Journal of Surgery

In the last years there was an increased interest towards the pancreatic cancer, especially considering its growing incidence (rapidly becoming the fifth cause of death by cancer in the developed countries), lack of any sustainable markers and/or risk factors and the chilling fact that almost 95% of the patients with this disorder are presenting to the hospital in the advanced and unresectable stages. Even more, although known and developed for almost 70 years, the surgical approach for the pancreatic cancer is a subject of debate because its efficacy and postoperative biological changes. It is known that the most common surgery in chronic pancreatitis and pancreatic cancer is represented by the Whipple pancreatico duodenectomy. Still, after an extended resection and reconstruction of the upper gastrointestinal tract, it seems that the digestive physiology can be disrupted. In this way, in the present mini-review we will describe some postoperative gastrointestinal biological and physiological changes after Whipple procedure, by mainly focusing on the gastrointestinal motility, bone demineralization, dumping and re-resection, as well as on the affected pancreatic function, postoperative weight loss and remnant pancreatic fibrosis and how the management of this related pathological aspects can be applied in these cases.

Objective: To investigate the feasibility. Safety and economical aspects of fast-track surgery (FTS) in patients with biliary intestinal anastomosis application security, effectiveness and its advantages.

Methods: 31 patients were randomly divided into FTS group (n=16) and the control group (n=15). Control group using conventional perioperative treatment, guided by the idea of FTS group use the FTS perioperative measures, analysis and comparison of postoperative day 1 bad psychological emotions, exhaust and defecation time, postoperative hospitalization days and the hospitalization expenses and so on. Postoperative complications and adverse reactions in the groups.

Results: Compared with the photographic, FTS group exhaust and defecation time in advance, and shorten hospitalization time, hospitalization expenses reduced (P<0.05), complications and adverse reaction is similar between the two groups has no statistical significance (P>0.05).

Conclusion: Fast- track surgery in patients with biliary intestinal anastomosis, with a safe, effective, economic and other characteristic, can accelerate the rehabilitation of patients.

Introduction: Ultrasound (US) and Fine-needle aspiration (FNA) are the main methods used for investigating thyroid nodules, with questionable predictive values in multinodular goiter (MNG) compared to solitary thyroid nodule (STN).

Objective: To detect the independent predictors of malignancy in patients with solitary and multiple nodules. Patients and Methods: Medical records of patients who were admitted for thyroidectomy at Alexandria Main University Hospital and Medical Research Institute Hospital between January 2014 and January 2016 were reviewed. Demographic and clinical data, US reports, FNA reports (Bethesda “B” system), and final histopathological results were recorded and analyzed. Patients with hyper- or hypo-thyroidism, previous history of thyroid cancer or those with incomplete data were excluded.

Results: Collectively, 20% (111/554) of the study population proved to have malignancyon final histopathology, 19.3% (82/422) with MNG and 22% (29/132) with a STN. Combining gender and age showed that significantly more male patients with MNG under the age of 45 years had thyroid cancer (X2=11.75, p=0.003).Statistically significant US features in the MNG Group included micro-calcifications, solid composition, echogenicity, incomplete halo, ill-defined margins, and suspicious cervical lymph nodes (LNs). In STN, significant US features included complex composition of nodules, peri-nodular vascularity, and also suspicious cervical LNs. The FNA results of BII-V reports showed that 16.9% (69/408) and 17.6% (22/125) of patients with MNG and STN, respectively, had false negative results. The risk of malignancy showed a significant rise from BIV to BVI lesions in both Groups. Multivariate analysis revealed that, in MNG, the highest malignancy predictor was micro calcification, followed by FNA (BVI) and then suspicious cervical LNs. In STN, the features that retained significance in multivariate analysis were suspicious LNs& BVI-FNA.

Conclusion: Based on the data presented, it may be concluded that the independent predictors of malignancy were US findings of micro-calcification in patients with MNG, suspicious cervical LNs and Bethesda VI on FNA in patients with both MNG and STN.

Background: Malnutrition is a common feature in gastric cancer patients and it is directly correlated with tumour stage. The goal of our study was the assessment of nutritional status in a large series of gastric cancer patients.

Methods: We performed a retrospective study which included all the patients newly diagnosed with gastric cancer which were submitted in our unit in a 2 year period. We performed a comparative analysis between the patient in which radical resection was performed and the patient in which a palliative procedure was made.

Results: There were 136 gastric cancer patients; radical resections were performed in 81 patients (34 total gastrectomies and 47 subtotal gastrectomies). Palliative procedures included 17 gastroenterostomy, 13 feeding jejunostomy and 25 exploratory laparoscopies. Patients in which radical resection was performed presented higher Karnofsky (P=0.006) and Charlson (P=0.007) indexes, higher BMI (P=0.017), higher albumin (P=0.001), lymphocytes (P=0.03) and Onodera index (P=0.0032).

Conclusion: An accurate clinical and biological nutritional assessment of newly diagnosed gastric cancer patients could identify the subgroup of patients with more advanced or metastatic lesions in which a thorough stadialisation should be performed.

Introduction: Successful endovascular aortic aneurysm repair (EVAR) aims to prevent catastrophic rupture, however despite technical excellence at index operation, long term follow up remainsm and atory. This is due to the fact that delayed aortic rupture may occur in certain patients after EVAR. We present a technically challenging case which illustrates this concern.

Case report: An 82 year old man underwent successful EVAR using a redesigned, clinical trial graft (Medtronic, Minneapolis, MN), five years prior to presentation. He was lost to follow after the initial procedure. At presentation to us, he demonstrated a 13.5cm, ruptured infrarenal aortic aneurysm due to proximal aortic neck enlargement and endograft slippage. Emergency repair included a proximal supra-renal endograft extension (Endologix, Irvine, CA), femoralfemoral bypass (PTFE), and open abdomen with negative-pressure therapy (Abthera, KCI, San Antonio, TX) He survived and was discharged with close follow-up. He re-presented six months later with flank pain and a WBC 22,000. A CT Scan was concerning for a new contained aortic rupture (16cm) and a recurrent proximal endograft slip.

High clinical suspicion resulted in a return to operating room for axillary to femoralfemoral artery bypass (PTFE), followed by explantation of the endograft system, aortic sac resection, and omental flap coverage. Operative cultures yielded Staphylococcus epidermis. He survived again and was discharged on a plan for long term antibiotics on postoperative day 10.

Conclusion: Long term follow up after EVAR may help to identify patients at high risk for endo-graft failures. Aortic neck enlargement leading to rupture may result from primary aneurysm growth, however infection can be an important cause. Time honored open aortic surgical techniques remain an important tool for every vascular surgeon.

Neoplasms of the appendix are rare, accounting for less than 0.5% of all gastrointestinal malignancies and found incidentally in approximately 1% of appendectomy specimen. Carcinoids are the most common appendicular tumors, accounting for approximately 66%, with cystadenocarcinoma accounting for 20% and adenocarcinoma accounting for 10%. Appendiceal adenocarcinomas fall into one of three separate histologic types. The most common mucinous type produces abundant mucin, the less common intestinal or colonic type closely mimics adenocarcinomas found in the colon, and the least common, signet ring cell adenocarcinoma, is quite virulent and associated with a poor prognosis. Adenocarcinoma of appendix is most frequently perforating tumour of gastrointestinal tract due to anatomical peculiarity of appendix which has an extremely thin subserosal and peritoneal coat and the thinnest muscle layer of the whole gastrointestinal tract. In addition to the risk of perforation, mucinous adenocarcinoma of appendix have peculiar tendency for fistula formation. Many of unusual presentations reported for primary appendicular carcinoma are the results of fistula formation into the adjacent viscera such as the urinary bladder, bowel or vagina as well as extraperitoneally into retroperitoneal tissues or directly to the skin surface.

Objective: Sinus mucoceles are true cysts that develop secondary to obstruction of sinus ostea and can be associated with significant morbidity.

Study Design: We present a case of obstructive-type sinus mucocele of the maxillary sinus, including clinical, radiographic, histologic findings, as well as treatment.

Results: An 18 year old female presented for evaluation and management of maxillary sinus swelling. A diagnosis of sinus mucocele was rendered after clinical, radiographic, surgical and histopathologic examinations. Recurrence developed within four months of the initial surgical intervention.

Conclusions: Sinus mucoceles may be associated with significant morbidity and are currently managed most often by endoscopic nasal surgery.

Additive Manufacturing (AM) technology is an engineering technology which has a wide scope in medical field. Of various medical fields, craniofacial and maxillofacial surgery adapted this technology and is making use of it to overcome the shortcomings of traditional procedures. Medical application of AM or Rapid prototyping was started two decades ago and is expanding its frontiers with the advancement in technology and technical expertise by the medical professionals. AM technology is widely being used in maxillofacial surgery for hassle free planning, patient education and execution of the surgical procedure and for precision using medical models. The Current case is of pan facial trauma with multiple facial bones fracture treated by surgical planning on AM medical model to adapt the mini plates to be prior to the surgery. This paper also deals with the importance of AM medical models in complex surgeries for better outcome.

Abdominal wall endometriosis is a very rare site for extragenital endometriosis. We present 4 cases diagnosed and treated in two gynecological services of Iași, Romania, and we review the literature data on this topic. The endometriotic implant in our cases occurred in the post-cesarean section scar, and was diagnosed after 1-4 years from the intervention. The main symptom was local pain (in 2 cases with a cyclical pattern). The initial diagnostic was endometriosis in 3 cases, and granuloma in one case. The ultrasound adequately described the situation and the consistency of the tumor in 2 cases. The treatment was surgical excision, and the post-operative evolution was favorable. In conclusion, although a rare disease, endometriosis is accessible for the diagnostic and treatment, being a pathology that both surgeons and gynecological should consider.

Cystic neoplasms of the pancreas have an incidence of 10% of all cystic tumors, represented by serous cystadenomas, mucinous cystic neoplasm and solid pseudopapillary neoplasm. We present two cases with rare pancreatic tumors: two women of 18 years old and 67 years old respectively were admitted for non specific abdominal pain and dyspepsia. The CT-scans diagnosed with corporeal pancreatic of 30 × 40 mm in the first case and 98 × 66 mm in the second. Distal pancreatectomy with spleen preservation was performed in both cases with uneventful postoperative course. The pathological exam revealed pseudopapillary pancreatic tumor in the first case and mucinous cystic neoplasm, in the second case. A short review of the literature was also performed.