Journal of Surgery

Hernia repair is the most common surgical procedure worldwide. The mesh repair is the gold standard technique for groin hernia in adults; anatomic, non-mesh repair is still indicated in contaminated wounds. The recommended techniques by the actual guidelines are: Lichtenstein and Shouldice technique for open access and TAPP (TransAbdominal PrePeritoneal) and TEP (Total ExtraPeritoneal) hernia repair for endoscopic repair. We present herein several aspects of TAPP hernia repair with highlighting its advantages. The present paper is a brief argument to do TAPP routinely in benefice of patients, residents and surgeons.

Colorectal cancer (CRC) is currently considered the third most common neoplasm in the world according to the World Cancer Research Fund International with 1.4 million cases diagnosed in 2012, and the second malignity as cause of death. Approximately 1/5 of patients present directly with metastatic disease (mCRC), and 30 to 50% develop metastasis after surgical treatment for initially localized disease. The aims of the current study are to review the diagnostic particularities, treatment options and clinical evolution of mCRC. Metastatic process in CRC is long and complex, involving several mechanisms, molecular pathways and cellular types. Advances in medical imaging now allow an early and accurate diagnosis of metastatic lesions no matter their location. The progress of fundamental research in CRC led to understanding the molecular basis of the metastatic process that was further translated into novel chemotherapic and biological agents, thus increasing overall survival and and progression-free survival rates. Resection of liver, lung and brain metastases is crucial for survival when achievable and is more effective when completed by an oncological treatment and rigorous follow-up. All patients with mCRC should be discussed by a multidisciplinary team (surgeon, oncologist, radiologist, and gastroenterologist) in order to identify the most appropriate therapeutic management.

Intravenous (IV) acetaminophen has become an accepted component of a multimodal analgesic strategy in perioperative patients. It is currently a branded drug (Ofirmev®) in the United States. The purchase price of the drug is greater than oral and rectal acetaminophen, intravenous ketorolac, and parenteral opioids. As a result, a large number of medication utilization evaluations (MUEs) have been conducted to evaluate the appropriateness of IV acetaminophen use. Many of these MUEs have failed to demonstrate the expected benefits observed with the use of IV acetaminophen in randomized, controlled trials. This review summarizes the major methodological flaws seen in many of these MUEs. The most common flaws of the available MUEs were inclusion of inadequate numbers of patients, failure to adequately define the timing and duration of IV acetaminophen use, and failure to adequately match characteristics of patients receiving IV acetaminophen with control patients. An appropriately designed MUE for IV acetaminophen should take into consideration the identified methodological flaws described in this review. A template for a comprehensive MUE of IV acetaminophen is provided in the review. This template can be modified to meet institution specific criteria applied to the use of IV acetaminophen.

A best evidence topic was arranged according to the previously accepted structured protocol. The question addressed here was if flap construction after excision of pilonidal sinus tracks showed difference in functional outcome compared to simple closure. A total of 118 papers were found using the reported search, six represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group, study type, outcomes and key results of these papers are tabulated. Of these six studies, one was one was systematic review of prospective randomized controlled trials and the other five were prospective randomized controlled studies. Four studies showed that flap construction was not superior to simple primary closure techniques in terms of outcome and patient satisfaction. The other two reported that excision and flap construction was better than excision and primary repair in treatment of pilonidal disease.

The use of dental implants for the rehabilitation of missing teeth has broadened the treatment options for patients and clinicians equally. As a result of advances in research in implant design, materials and techniques the use of dental implants has increased dramatically in the past two decades and is expected to expand further in the future. However the clinical complexity of the patient who present with limited bone volume often requires additional biomaterials and surgical procedures to ensure successful implant treatment. This review outlines the various biomaterials used in augmenting bone deficiencies encountered and the different surgical techniques that are used in order to achieve a predictable long term success of dental implants.

Background: Various biopsy types are used to diagnose melanoma, after which wide local excision (WLE) is the gold standard for treatment. Depending on the final pathology report, further re-excision may be necessary despite an initial, presumably adequate, WLE. In this study, we analyzed the impact of initial biopsy type (shave, punch, or excision) on the management of melanoma.

Methods: A retrospective chart review of 243 patients with clinically node-negative melanoma was completed. Evaluated variables included the initial biopsy type, initial and final peripheral and deep margin status, further reexcision rates, tumor site, and clinician specialty performing the biopsy. Univariate and multivariate analyses tests were performed using SPSS software.

Results: 29.5% of specimens with both positive peripheral and deep margins underwent further excisions. Overall, 14.6% of cases had re-excision regardless of initial biopsy type after initial WLE. There was higher rate of re-excision with an initial excision biopsy (28.6%) than with initial punch (13.3%) or shave biopsies (11.2%) Dermatologists, Surgeons, and Primary Care Physicians performed 13%, 34%, and 32% of the excision biopsies respectively. Neither the anatomic location of the tumor nor the survival rates were significantly correlated to the biopsy type, margin status, or re-excision rates.

Conclusion: Both shave and punch biopsies showed high rates of residual tumor in either peripheral or deep margins but this does not translate into a higher re-excision rate. Although the biopsy type is important, the clinical specialty performing the biopsy could be influential. Surprisingly, there was a higher positive peripheral margin than deep margin with shave biopsy.

Background: Colorectal cancer is a major public health problem worldwide. Tumor volume associated with the number of positive lymph nodes may be a new predictor of 5-year survival in colon cancer.

Material and Methods: We conducted a retrospective study of a prospective database that included all patients diagnosed with colon cancer (CC) between May 2012 and September 2013 in the Surgical Oncology Clinic of the Iasi Regional Cancer Institute. The patients underwent surgical resection and two tumor sizes were recorded. Tumor characteristics and their potential role in tumor aggressiveness were analyzed.

Results: The study group included 138 patients, of which 38 (27.54%) with metastases and 100 (72.46%) without metastases. Maximum tumor diameter showed significant differences depending on the degree of differentiation and histological type, and was significantly correlated with the total number of evaluated and positive lymph nodes (p=0.009 and p=0.00, respectively). Tumor volume was influenced by male gender (p=0.0404), tumor stage (p=0.0192), and type of tumor invasion (p=0.0159) in 23.02 % of cases (p=0.02809). Maximum tumor diameter and tumor volume had poor discriminatory power in predicting survival.

Conclusions: A statistically significant association was found between the metastatic group and advanced disease stages. Maximum tumor diameter and tumor volume could not predict overall survival of patients.

Background and Aim: In metastatic colorectal cancer, in the last 10 years, hepatic arterial infusion (HAI) was proposed as an alternative using various chemotherapy agents. The insertion of a port-a-cath in the hepatic artery is needed and there are various methods to do that, from classical to interventional approach.

Patients and Methods: Patients were selected with metastatic colorectal cancer with inoperable liver metastasis only and were treated with oxaliplatin HAI, combined with systemic intravenously chemotherapy. The port-a-cath insertion was done using the classical approach in the same surgical time with the subclavicular vein port insertion.

Results: Thirty-two patients were treated. During our experience we did not encounter intra-operative complications. Among the immediate post-operative complications mainly consisted of metabolic complications (6.2%) and infection was the most common late complication (9.4%). In one case we removed the port-a-cath, thus the patient was not able to continue the treatment.

Conclusion: When talking about the safety of the procedure, we didn’t find it to be more at risk for the patients compared to the literature. Even though the antibiotic prophylaxis is done regularly, the risk of infection remains, especially as a late complication.

Background: Mesenteric cysts, and particularly lymphangiomas, occur very rarely in adult patients. Due to this low incidence and their non-specific symptomatology, they often present a difficulty in diagnosis.

Case report: We present the case of a patient aged 58 years admitted to the Surgical Clinic 1, Târgu MureÈ? Emergency County Hospital accusing diffuse abdominal pain and tenderness in the epigastrium. Abdominal ultrasound revealed a fluid cystic tumor, multi-septated, located in the root of the mesentery and the abdominal computer tomography confirmed this diagnosis. Surgery consisted of total cystectomy without compromising the intestinal segment and sparing the vascular structures in its vicinity. Cyst dimensions were approximately 70x50x30 mm and contained lymphatic fluid. The histopathological report confirmed a mesenteric cystic lymphangioma. The postoperative evolution was uneventful, with quick recovery and no postoperative complications.

Conclusions: The diagnosis of mesenteric cyst should be included in the differential diagnosis of intra-abdominal tumors in patients with nonspecific symptoms. Once this diagnosis is established histological differentiation between lymphangiomas and simple lymphatic cyst is essential. The total excision minimizes the recurrence rate, and their early removal can prevent complications caused by the compression and invasion of neighboring organs.

Neuroendocrine tumors (NET) represent approximately 20% of all primary neoplasms of the lung. Histologic confirmation is important for treatment and prognosis determination. NET are classified according to four subtypes in the lung: typical carcinoid tumor (TC), atypical carcinoid tumor (AC), small cell carcinoma (SCC), and large cell neuroendocrine carcinoma (LCNEC). TC is low-grade, AC is intermediate-grade, and SCC and LCNEC are high-grade malignancies.

Case report: A 57 years old woman, affected by a cervical anterior tumor and a proliferative tissue below the glottis was referred to our Endocrinology Department from ENT service for a second opinion. An ultrasound scan of the neck showed a polynodular goiter with bilaterally lymph nodes enlargement with suspicious malignancy characters. She had undergone surgery for the cervical anterior mass and for the laryngeal biopsy. Histopathological examination results were consistent with a SCC; neoplastic cells showed immunoreactivity to synaptophysin, neuron specific enolase and chromogranin. The serum levels of serotonin, cromogranin A, calcitonin, carcinoembryonic antigen, ACTH, PTH, TSH, FT4 were normal. Fine needle aspiration biopsy of her left thyroid lobe nodule was performed and the cytopathological exam was compatible with a neuroendocrine tumor metastasis. Thoracic and abdominal computed tomography was normal at that moment. Chest CT revealed the primary pulmonary tumor at 6 months after presentation. The therapeutic option for advanced or metastatic NETs is mainly palliation of symptoms; options need to be individualized and, therefore, rely on the knowledge of multidisciplinary teams.

Spontaneous osteonecrosis of the knee presents with acute onset of severe pain in elderly patients, usually females, without a history of trauma. Originally described as idiopathic osteonecrosis, the exact etiology is still debated. Evidence suggests that an acute fracture occurs as a result of chronic stress or minor trauma to a weakened subchondral bone plate. We report one case of spontaneous osteonecrosis of medial femoral condyle in a 71-year-old female with no evidence of trauma involving a 4 cm weight bearing surface. According to Koshino this case can be classified as stage II. Various types of treatment have been reported, including conservative treatment with physical exercise and nonsteroidal anti-inflammatory drugs, arthroscopy alone, arthroscopy and drilling, valgus high tibial osteotomy, and total knee arthroplasty. Total knee arthroplasty was considered the appropriate management strategy in this case.

Portal cavernoma (network of collateral vessels around the portal vein) is found in one-third of patients with thrombotic portal vein. Management of Cholecystitis in such a patient is problematic. Laparoscopic cholecystectomy is usually contraindicated due to risk of haemorrhage.

A 32 year old female presented with symptomatic calculous cholecystitis and portal cavernoma without portal hypertension. Liver functions were normal (non-cirrhotic, no jaundice). Conservative treatment failed. Imaging assessment was by Ultrasound Doppler, followed by CT and MRCP, MRI and MRA.

We performed laparoscopic cholecystectomy was successfully performed. Operative time 210 minutes, blood loss 50 ml. Extreme caution and painstakingly meticulous dissection around the cavernoma was the key to success. Although open cholecystectomy may assume to be safer in such patients; enhanced magnified vision, access and maneuverability made laparoscopy a preferred option. Standby laparoscopic and open vascular instruments facility is essential.

Liver procurement is a race against time, which is mainly focused on obtaining a good quality of liver grafts with an ischemia time as short as possible. The actual procurement time definitely influence cold ischemia time, a reduction of it leading to shorter graft cold ischemia time.

Methods: We examined the use of tire-ups in the liver procurement, in terms of improving the procurement time (calculated as the time between incision and the time of starting infusing portal vein and aorta with cold preservation solutions).

Results: We enrolled in our study two groups of 30 donors each. In the first group we included patients on which we did not use the tire-ups, and in the second patients on which the tire-ups were used for dissection and rapid clamping of the infrarenal aorta and the portal vein. Procurement time in group 1 averaged 121.6 minutes (+/- 20.2 minutes) and in the second batch averaged 88 minutes (+/- 16.2 minutes), with statistical significance (p<0.05). We observe a reduction of about 30 minutes between batches, reduction which was possible using tire-ups in rapid dissection and clamping of the portal vein and aorta.

Conclusions: The use of tire-ups are a simple, cheap and feasible to shorten operative time in liver procurement. It can be successfully applied to all donors shortening the actual time of sampling, with direct consequences to cold ischemia time.

To support through personal experience the use on a large scale of the modern techniques of correction of the pelvic floor disorders by using polypropylene prosthetic devices. Objectives: To specify the technical details regarding the correct placement of prostheses in feminine genital prolapse. Show the personal casuistry in order to highlight the indications techniques and results of these types of surgeries. Plead for expending the modern techniques in pelvic-perineal floor dysfunctions. Material and Methods: The study was performed between July 2007 and July 2013, in the second surgical Clinic St.Spiridon Hospital Iasi, on 138 cases with different pelvic floor dysfunctions. Different procedures were practiced, isolated or associated, on the patients in the lot, depending on symptoms, the prolapse type and degree, age, local anatomical situation and the existence or absence of sexual life. Thus they were performed: strip urethrocystopexy or “hammock” device, with four arms transobturator - 68 cases; The sacrosciatic posterior colposuspension or the anal levator floor restoration–29 cases; abdominal colpopexy in 41 cases, 18 of which with hysterectomy or resection of residual cervix. In 5 cases a polypropylene mesh implant has been associated with this procedure at anal levator level; and in 11 cases the doctors used a suburethral transobturator vaginal strip for stress urinary incontinence (SUI). The abdominal approach allows the correct path of skeletonization of the internal genitalia and also of the vagina which is turned inside-out like a glove finger, avoiding damage on the ureters and bladder. The vaginal vault is secured to the promontory with a polypropylene device and it ensures the results maintain in time. Results: The treatment of the different pelvic-perineal floor disorders that are associated or not with stress urinary incontinence has benefited lately from new indications and techniques by using different prosthetic devices made of polypropylene, which are especially conceived and placed through minimally invasive procedures. Generally, all the cases had an immediate simple postoperatory evolution with only two haematomas that required surgical evacuation and 3 cases of vaginal mucosa necrosis, one of them requiring the removal of the device implanted. The anatomical and functional results were good. Conclusions: The use of strips, nets and polypropylene devices in correcting different pelvic floor disorders, shows certain advantages, as it is relatively easy tom implement, the hospitalization period is shortened and there are very good results that pass the test of time.