( III i IV) [26,27]. n studiul nostru, diagnosticul de CCR n stadiile
in situ, T1 i T2 a fost stabilit la un numr mai mare de pacieni cu istoric familial de
CCR dect la cei fr antecedente heredo-colaterale de aceast boal malign. n
ansamblu, numrul redus al cazurilor de CCR diagnosticate precoce s-ar putea datora
adresabilitii tardive a pacienilor, precum i programelor de screening din arealul
nostru de studiu.
Pacienii cu tumori colorectale prezint un risc crescut de a dezvolta leziuni
simultane (sincrone). Aproximativ 7% dintre pacienii cu CCR au o a doua leziune
malign colonic, iar la 25% se identific polipi adenomatoi sincroni [28]. n cazul
nostru, prezena leziunilor sincrone a fost asociat stadializrii tardive la pacienii cu
istoric pozitiv de CCR (OR = 1,946); n mod cert, datele obinute au fost subevaluate
(nu s-a putut efectua colonoscopie totala la pacienii cu tumori stenozante).
Exist unele limite ale studiului nostru care necesit atenie. n primul rnd este
un studiu retrospectiv; n al doilea rnd numrul pacienilor cu istoric familial de CCR
este limitat, procentajul fiind n realitate mai mare, informaiile obinute fiind de multe
ori insuficiente (pacienii cu nivel sczut al educaiei sanitare nu puteau preciza prezena
antecedentelor).
CONCLUZII
Istoricul familial de CCR este asociat cu un risc crescut al acestei boli maligne.
Unele caracteristici ale pacienilor cu istoric familial (sex, mediu de provenien) sunt
similare cu ale pacienilor fr antecedente familiale de CCR. La pacienii cu istoric
pozitiv, CCR apare mai frecvent la persoane tinere, 1/3 din cazuri fiind localizate la
colonul proximal. Majoritatea pacienilor se prezint cu boala n stadii avansate,
impunndu-se necesitatea optimizrii diagnosticului i iniierea unor programe de
screening la rudele pacienilor cu CCR pentru depistarea bolii ntr-un stadiu precoce,
vindecabil terapeutic.
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Cancer J Clin 2008; 58(2): 71-96.
2. Ferlay J, Parkin DM, Steliarova-Fucher E. Estimates of cancer incidence and mortality in Europe
in 2008. Eur J Cancer 2010; 46(4): 765-781.
3. Ministerul Sntii. Centrul de Calcul, Statistic Sanitar i Documentare Medical. Anuar de
statistic sanitar 2009. Bucureti 2009.
4. Fuchs CS, Giovannucci EL, Colditz GA, Hunter DJ, Speizer FE, Willet WC. A prospective
study of family history and the risk of colorectal cancer. N Engl J Med 1994; 331(25):
1669- 1674.
5. St John DJ, McDemott FT, Hopper JL, Debney EA, Johnson WR, Hughes ES. Cancer risk in
relatives of patients with common colorectal cancer. Ann Intern Med 1993; 118(10): 785-790.
6. Johns LE, Houlston RS. A sistematic review and meta-analysis of familial colorectal cancer risk.
Am J Gastroenterol 2001; 96(10): 2992-2993.
7. Goldgar DE, Easton DF, Cannon-Albright LA, Skolnick MH. Systematic population-based
assessment of cancer risk in first-degree relatives of cancer probands. J Natl Cancer Inst 1994;
86(21): 1600-1608.
8. Hemminki K, Li X. Familial colorectal adenocarcinoma from the Swedish family-cancer
dabatase. Int J Cancer 2001; 94(5): 743-748.
9. Burt RW, Neklason DW. Genetic testing for inherited colon cancer. Gastroenterology 2005;
128(6): 1696-1716.
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10. Butterworth AS, Higgins JP, Pharoah P. Relative and absolut risk of colorectal cancer for
individuals with a family history: a metaanalysis. Eur J Cancer 2006; 42(2): 216-227.
11. Taylor DP, Burt RW, Williams MS, Haug PJ, CannonAlbright LA. Population-Based Family
HistorySpecific Risks for Colorectal Cancer: A Constellation Approach Gastroenterology
2010; 138( 3): 877-885.
12. Pinol V, Andreu M, Castells A, Pay A, Bessa X, Rodrigo J. Frequency of hereditary
nonpolyposis colorectal cancer familial forms in Spain. A multicenter, prospective, nation-wide
study. Gastrointestinal Oncology Group of the Spanish Gastroenterological Association. Eur J
Gastroenterol Hepatol 2004; 16(1): 39-45.
13. Chu KC, Tarone RE, Chow WH, Alexander GA. Colorectal trend by race and anatomic subsites,
1975-1991. Arch Fam Med 1995; 4(10): 849-856.
14. US Cancer Statistics Working Group. United States Cancer Statistics: 1995-2005. Incidence and
Mortality Web-Based Report. Atlanta (GA): Department of Health and Human Services, Centers
for Disease Control and Prevention, and National Cancer Institute, 2009.
15. Trends in colorectal cancer incidence - United States, 1973-1986. MMWR Morb Mortal Wkly
Rep 1989; 38(42): 728-731.
16. Cancer Statistic Review 1973-1999. Surveillance, Epidemiology and End Result. Bethesda:
National Cancer Institute, 2000.
17. Cipaian CR. Carcinomul colorectal: aspecte epidemiologice i de screening. Tez de doctorat,
UMF Cluj-Napoca, 2003.
18. Gupta AK, Melton J, Petersen GM, Timmons LJ, Veqe SS, Harmsen WS, Diehl NN,
Zinsmeister AR, Ahlquist DA. Changing trends in the incidence, stage, survival, and screen-
detection of colorectal cancer: a population-based study. Clinical Gastroenterology and
Hepatology 2005; 3(2): 150-158.
19. Becker N. Epidemiology of colorectal cancer. Radiology 2003; 43(2): 98-104.
20. Troisi RJ, Freedman AN, Devesa SS. Incidence of colorectal carcinoma in the U.S.: an update of
trends by gender, race, age, subside, and stage, 1975-1994. Cancer 1999; 85(8): 1670-1676.
21. Bufil JA. Colorectal cancer: evidence for distinct genetic categories based on proximal or distal
tumor location. Ann Int Med 1990; 113(10): 779-788.
22. Newcomb PA, Taylor JO, Trentham-Dietz A. Interation of a familial and hormonal risk factors
for large bowel cancer in women. Int J Epidemiol 1999; 28(4): 603608.
23. Fenoglio-Preiser C, Noffsinger AE, Stemmermann GN. Gastrointestinal pathology: an atlas and
text. 2nd ed. Philadelphia, Lippincott Williams & Wilkins, 1999; 909-1068.
24. Ming SC, Goldman H. Pathology of gastrointestinal tract. Second ed. Williams & Wilkins,
Baltimore, 1998: 855-900.
25. Valcea ID, Bogdan F, Vasile I, enovici M, Meina C, Mogoant S. Cancerul colorectal
aspecte histologice. Craiova Medicala 2006; 8(1): 30-33.
26. Minsky BD, Mies C, Recht A, Rich TA, Chaffey JT. Resectable carcinoma of the rectosigmoid
and rectum. Patterns of failure and survival . Cancer 1988; 61(7): 1408-1416.
27. Skibber JM, Minsky BD, Hoff PMJ. Cancer of the Colon. In De Vita VT, Hellman S,
Rosenberg SA. eds. Cancers. Principles and Practice of Oncology 6th edition, Philadelphia:
Lippincot Williams & Wilkins Publishers 2001: 1216-1271.
28. Schuman BM, Simsek H, Lynos RC. The association of multiple colonic adenomatous polyps
with cancer of the colon. Am J Gastroenterol 1990; 85(7): 846-849.
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Coresponden: Prof. Dr. E. Trcoveanu, Clinica I Chirurgie, Spitalul Universitar Sf. Spiridon Iai, Bd.
Independenei nr. 1, Iai, 700111; e-mail: etarcov@yahoo.com*.
INTRODUCERE
Heterotopia pancreatic este o anomalie congenital rar, n care esutul
pancreatic accesoriu, format din esut nedifereniat pn la acini, ducte i insule
pancreatice, mai mult sau mai puin dezvoltate, se gsesc n afara i fr legtur
vascular canalar cu pancreasul normal situat. Un ultim caz, un brbat tnr a fost
internat cu semne clinico-radiologice de stenoz antral dup o reacie pancreatic,
confirmat biologic, interpretat ca tumor stromal antral, ce a impus antrectomia,
examenul histopatologic aducndu-ne surpriza unei heterotopii pancreatice antropilorice
chistice stenozante.
*
received date: 22.05.2011
accepted date: 12.07.2011
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PREZENTARE DE CAZ
Bolnavul S.M., n vrst de 29 ani, se interneaz n martie 2011 (FO 13731),
prin transfer de la Clinica de Gastroenterologie pentru dureri epigastrice, greuri,
vrsturi, scdere ponderal (10 kg/2 luni). Din antecedentele heredocolaterale reinem
c are un unchi operat de cancer de colon, iar mama este decedat la 42 ani prin
neoplasm ovarian.
Debutul bolii este insidios, n urm cu 3 luni, cu dureri epigastrice cu iradiere
transversal, urmat de greuri, apoi de vrsturi. A urmat un tratament cu
antiinflamatoare nesteroidice.
Endoscopia digestiv superioar a artat o gastrit antral drog-indus i a
descoperit o formaiune antral, imediat prepiloric, de 3 cm, bine delimitat, cu o mic
ulceraie n centru. Probele biologice sunt normale, inclusiv markerii tumorali, cu
excepia amilazelor serice (307,8 U/L) i urinare (1020 U/L) i a rezervei alcaline (30
mEq/L CO2).
Se transfer n serviciul nostru cu diagnosticul de tumor antral stenozant.
Bolnavul are stare general relativ bun i prezint vrsturi alimentare
postprandiale. Tranzitul baritat esogastric arat un stomac voluminos, cu pliuri groase,
cu lichid de secreie abundent, cu evacuare ntrziat din cauza unei formaiuni
extralumenale de 35 mm, situat pe faa posterioar gastric, juxtapiloric, care
stenozeaz lumenul (Fig. 1).
Ecografia abdominal evideniaz un stomac voluminos, cu bogat coninut
lichidian; pe aria de proiecie a antrului gastric se descoper o formaiune n cocard,
hiperecogen, de 35/28 mm, situat predominant extralumenal (Fig. 2).
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DISCUII
Pancreasul heterotopic gastric reprezint o cauz foarte rar de stenoz
antropiloric la adult. Heterotopia pancreatic a fost descris pentru prima dat n 1727
ntr-un diverticul ileal [cit. 1].
Heinrich, n 1909, mparte heterotopia pancreatic n trei tipuri histologice: tipul
I format din ducte, acini i insule pancreatice, tipul II format din acini i ducte i tipul
III format numai din ducte [cit. 1].
n 1973, Gaspar i Fuentes propun o nou clasificare histologic n patru tipuri:
tipul I format din ducte, acini i insule pancreatice endocrine, tipul II format numai din
ducte (varianta canalicular), tipul III format numai din acini i tipul IV n care
heterotopia conine numai celule endocrine [cit. 2]. Cazul descris aparine tipului I n
ambele clasificri.
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Prima localizare gastric este semnalat de Klob J., n 1859 [cit. 1], iar prima
stenoz antropiloric prin pancreas aberant gastric este consemnat de Krieg E.G., n
1941 [3]. n literatur aceast anomalie este cunoscut sub mai multe denumiri:
pancreas aberant, pancreas ectopic, heterotopie pancreatic, pancreas accesor sau
supranumerar, coristom [4].
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CONCLUZII
Incidena heterotopiei pancreatice este rar. Diagnosticul preoperator este dificil,
diferenierea de o tumor stromal fiind imposibil fr examenul histologic
extemporaneu care va exclude i o malignitate.
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Excizia chirurgical limitat prin abord minim invaziv este indicat n formele
simptomatice benigne.
BIBLIOGRAFIE
1. Tranu T, Vintil D, Neacu N, Popa Paula, Lunc C, Crumpei Felica, Rdulescu Doina,
Georgescu SO. Pancreasul accesor heterotopic n patologia chirurgical: experiena a 23 ani.
Chirurgia. 2010; 105(3): 347-353.
2. Christodoulidis G, Zacharoulis D, Barbanis S, Katsogridakis E, Hatzitheofilou K.: Heterotopic
pancreas in the stomach: a case report and literature review. World J Gastroenterol. 2007;
13(45): 6098-6100.
3. Krieg EG. Heterotopic pancreatic tissue producing pyloric obstruction. Ann. Surg. 1941; 113(3):
364-370.
4. Diaconescu MR, Georgescu S, Dnil N, Popescu E. Choristomas. Rev Med Chir Soc Med Nat
Iasi. 1990; 94(3-4): 529-531.
5. Hlavaty T, Lukac L, Vyskocil M, Galbavy S. Heterotopic pancreas in gastric antrum with
macroscopic appearance of gastric polyp. Bratisl Lek Listy. 2002; 103(3): 117-120.
6. Mnig SP, Selzner M, Raab M, Eidt S. Heterotopic pancreas. A difficult diagnosis. Dig Dis Sci.
1996; 41(6): 1238-1240.
7. Hsu SD, Wu HS, Kuo CL, Lee YT. Robotic-assisted laparoscopic resection of ectopic pancreas
in the posterior wall of gastric high body: case report and review of the literature. World J
Gastroenterol. 2005; 11(48): 7694-7696.
8. Tanaka K, Tsunoda T, Eto T, Yamada M, Tajima Y, Shimogama H, Yamaguchi T, Matsuo S,
Izawa K. Diagnosis and management of heterotopic pancreas. Int Surg. 1993; 78(1): 32-35.
9. Oka R, Okai T, Kitakata H, Ohta T. Heterotopic pancreas with calcification: a lesion mimicking
leiomyosarcoma of the stomach. Gastrointest Endosc. 2002; 56(6): 939-942
10. Rimal D, Thapa SR, Munasinghe N, Chitre VV. Symptomatic gastric heterotopic pancreas:
clinical presentation and review of the literature. Int J Surg. 2008; 6(6): 52-54.
11. Haj M, Shiller M, Loberant N, Cohen I, Kerner H. Obstructing gastric heterotopic pancreas: case
report and literature review. Clin Imaging. 2002; 26(4): 267-269.
12. Yamagiwa H, Ishihara A, Sekoguchi T, Matsuzaki O. Heterotopic pancreas in surgically
resected stomach. Gastroenterol Jpn. 1977; 12(5): 380-386.
13. Terada T. Heterotopic Pancreatic Tissue of the Stomach: Report of Three Cases and
Consideration of Its Histogenesis. Case Rep Gastroenterol. 2010; 4(3): 386-392.
14. Rimal D, Thapa SR, Munasinghe N, Chitre VV. Symptomatic gastric heterotopic pancreas:
clinical presentation and review of the literature. Int J Surg. 2008; 6(6): e52-54.
15. Ormarsson OT, Haugen SE, Juul I. Gastric outlet obstruction caused by heterotopic pancreas.
Eur J Pediatr Surg. 2003; 13(6): 410-413.
16. Hsia CY, Wu CW, Lui WY. Heterotopic pancreas: a difficult diagnosis. J Clin Gastroenterol.
1999; 28(2): 144-147.
17. Yamashita K, Yamazaki K, Ueno A, Arimura Y, Endo T, Imai K. Image of the month. A gastric
heterotopic pancreas with cystic change. Gastroenterology. 2005; 129(5): 1374, 1809.
18. Lopez-Pelaez MS, Hoyos FB, Isidro MG, Unzurrunzaga EA, Lopez Ede V, Collazo YQ. Cystic
dystrophy of heterotopic pancreas in stomach: radiologic and pathologic correlation. Abdom
Imaging. 2008; 33(4): 391-394.
19. Jiang LX, Xu J, Wang XW, Zhou FR, Gao W, Yu GH, Lv ZC, Zheng HT. Gastric outlet
obstruction caused by heterotopic pancreas: A case report and a quick review. World J
Gastroenterol. 2008; 14(43): 6757-6759.
20. Ormarsson OT, Gudmundsdottir I, Mrvik R. Diagnosis and treatment of gastric heterotopic
pancreas. World J Surg. 2006; 30(9): 1682-1689.
21. Ayantunde AA, Pinder E, Heath DI. Symptomatic pyloric pancreatic heterotopia: report of three
cases and review of the literature. Med Sci Monit. 2006; 12(6): CS49-52.
22. Yuan Z, Chen J, Zheng Q, Huang XY, Yang Z, Tang J. Heterotopic pancreas in the
gastrointestinal tract. World J Gastroenterol. 2009; 15(29): 3701-3703.
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KEY WORDS: TUMOR, INTERNAL ANGLE OF THE EYE, CERVICOFACIAL SKIN FLAP,
TUMOR EXCISION, SURGICAL RECONSTRUCTION.
Coresponden: Dr. Lucian Popa, medic primar, Clinica de Chirurgie Plastic Reconstructiv i Arsuri,
Sp. Sf. Spiridon, Iai, doctorand Universitatea de Medicin i Farmacie Gr. T. Popa Iai,
email:lucpopa@yahoo.com*.
INTRODUCERE
Chirurgia tumorilor cu localizare la nivelul unghiului intern al ochiului
reprezint o tem dificil deoarece n afar de dimensiunea tumorii, va trebui s se in
seama i de particularitile locale: dimensiunile mici ale ariei, tegumente aderente,
caruncula i ligamentul intern, orificiile i canalul lacrimal, peoapele structuri mobile,
precum i de structura lor, vecinatatea i importana receptorului visual [1].
Dimensiunea formaiunii tumorale constituie n contextul regional un element de
difereniere a rezultatelor tratamentului.
*
received date: 12.04.2011
accepted date: 24.05.2011
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CONCLUZII
Planificarea tratamentului chirurgical trebuie sa prevad ndepartarea complet a
leziunii. Susinem examenul anatomopatologic intraoperator (extemporaneu), deoarece
recidivele tumorale la acest nivel sunt urmate de cele mai multe ori de operaii
mutilante, cu efect important asupra aspectului i psihicului pacientului.
Planul operator specific pentru fiecare formaiune tumoral n parte, necesitnd
de foarte multe ori colaborarea ntre oftalmolog i chirurgul plastician, dar i cu
chirurgul maxilo-facial sau chiar neurochirugul.
Planificarea reconstruciei trebuie s includ de la nceput variante n funcie de
dimensiunile i profunzimea exciziei i care vor fi adaptate la necesitile operatorii.
Planul operator trebuie s cuprind modalitatea de reconstrucie a regiunii, cu
refacerea structural i funcional ntr-un procent ct mai mare. Se va alege varianta
care asigur o reconstrucie ct mai aproape de normal.
Urmrirea n timp a evoluiei cicatriciale i recidivelor tumorale este obligatorie
i tratamentul acestora constituie o parte integranta a tratamentului.
BIBLIOGRAFIE
1. Spaeth GL. Ophtalmic Surgery. Principles and Practice, Philadelphia, WB Saunders
Company, 1982.
2. Jelks GW, Glat PM, Jelks EB, Longaker MT. Medial canthal reconstruction using a medially
based upper eyelid myocutaneous flap. Plast Reconstr Surg 2002; 110(7):
1636-1643.
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Correspondence-to: Dr. Nilanjan Panda, address: P 318B CIT Road, Scheme 6 M, Kankurgachi, Kolkata,
West Bengal, India pin 700054, e-mail: drnilanjanpanda2002@yahoo.co.in*.
INTRODUCTION
The variety of foreign bodies inserted into or externally attached to the
genitourinary tract defies imagination and includes all types of objects [1,2]. The most
common motive is sexual or erotic in nature and is frequently associated with mental
health disorders or drug intoxication [2].
Most self-inflicted foreign bodies of the urethra and bladder can be removed
endoscopically [2,3]. The primary goal is extraction of the foreign body using
minimally invasive techniques and preservation of urinary voiding and erectile
functions. However, in some cases open surgery becomes necessary. We present a rare
case where an electric wire inserted into the urethra could not be extracted per urethra
due to a knot in the bladder, thereby requiring suprapubic cystostomy.
CASE REPORT
A twenty-five year old male goldsmith presented in the emergency department
with a history of bleeding and pain in the urethra and suprapubic region for a few hours
following insertion of an electrical wire in his urethra.
He was also unable to control micturation. The malleable wire, almost 60
centimeter long and five millimeter in diameter was introduced for sexual gratification.
*
received date: 18.03.2011
accepted date: 21.07.2011
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However, later when he tried to remove it there was pain, bleeding from the
urethra followed by incontinence. The wire could not be removed. The patient was not
married and his socioeconomic status was of lower middle class. It was the first time he
had ever self-inflicted a foreign body in his urethra and he had no history of drug
addiction or psychiatric illness.
Examination revealed an electrical wire with one end protruding about eight cm
out of the penis (Fig 1). The patient was dribbling urine. Abdomen was soft and elastic.
Suprapubic swelling suggestive of distention of the urinary bladder was absent and
there was mild suprapubic tenderness. There was no injury in the ano-scrotal region.
During rectal and perineal region examination, the wire was palpable. Other physical
examinations were normal.
Fig. 1 Electrical wire protruding out Fig. 2 X-ray showing coiled wire in
of the penis. the bladder.
Initial attempts in the emergency department to remove the foreign body failed.
A plain X-ray of the abdomen including pelvic region was advised anticipating surgical
intervention which revealed a radio-opaque, smooth and coiled wire in the urethra and
urinary bladder (Fig. 2).
Cystoscopic removal was unsuccessful as the protruded wire obstructed the
pathway and suprapubic cystostomy had to be done (Fig. 3). The foreign body was
removed intact followed by urethral catheterization (Fig. 4). Haematuria subsided
within two days. The patient was discharged on the 7-th postoperative day and the
urethral catheter was removed after two weeks. He was on intravenous antibiotics for
five days and on oral regimen for another ten days.
Post operative recovery was uneventful. The patient reported no voiding
problems or erectile dysfunction in further follow-up. No urethral stricture was seen by
the urethrogram performed in the follow-up.
After discharge he was advised psychiatric consultation where he was diagnosed
with depression and anxiety disorder for which he is receiving medication.
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DISCUSSION
A large number of self-inflicted foreign bodies in the urethra and urinary bladder
have been reported by various studies, which include needle, pencil, wire, rubber tube,
snakes, fish, cucumber, glue and cocaine [1-5]. It was reported that almost 100% of
cases in males and 85% of those in females inserted objects for masturbation or sexual
gratification [2,6]. Mental illness, drug intoxication or as an aid to voiding may also be
the reasons [1,2]. In the majority of cases, the patient feels guilty and humiliated [1,2],
therefore do not seek early medical help. In our case, the patient was regretting his
action.
Fig. 3 Cystostomy with coiled wire inside. Fig. 4 Foreign body after removal.
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Depending on the type of foreign body, its location and mobility, various
methods of removal have been described. In this case due to the knot of electric wire in
the bladder, pulling by holding distal end was not possible for removal of wire.
Endoscopic removal is the standard but was futile for this patient as the wire
obstructed the pathway. Majority of the mobile objects inside the urethra can be
removed utilizing forceps and snares, balloon-wires, and stone-retrieving baskets.
Nephroscopes, and magnetic retrievers for galvanic objects have been used [2].
The YAG laser has also been used lately [5]. In few cases as in this one, where
endoscopic procedures are unsuccessful, open surgery such as external urethrotomy or
suprapubic cystostomy is recommended [9].
CONCLUSION
Urethral foreign body insertion as paraphilia can cause major complications and
emergency surgeons need to be aware of the problem and its management. If
cystoscopic removals fail then open procedure like cystostomy may be required.
Psychiatric evaluation of the patient is important.
REFERENCES
1. Rahman NU, Elliott SP, McAninch JW. Self-inflicted male urethral foreign body insertion:
endoscopic management and complications. BJU Int 2004; 94(7): 1051-1053.
2. Van Ophoven A, DeKernion JB. Clinical management of foreign bodies of the genitourinary
tract. J Urol 2000; 164(2): 274-287.
3. Sukkarieh T, Smaldone M, Shah B. Multiple foreign bodies in the anterior and posterior urethra.
Int Braz J Urol 2004; 30(3): 219-220.
4. Gonzalgo ML, Chan DY. Endoscopic basket extraction of a urethral foreign body. Urology
2003; 62(2): 352.
5. Wyatt J, Hammontree LN. Use of holmium YAG laser to facilitate removal of intravesical
foreign bodies. J Endourol 2006; 20: 672-674.
6. Campbell RJ. Psychiatric Dictionary 5th ed. New York, Oxford University Press, 1981.
7. Kenney RD. Adolescent males who insert genitourinary foreign bodies: is psychiatric referral
required? Urology 1988; 32(2): 127-129.
8. Wise TN. Urethral manipulation: an unusual paraphilia. J Sex Marital Ther 1982; 8(3): 222-227.
9. Lee JD, Jeng SY, Hsieh DS. Self-introduction of unusual foreign body into the urethra: a case
report. Zhonghua Yi Xue Za Zhi 1995; 56(6): 440-442.
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INTRODUCERE
Tumorile chistice ale ovarului reprezint o patologie frecvent la femeie n
timpul perioadei de activitate genital.
Dei mult timp chisturile ovariene gigante erau abordate prin laparotomie,
actualmente, abordul laparoscopic tinde s devin gold standard n tratamentul
chisturilor de ovar indiferent de dimensiunile acestora. Tratamentul minim invaziv al
chisturilor ovariene de dimensiuni mari poate fi dificil punnd probleme att de tehnic
chirurgical datorit mrimii, precum i existenei riscului de malignitate. Avantajele
acestui abord sunt bine cunoscute: analgezie postoperatorie redus, sngerare minim,
inciden redus a aderenelor postoperatorii, rezultat cosmetic superior, spitalizare de
scurt durat, recuperare rapid, costuri sczute, reinserie socio-profesional rapid.
*
received date: 04.04.2011
accepted date: 30.05.2011
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PREZENTARE DE CAZ
Pacient n vrst de 21 ani, nulipar, cu cicluri menstruale regulate, fr
antecedente personale patologice sugestive, s-a internat n Clinica I Chirurgie pentru
dureri la nivelul hipogastrului i fosei iliace drepte, tulburari de tranzit intestinal. La
examenul clinic s-a constatat prezena n hipogastru i mezogastru a unei formaiuni
tumorale cu dezvoltare pelviabdominal, diametru 18-20 cm, consisten ferm-elastic,
mobil, nedureroas (Fig. 1). Examenul ecografic abdomino-pelvin evideniaz prezena
n poziie medio-abdominal a unei formaiuni lichidiene voluminoase, uniloculare, de
231/140 mm, chist ovarian stang. Nu au fost vizualizate septuri, vegetaii, sau semnal
Doppler n interiorul formaiunii. Ovarul drept i uterul au avut aspect ecografic normal.
Nu a fost evideniat prezena lichidului de ascit, iar ficatul avea ecostructur normal,
dar s-a constatat ureterohidronefroz dreapt gradul II i ureterohidronefroz stng
gradul I.
Marker-ii tumorali serici (CA 125, CEA) erau n limite normale, fr anomalii
ale constantelor hematologice sau biochimice cu excepia unei uoare
hipercolesterolemii (219 mg/dL).
S-a decis abordul laparoscopic cu anestezie general cu intubaie orotraheal.
S-a practicat laparoscopie deschis supraombilical. La explorarea cavitii peritoneale
s-a constatat prezena la unui chist de aproximativ 30 cm care atingea ficatul cu
suprafa neted, mobil, avnd originea la nivelul ovarului stng i exercitnd efect
compresiv asupra anselor intestinale. Cupolele diafragmatice, ficatul, stomacul, ansele
intestinale i colice, ovarul contralateral i uterul aveau aspecte normale. Nu a fost
evideniat prezena aderenelor intraabdominale i a lichidului de ascit.
S-au introdus dou trocare adiionale de 10 mm n fosa iliac stng (FIS) i de 5
mm n fosa iliac dreapt (FID). S-a puncionat chistul cu acul de puncie laparoscopic
de 5 mm introdus prin trocarul din FID care se etaneizeaz perfect la peretele chistului
(Fig. 2) i s-a adaptat la un aspirator chirurgical.
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S-au aspirat 3 litri de lichid serocitrin i dup golirea chistului s-a practicat
anexectomie stng cu pensa Ligasure (Fig. 3). S-a extras piesa operatorie ntr-un
endobag dup lrgirea inciziei din FIS.
Intervenia a fost finalizat prin plasarea unui tub de dren n Douglas,
exteriorizat prin traiectul de trocar din FID (Fig. 4).
DISCUII
Chistadenomul mucinos este o tumor care se dezvolt printr-o proliferare a
celulelor mucosecretante. Originea sa nu este clar. La paciente peste 40 ani originea
este cel mai probabil mezotelial, n timp ce la pacientele tinere chistul se dezvolt
frecvent dintr-un teratom [1]. Reprezint 15-20% din tumorile ovariene benigne [2] i
este rar ntlnit bilateral.
Tumora poate atinge dimensiuni mari, pn la 50 cm diametru. La suprafa este
neted, cu perete subire de culoare alb cenuie. n interior este frecvent multiloculat,
septurile sunt subiri i determin formarea de caviti umplute cu o substan mucoid,
transparent. Cavitile pot fuziona formnd un compartiment unic voluminos.
n interior, peretele chistului este tapetat de un epiteliu columnar unistratificat
asemntor cu epiteliul endocervical sau intestinal [3]. Potenialul malign este redus..
Tradiional, abordul chistadenomului este prin laparotomie, dar actualmente,
laparoscopia se impune n ginecologie ca i n toate ramurile chirurgicale.
Abordul laparoscopic al chisturilor ovariene reprezint n prezent standardul de
aur.
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CONCLUZII
Particularitatea cazului prezentat const n rezolvarea integral laparoscopic a
unei tumori chistice ovariene de mari dimensiuni cu dezvoltare pelvi-abdominal la o
pacient tnr cu compromiterea limitat a fertilitii datorit avantajelor tratamentului
chirurgical minim invaziv.
Abordul laparoscopic este fezabil i se poate practica, pe cazuri selectate, chiar
n situaia chisturilor gigante de ovar.
BIBLIOGRAFIE
1. Novak ER, Woodruff JD. Novaks gynecologic and obstetric pathology with clinical and
endocrine relations. Philadelphia, WB Saunders Company, 1979.
2. Duvillard P. Classification anatomo-pathologique des tumeurs de lovaire. Reproduction
humaine et hormones 1998; 11(9): 619-628.
3. Scully RE, Young RH, Clement PB. Atlas of Tumor Pathology. 3rd series, fascicle 23.
Washington DC. AFIP 1998.
4. Sevelda P, Dittrich C, Salzer H. Prognostic value of the rupture of the capsule in stage 1
epithelial ovarian carcinoma. Gynecol Oncol 1989; 35: 321322.
5. Dembo A, Davy M, Stenwig A. Prognostic factors in patients with stage 1 epithelial ovarian
cancer. Obstet Gynecol 1990; 75: 263272.
6. Eltabbakh GH, Kaaisar JR. Laparoscopic management of a large ovarian cyst in an adolescent. J
Reprod Med 2000; 45(3): 231234.
7. Nagele F, Magos AL. Combined ultrasonographically guided drainage and laparoscopic excision
of a large ovarian cyst. Am J Obstet Gynecol 1996; 175(5): 13771378.
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8. Rabbani I, Wynn JS, Hickling DJ. Laparoscopic excision of a large ovarian cyst. Gynecol Surg
2007; 4: 225227.
9. Salem HA. Laparoscopic excision of large ovarian cysts. J Obstet Gynaecol Res 2002; 28(6):
290294.
10. Goh SM, Yam J, Loh SF, Wong A. Minimal access approach to the management of large
ovarian cysts. Surg Endosc 2007; 21(1): 8083.
11. Lee LC, Sheu BC, Chou LY, Huang SC, Chang DY, Chang WC. An easy new approach to the
laparoscopic treatment of large adnexal cysts. Minim Invasive Ther Allied Technol. 2011; 20(3):
150-154.
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Coresponden: Asist. Univ. dr. Daniela Trandafir, Clinica de Chirurgie Oral i Maxilo-Facial Iai,
Spitalul Sf. Spiridon, Bulevardul Independenei nr. 1, cod 700111; e-mail:
trandafir.daniela@gmail.com*.
INTRODUCERE
Este binecunoscut interdependena dintre bolile autoimune i bolile
limfoproliferative, fiind sugerate mai multe modele menite s explice rata crescut a
limfoproliferrii n condiiile autoimunitii. Printre bolile autoimune, sindromul
Sjgren prezint cea mai mare inciden a tulburrilor limfoproliferative maligne.
Prezentm un caz clinic de limfom MALT cu localizare parotidian, asociat unui
sindrom Sjgren primar.
PREZENTAREA CAZULUI
Pacienta F.E. n vrst de 64 ani, pensionar, se interneaz n Clinica de
Chirurgie OMF Iai n aprilie 2008, pentru mrirea de volum a ambelor glande parotide
(dar mai important pe partea dreapt) (Fig. 1).
n 2003 a fost diagnosticat cu Parotidit cronic recidivant bilateral
(imaginea sialografic relevnd modificrile specifice ale arborelui salivar parotidian
bilateral, cu aspectul tipic de pom nflorit), iar n 2004 se reinterneaz n clinic
pentru tumefacie parotidian marcat, asimetric; examenul clinic constatnd pe lng
parotidomegalia bilateral i senzaia persistent de uscciune a gurii, apariia unor
acuze n sfera oftalmologic: senzaia de uscciune a ochilor, alternnd cu senzaiile de
arsur i corpi strini intraoculari.
*
received date: 21.04.2011
accepted date: 12.07.2011
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Fig. 3 Aspecte intraoperatorii al tumorii parotidiene drepte (stnga) i aspectul lojei dup
parotidectomie, cu pstrarea nervului facial (dreapta).
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Fig. 6 Teste imunohistochimic CD20 (x10): Fig. 7 Test imunohistochimic citokeratina MNF
pozitiv difuz n tumor; central se gsete un 116: negativ n tumor (fondul), pozitiv n
duct restant cu leziune limfo-epitelial ducte restante cu leziune limfoepitelial
DISCUII
Sindromul Sjgren este o boal inflamatorie cronic lent progresiv care
afecteaz n primul rnd glandele exocrine. Sexul feminin este interesat mai frecvent n
decadele 4 i 5 de via, rata femei/brbai fiind de 9/1. Manifestrile clinice variaz de
la exocrinopatia autoimun la interesrile extraglandulare (sistemice) ale plmnilor,
rinichilor, vaselor sanguine sau muchilor.
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CONCLUZII
Pacienii cu sindroame Sjgren i limfoame MALT salivare prezint de obicei o
evoluie clinic necomplicat. Este important s se identifice aspectele clinice care
predispun la progresia histologic a bolii ct i parametrii care orienteaz ctre
tratamentul eficient care trebuie indicat n cazul transformrii ntr-un limfom de nalt
malignitate.
BIBLIOGRAFIE
1. Manoussakis M, Moutsopoulos H. Sjgrens syndrome: current concepts. Adv Intern Med 2001;
47: 191-217.
2. Mitsias DI, Kapsogeorgou EK, Moutsopoulos HM. Sjgrens syndrome: why autoimmune
epithelitis? Oral Diseases 2006; 72: 523-532.
3. Tzioufas AG, Voulgarelis M. Update on Sjgrens syndrome autoimmune epithelitis: from
classification to increased neoplasias. Best Practice Research Clin Rheumatol 2007; 21(6):
989-1010.
4. Vitali C, Bombardieri S, Jonsson R, et al. Classification criteria for Sjgrenssyndrome: a revised
version of the European criteria proposed by the American-European consensus group. Ann
Rheum Dis 2002; 61(6): 554-558.
5. Mahoney EJ, Speigel JH. Sjgrens disease. Otolaryngol Clin North Am 2003; 36: 733-745.
6. Saint-Marcoux B, De Bandt M. Syndrome de Gougerot-Sjgren: critres de classification,
lymphomes, traitements. Rev Rhumatisme 2007; 74: 737-744.
7. Theander E, Henriksson G, Ljungberg O, Mandl T, Manthorpe R, Jacobsson L. Lymphoma and
other malignancies in primary Sjgrens syndrome: a cohort study on cancer incidence and
lymphoma predictors. Ann Rheum Dis 2006; 65: 796-803.
8. Ioannidis JP, Vassiliou VA, Moutsopoulos HM. Long term risk of mortality and
lymphoproliferative disease and predictive classification of primary Sjgrens syndrome.
Arthritis Rheum 2002; 46: 741-747.
9. Gottenberg JE, Busson M, Cohen Solal J, Lavie F, Abbed K, Kimberly RP, et al. Correlation of
serum B lymphocyte stimulator and beta-2-microglobulin with autoantibody secretion and
systemic involvement in primary Sjgrens syndrome. Ann Rheum Dis 2005; 64: 1050-1055.
10. Pijpe J, van Imhoff GW, Spijkervet FK, Roodenburg JL, Wolbink GJ, Mansour K, et al.
Rituximab treatment in patients with primary Sjgrens syndrome: an open label phase II study.
Arthritis Rheum 2005; 52: 2740-2750.
11. Seror R, Sordet C, Guillevin L, Hachulla E, Masson C, Ittah M, et al. Tolerance and efficacy of
rituximab and changes in serum B cell biomarkers in patients with systemic complications of
primary Sjgrens syndrome. Ann Rheum Dis 2007; 66: 351-357.
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Correspondence to: Dr. Ctlin Mihai Buzdug, Department of Endocrinology, St Spiridon University
Hospital Iasi, Bulevardul Independenei no 1, 700111, Iai, Romania. e-mail: catalinbuz@yahoo.com*.
INTRODUCTION
The Syndrome of Inappropriate Secretion Of Antidiuretic Hormone (SIADH)
was first reported by Schwartz et al. in 1957 [1] and was reviewed by Bartter and
Schwartz in 1967 [2]. They described two patients with lung cancer, who developed
unexplained hyponatremia due to renal sodium loss, and thought that production by the
tumour of an ADH-like substance might be the responsible mechanism.
Criteria for the definition of SIADH secretion are:
1) hyponatremia with a serum sodium lower than 130 mEq/1;
2) plasma osmolality lower than 275 mOsm/kg;
3) urine osmolality higher than the plasma osmolality and above 500 mOsm/kg;
4) absence of clinical evidence of volume depletion;
5) normal renal and adrenal function;
6) normal thyroid function.
The tumour most frequently associated with SIADH is small-cell lung cancer
(SCLC), but the syndrome may also occur in a variety of other carcinomas arising in the
brain, prostate, bladder, pancreas, adrenal cortex, duodenum, head and neck, in
mesothelioma, thymoma or sarcoma, and in Hodgkin's disease [3].
*
received date: 22.03.2011
accepted date: 03.07.2011
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CASE REPORT
A 72 years old male patient, admitted at Clinical of Endocrinology University
Hospital St Spiridon Iasi with marked asthenia and severe osteoarticular pain and 20 kg
weight loss. There was no history of haemoptysis or chest pain. He was a smoker who
consumed one and a half pack per day for more than 20 years.
On examination the following points were noted:
- the skin pale,
- hyperpigmented the swelling of the fourth finger of the left hand.
- respiratory rate 28 per min,
- cyanosis absent,
- accessory muscles of respiration- working.
- AP diameter of thorax increased.
- bilateral hyperresonant note on percussion.
- breath sound - vescicular with prolonged expiration, bilateral rhonchi present,
crepitation present.
The lab exam revealed: haemoglobin - 13 mg %, TLC - 8950/mm3, ESR 87
mm/hr, PPBS - 120mg%, urea 29 mg /dl, creatinine -.0.81 mg/dl. Plasma sodium level
was 125 mEq/L, potassium was 4.52 mEq/L. The thyroid and adrenal function were
normal: ACTH = 34.6 pg/mL (7.9-66.1), cortisol = 210 mg/dL (50-220), TSH =
1.2uUI/mL (0.4-7). The blood glucose level was normal.
The diagnosis of SIADH was confirmed by an elevated urine osmolality (590
mOsm/kg), a decreased serum osmolality (882 mOsm/kg) and high levels of urinary
sodium.
.Hand X ray showed loss of bone mass of the finger fourth, left hand (Fig. 1).
Chest X Ray showed a nodular opacity in the right lower lobe of the lung (Fig 2). He
was transfered to Orthopaedics Clinic to investigate and treat. The finger was
amputated. The histologic exam revealed bone metastasis with starting point from the
lung.
Fig. 1 X Ray of the left Hand - loss of bone Fig. 2 Chest X Ray - nodular opacity in the
mass of the finger fourth right lower lobe of the lung
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DISCUSSION
SIADH is one of the most common causes of hyponatremia in hospitalised
patients. It may occur in a variety of conditions. Also, the occurrence of hyponatremia
due to SIADH at initial diagnosis is a well known paraneoplastic feature of small lung
cancer.
In different studies, there is an occurrence of SIADH in SCLC of about 10%
with a range of 1.3%-69%. On the other hand, SCLC accounts for about 75% of the
malignancies associated with SIADH [3-7].
Bronchogenic carcinoma is the commonest cause of male death from primary
malignant diseases [8]. Clinical manifestations vary from change in character of cough,
haemoptysis, chest pain, breathlessness etc. with or without features of metastasis in
different tissues. Very rarely, lung cancer of small cell type may manifest with only
features of SIADH (Syndrome of inappropriate secretion of ADH) [9].
A broad spectrum of other malignant tumours have also been reported to cause
this syndrome: primary brain tumours, haematological malignancies, intrathoracic non-
pulmonary cancers, non-small-cell lung cancer, skin tumours, gastro-intestinal cancers,
gynaecological cancers, breast cancer, prostate and bladder cancer, head and neck
cancer, sarcomas [7].
Several non-malignant intrathoracic disorders, such as pulmonary infections and
conditions associated with changes in intrathoracic pressure can be accompanied by
SIADH. The hallmarks of SIADH are hyponatremia, low plasma osmolality and a less
than maximally diluted urine in the absence of volume depletion (criteria of Bartter and
Schwartz) [1]. Plasma ADH levels are usually elevated. Renal, adrenal and thyroid
function are normal. The prognosis of SIADH depends on the underlying cause. In
SIADH due to malignancies, the correlation with the prognosis of the disease is not
always clear and the results are controversial [6-10].
CONCLUSIONS
SIADH is the most common cause of hyponatremia in hospitalised cancer
patients. The criteria for diagnosis of SIADH should be used and the correct cause
identified from the numerous possible differential diagnoses. The case report
emphasizes the importance of early recognition of SIADH which may be the only
manifestation in the initial part of lung cancer.
REFFERENCE
1. Schwartz WB, Bennett W, Curelop S, Bartter FC. A syndrome of renal sodium loss and
hyponatremia probably resulting from inappropriate secretion of antidiuretic hormone. Am J
Med 1957; 23: 529-542.
2. Bartter FC, Schwartz WB. The syndrome of inappropriate secretion of antidiuretic hormone. Am
J Med 1967; 42: 790-806.
3. Sorensen JB, Andersen MK, Hansen HH. Syndrome of inappropriate secretion of antidiuretic
hormone (SIADH) in malignant disease. J Intern Med 1995; 238(2): 97-110.
4. Eshuis M, Verschoor AJ, Koster T. A case of sweet taste perception caused by lung cancer-
related hyponatraemia. Ned Tijdschr Geneeskd. 2011; 155(26): A3150.
5. Kobayashi T, Watanabe T, Ashinuma H, Amano H, Kuroda F, Tada Y, Takiguchi Y, Hiroshima
K, Tatsumi K. A case of small-cell lung carcinoma accompanied by the syndrome of
inappropriate secretion of antidiuretic hormone and Lambert-Eaton myasthenic syndrome. Nihon
Kokyuki Gakkai Zasshi. 2011; 49(3): 197-202.
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Coresponden: Fabian Ovidiu, Spitalul Clinic CF Cluj-Napoca, Clinica Chirurgie IV, str. Republicii, nr.
18, cod 400015, e-mail: fabianovidiu@yahoo.com*.
INTRODUCERE
Lezarea nervilor laringei, dei rar, este o complicaie redutabil care poate
surveni n cursul tiroidectomiei. Att nervii laringei inferiori, ct i ramurile externe ale
nervilor laringei superiori pot fi lezate n cursul tiroidectomiei. Lezarea unui nerv
laringeu inferior duce la fixarea corzii vocale corespunztoare n poziie paramedian;
prin micarea corzii vocale peste linia median fonaia este relativ bun; n cursul
deglutiiei exist riscul de aspiraie traheal. Cnd leziunea este bilateral fixarea
ambelor corzi vocale n poziie median duce la obstrucie respiratorie, ceea ce necesit
instituirea traheostomiei. Lezarea ramurii externe a nervului laringeu superior e urmat
de rgueal, scderea amplitudinii vocii i a gamei de frecvene; n majoritatea
cazurilor deficitul nu este semnificativ, dar n cazul persoanelor care folosesc mult
vocea deficitul poate fi grav. Lezarea de aceeai parte a nervului recurent i a nervului
laringeu superior extern duce la fixarea corzii vocale n poziie paramedian; vocea este
rguit. Lezarea bilateral a nervilor laringei (superior extern i inferior) duce la
imobilizarea corzilor vocale n poziie paramedian; respiraia este adecvat, dar fonaia
este compromis.
*
received date: 22.04.2011
accepted date: 10.06.2011
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ELEMENTE DE EMBRIOLOGIE
Dezvoltarea tiroidei ncepe n sptmna a 4-a de via embrionar (aprox. ziua
24) prin apariia unei invaginaii la nivelul limbii la nivelul jonciunii dintre partea oral
i cea faringian a limbii. Acest diverticul descinde anterior de faringe, hiod i laringe
formnd ductul tireoglos. Glanda ajunge n poziia definitiv n sptmna a 7-a, capt
forma caracteristic, iar ductul tireoglos involueaz [1].
O contribuie la dezvoltarea tiroidei are i corpul ultimobranhial, derivat din a 5-
a pung faringian. Acesta conine celule originare din creasta neural care vor deveni
celule parafoliculare (denumite i celule C) secretante de calcitonin. Corpul
ultimobranhial fuzioneaz cu tiroida n cursul sptmnii a 5-a de via intrauterin.
Contribuia corpului ultimobranhial are o importan deosebit n contextul subiectului
nostru deoarece la nivelul fuziunii dintre corpul ultimobranhial i tiroid se formeaz
tuberculul Zuckerkandl (Fig. 1) [2-6].
Dezvoltarea nervilor laringei e n strns legtur cu dezvoltarea arcurilor
faringiene i a arcurilor aortice (Fig. 2). Fiecare arc faringian este inervat de propriul
nerv cranian; pentru arcurile 4 i 6 nervul cranian corespunztor este nervul vag; de
fiecare parte musculatura care se formeaz din arcul 4 e inervat de nervul laringeu
superior, iar cea din arcul 6 de nervul laringeu inferior[4].
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Nervul laringeu inferior se desprinde din vag sub nivelul arcului 6 aortic i are
un traiect orizontal[5]. Arcurile aortice 5 i 6 involueaz i astfel cei 2 nervi laringei
inferiori rmn ancorai de structurile care se dezvolt din cea de-a 4-a pereche de arcuri
aortice (artera subclavie n dreapta i arcul aortic n stnga) [5]. Ca urmare a coborrii
acestor vase n torace cei 2 nervi capt traiectul recurent caracteristic. Acest tipar de
dezvoltare explic raportul constant dintre tuberculul Zuckerkandl (atunci cnd exist)
i nervul laringeu inferior (recurent). O alt consecin a modului de formare a tiroidei
i nervului recurent e faptul c nervul nu trece niciodat prin parenchimul tiroidian.
Rar arcul aortic 4 din dreapta involueaz; artera intersegmentar 7 rmne
ataat la aort i devine poriunea iniial a arterei subclaviculare drepte [7]. Ca urmare
aceast arter pornete din stnga, din arcul aortei i trece napoia esofagului sau ntre
trahee i esofag. Anomalia vascular a fost descris de Bayford (1789) i denumit de
el disfagia lusoria [8]. n aceast situaie nervul laringeu inferior drept nu are traiect
recurent ascendent, ci se desprinde din vag la nivel cervical i are traiect orizontal [5].
A B C
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Cele 3 tipuri Cernea ale ramurii externe ale nervului laringeu superior au fost
gsite n proporii variate n diferite studii, depinznd de tipul studiului i patologia
tiroidian n Tabel 1.
Tabel 1
Proporia celor 3 tipuri Cernea ale nervului laringeu superior extern n diferite studii.
Studiul Tipul 1 Tipul 2a Tipul 2b Tipul NI
Cernea (1992) [11] 68% 11% 14% 7%
Cernea (1995) [11] 23% 15% 54% 8%
Kierner [12] 42% 27% 13% 13% (tipul 4)
Aina [13] 17,3% 56% 26,7% -
Hurtado-Lopez [14] 16,4% 39,7% 38.4% 5,5%
Bellantone [15] 58.6% 19.6% 10.2% 11.6%
Furlan [16] 47% 31% 22% -
Meyer [17] 62.4% 20.6% 15.2% 1.8%
Mishra [18] 28.2% 53.8% 10.2% 7.8%
Pagedar [19] 7.3% 42.7% 48.3% -
Chuang [20] 17.2% 42% 40.8% -
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Dup Furlan frecvena tipurilor cu risc (Cernea 2a i 2b) este mai mare la
subiecii de statur mic: media nlimii pacienilor cu tipul 1 era 1.79 m, pentru tipul
2a 1.72 m, iar pentru tipul 2b 1.70m [16].
O clasificare asemntoare este cea introdus de Kierner, care introduce un al 4-
lea tip (Fig. 5). n tipul 1 nervul ncrucieaz vasele tiroidiene superioare la mai mult de
1 cm de polul superior al lobului tiroidian. n tipul 2 ncruciarea e situat la mai puin
de 1 cm. n tipul 3 nervul ncrucieaz artera napoia polului superior al lobului
tiroidian. Tipurile 2 i 3 corespund de fapt cu tipurile 2a i 2b din clasificarea Cernea. n
tipul 4 nervul trece printre ramurile arterei n imediata vecintate a polului superior al
lobului tiroidian [12].
Fig. 5 Raporturile nervului laringeu superior extern cu polul superior al lobului tiroidian i
pediculul vascular tiroidian superior dup Kierner;
RENLS = ramura extern a nervului laringeu superior, ATS = artera tiroidian superioar, ACC = artera carotida
comun, GT = glanda tiroid.
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Tabel 2
Situaia nervului recurent fa de esofag i trahee dup Ardito
Nervul recurent drept Nervul recurent stng
n anul traheo-esofagian 61.4% 67.3%
Lateral de trahee 37.8% 31%
Antero-lateral de trahee 0.6% 1.6%
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La intrarea n laringe nervul recurent se poate prezenta sub forma unui trunchi
unic sau sub forma a dou sau mai multe ramuri. Numeroase studii chirurgicale i
anatomice au investigat modul de ramificare a nervului recurent (Tabel 3).
Tabel 3
Ramificarea nervului recurent
Autorul Trunchi unic 2 ramuri 3 ramuri 4 ramuri
Weeks[25] 11.8% 82.3% 5.9% -
Steinberg[26] 18% 92% - -
Schweizer[27] 11.9% 52.4% 35.7% -
Hisham[28] 65.8% 33.4% 0.8%
Page[29] 91.9% 19.1%
Ardito[22] 27.6% 72.4%
Beneragama[30] 59.6% 36.2% 4.2% -
Yalin[31] 7.3% 85.4% 7.3% -
Casella[32] 91.5% 17.5% 1% -
Cernea[33] 35.5% 56.9% 7.5% 0.1%
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*
Rustad, 1954, citat de Beneragama[30] i Cassela[32]
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Chiar dac sistemul de gradare propus de Pelizzo este contestat de unii autori
[43], el st la baza celor mai multe studii despre tuberculul Zuckerkandl. Dup cum se
observ n tabelul 4 tuberculul Zuckerkandl a fost gsit ntr-o proporie cuprins ntre 60
i 80% la pacienii supui tiroidectomiei [44] n marea majoritate a studiilor. Yalin
propune termenul de tubercul Zuckerkandl recognoscibil pentru gradele 2 i 3 din
clasificarea Pelizzo [45].
Tabel 4
Gradele tuberculului Zuckerkandl n diferite studii
Autorul Gradul 0 Gradul 1 Gradul 2 Gradul 3
Pelizzo[2] 23% 8.7% 53.8% 14.5%
Hisham[46] 19.8% 25% 55.2%
Gauger[42] 18% 37% 45%
Hisham[28] 24.1% 75.9%
Yalin[47] 11.25% 20% 56.25% 12.5%
Yalin[48] 13.8% 21.2% 52.5% 12.5%
Yun[3] 12.5% 9.5% 41% 37%
Page[49] 93% 7%
*
citat de Gauger[42] i Yun[3]
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Atunci cnd exist tuberculul Zuckerkandl (TZ) indic nervul recurent sau
ramurile acestuia [45], fiind comparat de Pelizzo cu o sgeat intind spre nervul
laringeu inferior [2].
Traiectul nervului recurent este napoia TZ (91.9%) i mai puin frecvent lateral
de acesta (7,7%); foarte rar (0.4%) doar n cazul unui TZ gr.1 nervul poate trece
anterior. Cnd TZ este de gr. 2 i 3 nervul trece aproape ntotdeauna posterior (96.5%,
respectiv 96.4%). Cnd nervul e situat lateral de TZ (7.7%) poate fi situat lipit de vrful
tuberculului (4.9%) sau deprtat de acesta (2.8%) (Fig. 10). Relaia este valabil i cnd
nervul este ramificat; n aceast situaie este posibil ca ramurile s aib o situaie diferit
fa de tubercul (cea anterioar posterior de tubercul, iar cea posterioar lateral de
acesta) [48]. Uneori TZ e situat n imediata vecintate a intrrii nervului sau ramurilor
n laringe [50].
A B C
Foarte rar nervul laringeu inferior poate s nu aib un traiect recurent. Anomalia
se ntlnete cu o frecven de sub 1% aproape exclusiv n dreapta (0,64% n dreapta i
0.04% n stnga dup Henry [51]); apare n urma involuiei celui de-al 4-lea arc aortic
drept; ca urmare nervul laringeu inferior drept nu mai e ancorat de artera subclavie
(care se desprinde din arcul aortic) i n dezvoltare ia un traiect direct, nerecurent; n
stnga se asociaz cu situs inversus [51].
Anomalia are un risc chirurgical ridicat. n seria publicat de Toniato leziunea
nervului laringeu inferior a avut o frecven de 1.8% la pacienii la care traiectul
nervului era recurent i 12.9% la pacienii cu nerv cu traiect nerecurent [52].
n funcie de locul emergenei din nervul vag i de traiectul su se descriu
urmtoarele tipuri de nerv laringeu inferior nerecurent (Fig. 11): tipul 1 emergena
nervului este nalt i traiectul este descendent n vecintatea pediculului tiroidian
superior (risc chirurgical major); tipul 2A - emergena este joas i nervul are un traiect
transversal; tipul 2B emergena este joas, nervul urc alturi de trunchiul sau de
ramurile arterei (traiect ce poate fi confundat cu un traiect recurent obinuit) [52,53].
Avnd n vedere riscul operator ridicat este de dorit ca aceast variant
anatomic s fie cunoscut preoperator. Identificarea preoperatorie a anomaliei
vasculare ar preveni chirurgul asupra existenei unui nerv laringeu inferior nerecurent,
dar recunoaterea preoperatorie e dificil ntruct cele mai multe cazuri sunt
asimptomatice.
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A B C
IMPLICAII CHIRURGICALE
Prevenirea lezrii intraoperatorii a nervilor recureni este unul din obiectivele
eseniale ale tiroidectomiei.
Leziunile nervului laringeu superior extern duce la modificri mai puin
importante ale vocii, uneori insesizabile. De aceea acesta este nervul uitat n cursul
tiroidectomiei. De altfel nu exist date clare cu privire la frecvena lezrii sale n cursul
tiroidectomiei. Totui prevenirea lezrii acestui nerv este important, n particular
pentru persoanele care folosesc intens vocea (cntrei, profesori etc).
Dintre variantele anatomice, tipurile Friedman 1, Cernea 2a-2b i Kierner 3-4 au
riscul cel mai ridicat de lezare operatorie, iar frecvena acestor tipuri nu e mic: 22.5%
(Friedman 1) [9], 11-53% (Cernea 2a) [11-20], 10.2-48.3% (Cernea 2b) [11-20],
respectiv 13% (Kierner 3 i 4) [12].
Pentru prevenirea leziunii acestui nerv exist 2 atitudini: evidenierea nervului
nainte de ligaturarea pediculului tiroidian superior i ligatura ramurilor vasculare pe
capsula tiroidian.
Descoperirea nervului laringeu superior extern nainte de ligatura pediculului
vascular tiroidian superior e susinut n special de autorii care utilizeaz
neuromonitorizarea electric a acestuia n timpul operaiei [10,11,13,14,17-19,55].
Ali autori consider nenecesar descoperirea nervului [15,20,56,57]. Ligatura
pediculului tiroidian superior nu trebuie ns fcut n bloc, ci ramurile vasculare se
ligatureaz individual razant cu capsula tiroidian (Fig. 12) [58].
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Fig. 12 Ligatura ramurilor vasculare din pediculul superior tiroidian dup Sharma.
A B C
Fig. 13 Raporturile nervului laringeu superior extern cu polul superior al lobului tiroidian i vasele
pediculului tiroidian superior dup Delbridge; A spaiul avascular dintre polul superior al lobului
tiroidian i muchiul cricotiroidian; B tipul Cernea 1; C tipul Cernea 2b
Descoperirea nervului laringeu inferior n cursul tiroidectomiei este manevra
esenial pentru reducerea frecvenei leziunilor acestui nerv. Aceast atitudine este
practic unanim acceptat la momentul actual. Paralizia recurentului apare totui chiar i
dac se face identificarea de rutin a nervului (chiar i combinat cu
neuromonitorizarea), dar n cele mai multe cazuri este temporar [59]. Mecanismele
lezrii nervului sunt secionarea, strivirea, pensarea, ligatura, ntinderea sau arsura [59];
ischemia prin edemul tranzitor intraoperator poate explica o parte din paraliziile
tranzitorii postoperatorii [60].
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Cel mai obinuit loc n care se produce lezarea nervului este n aria ligamentului
Berry, n vecintatea punctului de intrare n laringe [22]. Al doilea loc este la nivelul
ncrucirii cu artera tiroidian inferioar i ramurile acesteia; ruperea unei ramuri
arteriale e urmat de hemoragie; aplicarea oarb a unei pense hemostatice sau a
electrocauterului pentru obinerea hemostazei poate duce la pensarea sau arsura
nervului [27,31,40,61].
Pentru descoperirea nervului trebuie s se in seama de raporturile sale cu
tuberculul Zuckerkandl, ligamentul Berry, artera tiroidian inferioar i de faptul c
nervul nu intr niciodat n parenchimul tiroidian.
Exist 3 ci de abord pentru descoperirea nervului recurent [62]. Abordul lateral
este cel mai frecvent utilizat n cursul tiroidectomiei. Are avantajul simplitii i al
faptului c permite pstrarea vascularizaiei paratiroidei superioare. Dup ligatura venei
tiroidiene mijlocii i a pediculului tiroidian superior lobul tiroidian este tracionat
medial. Disecia se face lipit de capsula tiroidian. Tuberculul Zuckerkandl este cel mai
important reper; nervul se afl posterior sau lateral-posterior de tubercul. Nervul poate fi
ns mai apropiat sau mai ndeprtat de tubercul i poate avea diferite nclinaii fat de
axul traheei; unghiul dintre direcia nervului fa de trahee tinde s fie mai deschis la
persoanele cu gtul scurt [24]. n situaia rar n care nervul trece anterior de tubercul
disecia strict n contact cu capsula tiroidian i ligatura numai a elementelor vasculare
care intr n perenchimul tiroidian previne lezarea nervului ca urmare a confundrii cu
un o ramur arterial. posibilitatea ramificrii nervului la acest nivel trebuie avut n
vedere; un nerv subire ar putea s fie de fapt doar ramura posterioar, iar ramura
anterioar s fie lipit de poriunea posterior a lobului tiroidan. Aceast ramur trebuie
cutat prin disecie extracapsular, n contact intim cu glanda. Dup identificare nervul
va fi descoperit spre intrarea n laringe. La nivelul ligamentului Berry nervul poate fi
acoperit de o prelungire a acestuia; disecia n lungul nervului deja descoperit permite
secionarea acestui esut n siguran dup care apare punctul de intrare a nervului n
laringe. Trebuie s se in seama de posibilitatea ramificrii nervului la acest nivel
Abordul inferior este potrivit n cazul reinterveniilor i a guilor voluminoase
fr extensie retrosternal [62]. Nervul e descoperit n esutul areolar de la baza gtului,
departe de cicatricea de la prima intervenie. Nervul e situat n anul traheoesofagian n
stnga i lateral de acesta n dreapta (mai ndeprtat de esofag i trahee). Odat
descoperit nervul va fi eliberat din esutul cicatriceal, disecia avansnd spre intrarea n
laringe. Metoda este mai dificil dect cea prin abord lateral i are un risc mai mare de
devascularizare a glandelor paratiroide [62].
Abordul superior identific nervul la intrarea sa n laringe; e util n guile
voluminoase retrosternale [62]. Dei poziia sa la acest nivel este constant nervul este
dificil de gsit datorit aderenei sale la ligamentul Berry. Fiind vorba de gui
voluminoase poate fi util secionarea muchilor sternotiroidieni; dup ligatura
pediculului superior nervul va putea fi identificat caudal de fibrele constrictorului
inferior, la aproximativ 1 cm de marginea inferioar a cartilajului tiroid. Dup
identificarea nervului la intrarea n laringe disecia se continu caudal pentru a identifica
o eventual a doua ramur nervoas.
Situaia cea mai periculoas este existena unui nerv laringeu inferior cu traiect
nerecurent. Identificarea preoperatorie a anomaliei vasculare care anun aceast
variant anatomic e posibil, dar e cutat numai la cazurile simptomatice (disfagia
lusoria); aceste cazuri sunt ns rare.
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Anatomie i tehnici chirurgicale Jurnalul de Chirurgie, Iai, 2011, Vol. 7, Nr. 3 [ISSN 1584 9341]
CONCLUZIE
Pentru o chirurgie sigur a glandei tiroide chirurgul trebuie s in seama de
reperele anatomice consacrate i de existena variantelor anatomice.
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Tratamentul mortality to critical patient is 30 -70%. Mortality and frequency of NP require specific guidelines.
Antibiotherapy should not be postponed (especially when there are risk factors); appropriate initial
therapy reduces mortality. Empirical therapy recommended is: antipseudomonas cephalosporins /
Coresponden: Conf. Dr. Ioana Grigora, Clinica Anestezie-Terapie Intensiv, Spitalul Universitar Sf. Spiridon
Iai, UMF Gr. T. Popa Iai, str. Independenei nr. 1, 700111.
Conf. Dr. Ioana Grigora
Universitatea de Medicin i Farmacie Gr.T. Popa, Iai
Clinica Anestezie-Terapie Intensiv
Spitalul Universitar Sf. Spiridon Iai
A patient-
patient-based antibiotic management
PN in TI programme: the Tarragona strategy
Patients with VAP
Nosocomial Pneumonia in the Intensive Care Unit: Controversies and Dilemmas Strategy summary:
Ravindra M. Mehta, MD
Hit hard and fast
fast with a high dose of broad-
broad-spectrum
Ravindra M. Mehta: Journal of Intensive Care Medicine, Vol. 18, No. 4, 175-188 (2003) antibiotic
diagnostic Get to the point
point: take pharmacodynamics into account
VAP/ alte afeciuni infecioase ? Focus, focus, focus
focus: tailor or stop therapy according to
colonizare / infecie ? microbiological results
Listen to your hospital
hospital: tailor antibiotic policy regularly
tratament
Look at your patient
patient: administer antibiotics according
early-onset / late-onset ?
to comorbidities, intubation period and previous
monoterapie / combinaii de antibiotice ? antibiotic exposure
durata antibioterapiei ?
Sandiumenge et al. Intensive Care Med 2003;29:876
2003;29:876883
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Prognostic n func
funcie de momentul debutului
Prezen
Prezena factorilor de risc pentru GMR Debut Precoce + ATB sau spitalizare
(ultimele 90 de zile)
=
Risc crescut de infectie cu GMR
=
!!! Management similar PN cu debut tardiv !!!
+
Terapie antibiotic n 90 zile precedente spectru bacteriologic adecvat
Spitalizare curent > 5 zile +
Rezistena local crescut la antibiotice doz util
Prezena factorilor de risc pentru HCAP +
Spitalizare > 2 zile n 3 luni precedente penetrabilitate la locul infeciei
-lactaminele
Dializa cronic (>30 zile) - concentraie pulmonar = <50% concentraia seric
Internri prelungite n centrele de asisten Linezolid, fluoroquinolone
- concentraia pulmonar = concentraia seric
Patologie / terapie imunosupresiv
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dg. de VAP
60
20
20
15 17
40
10 12
20
5
0 0
30 12 23 34 45 56 69 912 12
0 30 1224 24
2436 >36
30
30 1h Time of first dose of antibiotics after durat VM durata ederii ATI
the onset of shock (hours) 14
Epidemiologia HAP/VAP
20
18 18 18
18 17
16
Evidene clinice n PN
14
Pneumonia (%)
12
12 11
8 7 7
6 5 5
4 4 4 4
4
0
S aureus P aeruginosa Enterobacter spp Klebsiella Candida Escherichia coli Haemophilus
pneumoniae albicans influenzae
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Frecven
Frecven
a rezisten
rezistenei
germenilor gram pozitivi n Europa
Country MRSA MR-
MR-CoNSa VR E. faecalis VR E. faecium
France 31.5 71 0 0
Germany 17.2 67.4 0 19.7
Greece 36.6 83.3 0 16.7
Ireland 54.7 66.7 0 71.4
Israel 46 80 0 40
Italy 38.3 82.4 1.6 19.4
Poland 27.2 81.3 0 4.3
Spain 25.3 61.9 0 14.3
Sweden 2.1 54.8 0 0
Switzerland 15.7 65.6 0 0
Turkey 30.9 74.4 0 8.6
United Kingdom 42.5 53.3 17.9 66.7
Overall 29.1 71.5 0.9 17.9
60 Plasm
20
Concentration (mg/L)
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(mg/L)
90 6
5
80 4
3
70
2
1
60 Linezolid Vancomycin 0
0 2 4 6 8 10 12 14 16 18 20 22 24
50
4 9 14 19 24 29 Timpul dup administrarea dozei (ore)
Time After Diagnosis (days)
Adapted from Kollef MH, et al. Intensive Care Med. 2004;30:388-94. Norrby R. Exp Opin Pharmacother. 2001;2:298.
Adapted from Wunderink R, et al. Chest. 2003;124:1789-97.
De-
De-escalation in clinical practice Concluzii
Changes in antibiotic therapy based on microbiological results
121 episodes
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cu lancea-i lovit la old, unde muchiul omului e mai vnjos i-i despic
vinele; umru-i taie i i curm puternicul su bra care-i cade rou de snge
pe cmp; cu un pietroi foarte greu, Diomede l lovete pe Eneas n partea de
unde coapsa se mbuc n old, de aceea i noad se cheam; i-o scrijeli cu
pietroiul muchiat, viteazul cade n genunchi i n pmnt i sprijin mna
vnjoas (descrierea i sugereaz lui A. Castiglioni fractura de col femural);
ntreag e spintecat vna ce se-nir de-a lungul n spate i ajunge la ceaf.
Cum i-o reteaz, pe spate deodat prin colb se rstoarn; cu o sabie mare e
tiat, de la grumaz i pn la spate de-a lungul, tot umru-i se rupse.
n ceea ce privete tratamentul acordat rniilor, vechii greci recurgeau la
procedee simple, empirice, dar raionale. Pe cmpul de lupt se recurgea la extragerea
sau retezarea vrfurilor de sgei sau lance, precum i la oprirea hemoragiei prin bandaj.
n tabr, la corturi, plgile erau splate cu ap fiart sau vin vechi, asigurndu-se i o
imobilizare improvizat. Local erau aplicate pulberi, balsamuri de plante, iar pentru
alinarea durerilor se recurgea la leacuri uoare. Pentru a opri hemoragia era folosit
un praf de roc calcaroas, dar i balsamuri de plante. Pentru a grbi cicatrizarea se
folosea lapte sau miere.
Se pare c pe atunci, medicii militari erau n stare s trateze cel mai bine plgile
prin sgeat; erau n dificultate n plgile prin suli sau pratie i neputicioi n cele
prin spad sau n orice plag profund penetrant.
n epopeea lui Homer, Podalir i Mahaon apar ca cei doi mari istei ai otirii
vraci. n special Mahaon, fiul vraciului cel mai destoinic al oastei Asklepiu apare
cel mai des citat.
Cnd nsui Mahaon e rnit de Paris la umr de o sgeat ntreit vrfuit i
cnd preatremurnfocaii Ahei s nu cad Mahaon, Nestor este ndemnat de
Idomeneu s-l ia n carul su cci:
Face ct oameni mai muli un om care vindec oamenii.
Taie din rane sgei i cu leacuri alin durerea
Mahaon rsadul vraciului fr seamn Asclepiu i al oastei frunta este
dus n fug la corturi, unde: Scurgerea de snge i-a fost splat cu ap ncropit n
cldare pe foc i-i s-a vindecat.
El se bucur de ncrederea lui Agamemnon, iar cnd cnd fratele su, Menelau, e
rnit i sngele su se scurge pn la glezne, vindectorul va ngriji de a ta rana i
pune leacuri ce alin cele mai crunte dureri, apeleaz la Mritul Mahaon,
Asklepianul chemat dintre cetele lui tari i cu pavezi n spate i d asisten:
Din cheutoarea curelei Mahaon i smulse sgeata,
Rupse ascuitele-i cngi cnd o scoase cu mna din ran
i desfcu sbierul mpiestrit i apoi de sub dnsul
Brul i platoa cea furit de meteri fauri.
Locul apoi nimerind, pe unde sgeata-l brodise,
Sngele i-a stors i i-a pus cu pricepere leacuri uoare
Date pe vremuri printelui su de prietenui Hiron
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Mahaon a mai tratat rana infectat de la picior a lui Filoctetes care n drum spre
Troia a fost mucat de un arpe n insula Tenedos; rana i s-a infectat rspndind un
miros ngrozitor (gangren?), nct corbierii au trebuit s-l prseasc. Adus la Troia
dup 9 ani, rana i-a vindecat-o Mahaon.
Dar n afar de Mahaon i ali lupttori puteau s trateze rni.
Patrocle nvat de Ahile tie s-l trateze pe Evripil rsadul lui Zeus cnd
acesta sgetat la coaps se tra ovind, sngele-i negru uruind din amarnica-i
ran; dup ce l culc Patrocle sgeata i-o taie din coaps cu un cuit, apoi sngele-l
spal cu ap ncropit, freac deasupra cu minile o rdcin amar mulcumitoare, ce
curma-a rnitului crud durere, sngele-i face s stee i coaj s prind pe ran.
Agenor improvizeaz un tratament de urgen cnd lancea lui Menelau s-a nfipt
n mna lui Henelos: Din rana-i o trage pe loc; mna pe urm i-o leag cu lna cea
toars de oaie, smuls din pratia celui care mna carul de lupt.
Diomede rnit de sgeata lui Paris i smulge singur sgeata sub protecia
scutului lui Ulise.
Ahile trateaz rana produs de el regelui Misiei. Ahile l trateaz pe Patrocle, iar
cnd nsui Ahile e rnit de moarte, i smulge singur sgeata din ran.
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n perioada 10-11 iunie 2011 a avut loc, n oraul de pe Bega, Timioara, primul
congres naional al Societii Romne de Coloproctologie (SRCP). Tnra societate,
nfiinat n 2010, a reuit s reuneasc chirurgi i gastroenterologi, ali specialiti din
grupul de profesioniti ai echipei multidisciplinare care rezolv aceast patologie
frecvent.
Vineri 10 iunie a avut loc un curs pre-congres n limba englez, EFISDS, condus
de Jan Jenkins, din Londra i Sorin Barbu de la Cluj, axat pe complicaiile chirurgiei
colo-rectale.
Congresul s-a deschis n prezena prof. Lazr Fulger, preedinte fondator al
SRCP, prof. V. Srbu, preedintele Societii Romne de Chirurgie, la care SRCP este
afiliat, conf. Dr. A. Goldi, preedintele ales SRCP.
Participarea internaional aleas a crescut nivelul tiinific al manifestrii prin
conferinele cu informaii de ultim or i comentariile fructuoase care le-au urmat.
Prima sesiune a abordat patologia benign
colo-rectal. Au fost prezentate lucrri privind
rolul capsulei n diagnosticul bolilor inflamatorii
intestinale IBD (Anca Trifan), tratamentul IBD
(A. Tanu), patologia hemoroidal (Cristina
Cijevschi, G. Mitulescu, V. Radu, R. Mehic),
insistndu-se asupra metodelor terapeutice
moderne ale acestei boli (procedeul LONGO,
dezarterializarea transanal hemoroidal THD,
radiochirurgia), care s-au dezvoltat i la noi n
ambulatoarele private.
Au mai fost dezbtute aspectele chirurgicale ale fistulelor perianale (B.V.
Marian) i a fistulei plug (M. Beuran).
Urmtoarea sesiune n limba romn a fost dedicat cancerului rectal. S-au
prezentat lucrri deosebite care au suscitat numeroase discuii: Tratamentul multimodal
al cancerului de rect avansat P. Piso (Regensburg), Tratamentul endoscopic al
tumorilor rectale (M. Tanu), Rezecia laparoscopic a cancerului de colon stng (F.
Lazr), Chirurgia robotic vs chirurgia laparoscopic n cancerul rectal (V.
Tomulescu), Chirurgia cancerului rectal local avansat (G. Mitulescu), anastomozele
mecanice n neoplasmul colorectal (M. Beuran), Operaia Hartmann cu excizie total
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E. Trcoveanu
490