Scientific research

Breast Reconstruction following Mastectomy for Breast Cancer or Prophylactic Mastectomy: Therapeutic Options and Results


(1) Importance of problem: Breast cancer accounted for 685,000 deaths globally in 2020, and half of all cases occur in women with no specific risk factor besides gender and age group. During the last four decades, we have seen a 40% reduction in age-standardized breast cancer mortality and have also witnessed a reduction in the medium age at diagnosis, which in turn means that the number of mastectomies performed for younger women increased, raising the need for adequate breast reconstructive surgery. Advances in oncological treatment have made it possible to limit the extent of what represents radical surgery for breast cancer, yet in the past decade, we have seen a marked trend toward mastectomies in breast-conserving surgery-eligible patients. Prophylactic mastectomies have also registered an upward trend. This trend together with new uses for breast reconstruction like chest feminization in transgender patients has increased the need for breast reconstruction surgery. (2) Purpose: The purpose of this study is to analyze the types of reconstructive procedures, their indications, their limitations, their functional results, and their safety profiles when used during the integrated treatment plan of the oncologic patient. (3) Methods: We conducted an extensive literature review of the main reconstructive techniques, especially the autologous procedures; summarized the findings; and presented a few cases from our own experience for exemplification of the usage of breast reconstruction in oncologic patients. (4) Conclusions: Breast reconstruction has become a necessary step in the treatment of most breast cancers, and many reconstructive techniques are now routinely practiced. Microsurgical techniques are considered the “gold standard”, but they are not accessible to all services, from a technical or financial point of view, so pediculated flaps remain the safe and reliable option, along with alloplastic procedures, to improve the quality of life of these patients.

Keywords: breast reconstructionreconstruction following mastectomyprophylactic mastectomychest feminizationtransgenderimplant reconstruction of breastimmediate reconstructiondelayed reconstructiontwo-stage breast reconstructionautologous breast reconstruction

Why Is Surgery Still Done after Concurrent Chemoradiotherapy in Locally Advanced Cervical Cancer in Romania?


The incidence and mortality of cervical cancer are high in Romania compared to other European countries, particularly for locally advanced cervical cancer cases, which are predominant at the time of diagnosis. Widely accepted therapeutic guidelines indicate that the treatment for locally advanced cervical cancer consists of concurrent chemoradiotherapy (total dose 85–90 Gy at point A), with surgery not being necessary as it does not lead to improved survival and results in significant additional morbidity. In Romania, the treatment for locally advanced cervical cancer differs, involving lower-dose chemoradiotherapy (total dose 60–65 Gy at point A), followed by surgery, which, under these circumstances, ensures better local control. In this regard, we attempted to evaluate the role and necessity of surgery in Romania, considering that in our study, residual lesions were found in 55.84% of cases on resected specimens, especially in cases with unfavorable histology (adenocarcinoma and adenosquamous carcinoma). This type of surgery was associated with significant morbidity (28.22%) in our study. The recurrence rate was 24.21% for operated-on patients compared to 62% for non-operated-on patients receiving suboptimal concurrent chemotherapy alone. In conclusion, in Romania, surgery will continue to play a predominant role until radiotherapy achieves the desired effectiveness for local control.

Keywords: locally advanced cervical cancerconcurrent chemoradiotherapyadjuvant surgerylocal controlhigh cervical cancer morbidityresidual diseasecervical cancer in Romania

Challenging Correlations Between Psoriasis Severity and TNF-α Level in Hard-To-Treat Areas.

The current study highlights the important role of tumour necrosis factor-α (TNF-α) in the development of psoriasis and suggests that an assessment of serum TNF-α levels might be useful as a predictor of psoriasis severity. Furthermore, these results could answer the dilemma raised by this article itself, more precisely the cause of the severity of special sites. We evaluated a group of 47 patients for the possible link between the severity according to Psoriasis Area and Severity Index (PASI), Psoriasis Scalp Severity Index (PSSI), Nail Psoriasis Severity Index (NAPSI), or Erythema, Scaling, Induration,Fissuring Scale (ESIF) scores and pro-inflammatory cytokines profile in difficult-to-treat areas. The severity of the disease was
assessed using PASI and other scores dedicated to these special sites. The correlation between the PASI score and serum TNFα was evaluated. Serum TNF-α levels are significantly increased in patients with severe psoriasis, which is correlated with the PASI score, and are within limits as long as the PASI score is lower, regardless of the severity of the difficult-to-treat areas. Deciphering the cause of the severity of special sites might change the therapeutic approach in order to personalise therapy according to the cytokine profile and increase access to biological therapies with significant benefits for the patient.

Keywords: psoriasis, TNF-α, hard-to-treat areas, biologics,dermatology, predictor, PASI score,Prognosis

Indocyanine Green(Icg) And Colorectal Surgery: A Literature Review on Qualitative and Quantitative Methods of Usage

Abstract: This literature review investigates qualitative and quantitative uses of indocyanine green (ICG) in surgical treatment, as this novel technique has become increasingly popular in ORs (operating rooms) worldwide due to its many advantages. Method: An extensive literature review was performed by searching for relevant terms in 5 international databases (,,,, The results of this search were summarized into the main advantages of employing ICG in colorectal surgery as follows: a) intraoperative fluorescence angiography capability; b) fluorescence-guided identification of lymph node involvement in colorectal cancer and the sentinel lymph node method; c) positive fluorescence flagging of a liver tumour as small as “only” 200 tumour cells; d) facilitation of fistula diagnosis; and e) tumour tattooing. Moreover, in addition to qualitative intraoperative ICG use, this technique can be combined with quantitative methods and parameters, such as maximum intensity, relative maximum intensity, and different inflow parameters (time-to-peak, slope, and t1/2max). The conclusion of this article is that fluorescence surgery with ICG aided by near-infrared (NIR) light is a relatively recent technology, an advantage of which is improving the specific anatomic and functional information provided, thus allowing more comprehensive and safer tumour removal as well as preservation of important structures.

An Update on the General Features of Breast Cancer in Male Patients

Abstract: Male breast cancers are uncommon, as men account for less than 1 percent of all breast carcinomas. Among the predisposing risk factors for male breast cancer, the following appear to be significant: (a) breast/chest radiation exposure, (b) estrogen use, diseases associated with hyper-estrogenism, such as cirrhosis or Klinefelter syndrome, and (c) family health history. Furthermore, there are clear familial tendencies, with a higher incidence among men who have a large number of female relatives with breast cancer and (d) major inheritance susceptibility. Moreover, in families with BRCA mutations, there is an increased risk of male breast cancer, although the risk appears to be greater with inherited BRCA2 mutations than with inherited BRCA1 mutations. Due to diagnostic delays, male breast cancer is more likely to present at an advanced stage. A core biopsy or a fine needle aspiration must be performed to confirm suspicious findings. Infiltrating ductal cancer is the most prevalent form of male breast cancer, while invasive lobular carcinoma is extremely uncommon. Male breast cancer is almost always positive for hormone receptors. A worse prognosis is associated with a more advanced stage at diagnosis for men with breast cancer. Randomized controlled trials which recruit both female and male patients should be developed in order to gain more consistent data on the optimal clinical approach.

Keywords: male; breast; cancer; diagnosis; treatment; prognosis

Intra-Abdominal Malignant Melanoma: Challenging Aspects of Epidemiology, Clinical and Paraclinical Diagnosis and Optimal Treatment

Abtrasct : According to European consensus-based interdisciplinary guidelines for melanoma, cutaneous melanoma (CM) is the most deadly form of dermatological malignancy, accounting for 90% of the deaths of skin cancer patients. In addition to cutaneous melanoma, mucosal melanoma occurs in four major anatomical sites, including the upper respiratory tract, the conjunctiva, the anorectal region, and the urogenital area. As this cancer type metastasizes, a classification used in the current medical literature is the distinction between secondary lesions and primary malignant melanoma of the abdominal cavity. Given that malignant melanoma is the most common cancer that spreads to the gastrointestinal tract, different imaging modalities compete to diagnose the phenomenon correctly and to measure its extension. Treatment is primarily surgery-based, supported by immunotherapy, and prolongs survival, even when performed at stage IV illness. In the end, special forms of malignant melanoma are discussed, such as melanoma of the genito-urinary tract and amelanotic/achromic melanoma. The importance of this present literature review relies on yielding and grouping consistent and relevant, updated information on the many aspects and challenges that a clinician might encounter during the diagnosis and treatment of a patient with intra-abdominal melanoma.


malignant melanoma; abdominal metastases; diagnosis; review; surgical oncology; dermato-oncology; immunotherapy; surgery; prognosis; achromic melanoma


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Indocyanine Green (ICG) and Colorectal Surgery: A Literature Review on Qualitative and Quantitative Methods of Usage

Abstract : Due to its many benefits, indocyanine green (ICG) has gained progressive popularity in operating rooms (ORs) globally. This literature review examines its qualitative and quantitative usage in surgical treatment. Method: Relevant terms were searched in five international databases (1. Pubmed, 2. Sciencedirect, 3. Scopus, 4. Oxfordjournals, 5. Reaxys) for a comprehensive literature review. The main benefits of using ICG in colorectal surgery are: intraoperative fluorescence angiography; fluorescence-guided lymph node involvement detection and the sentinel technique; the fluorescent emphasis of a minute liver tumour, counting just 200 tumour cells; facilitation of fistula diagnosis; and tumour tattooing. This methodology can also be used with quantitative characteristics such as maximum intensity, relative maximum intensity, and in-flow parameters such as time-to-peak, slope, and t1/2max. This article concludes that fluorescence surgery with ICG and near-infrared (NIR) light is a relatively new technology that improves anatomical and functional information, allowing more comprehensive and safer tumour removal and the preservation of important structures.


colorectal; fluorescence; ICG; ICG-NIR; colorectal surgery; intraoperative staining; q-ICG

Differential Diagnosis of Abdominal Tuberculosis in the Adult—Literature Review


Tuberculosis (TB) is a public health issue that affects mostly, but not exclusively, developing countries. Abdominal TB is difficult to detect at first, with the incidence ranging from 10% to 30% of individuals with lung TB. Symptoms are non-specific, examinations can be misleading, and biomarkers commonly linked with other diseases can also make appropriate diagnosis difficult. As a background for this literature review, the method used was to look into the main characteristics and features of abdominal tuberculosis that could help with differentiation on the PubMed, Science Direct, and Academic Oxford Journals databases. The results were grouped into three categories: A. general features (the five forms of abdominal tuberculosis: wet and dry peritonitis, lymphadenopathy, lesions at the level of the cavitary organs, lesions at the level of the solid organs), B. different intra-abdominal organs and patterns of involvement (oesophageal, gastro-duodenal, jejunal, ileal, colorectal, hepatosplenic, and pancreatic TB with calcified lymphadenopathy, also with description of extraperitoneal forms), and C. special challenges of the differential diagnosis in abdominal TB (such as diagnostic overlap, the disease in transplant candidates and transplant recipients, and zoonotic TB). The study concluded that, particularly in endemic countries, any disease manifesting with peritonitis, lymphadenopathy, or lesions at the level of the intestines or solid organs should have workups and protocols applied that can confirm/dismiss the suspicion of abdominal tuberculosis. View Full-Text

Keywords: tuberculosis; differential; diagnosis; peritonitis; lymphadenopathy; granuloma; nodules; cyst; laparotomy; laparoscopy

The Use of Indocyanine Green in Colorectal Surgery


This chapter looks at the use of indocyanine green (ICG) in colorectal surgery, by exploring at first the definition of vital dyes generally used in the surgical field, afterward the benefits of fluorescence-guided surgery, and furthermore, it enumerates several uses of ICG in the broad surgical field. The identification of tumor nodules in the peritoneum can help with proper cancer staging, and the same advantage is brought by the accurate detection of the sentinel lymph node, which concerns the use of ICG specifically in colorectal surgery, and this can be summed up through the following assets brought by the technique: (a) intraoperative fluorescence angiography as an adjuvant in the process of anastomosis, (b) fluorescence-guided detection of lymph node metastases in colorectal cancer and the sentinel lymph node technique, which was proved better than formal methods in some studies, (c) the positive fluorescence of a liver nodule as small as “only” 200 tumor cells, (d) the help in diagnosing a fistula, (e) the possibility to be used for tumor tattooing also, and (f) the help in maintaining a clean surgical field and preventing wound infection in abdominoperineal resection.

The Problem of the Colorectal Anastomosis


Colorectal anastomosis is defined as a surgical procedure in which the colon is attached to the remainder of the rectum after most or some part of it was removed during an intervention. A straight colorectal anastomosis implies a direct attachment, while a J-pouch colorectal anastomosis implies a previous creation of a reservoir, or “pouch” out of bowel material. The problem of colorectal anastomosis safety and outcome is among the most important and persistent issues in colorectal surgery, mainly due to the anastomotic leakage, a threatening and dangerous complication, with an incidence of up to 20% or even more in case of surgical oncology. Various prediction models and anastomosis testing techniques have been described in order to prevent or identify early any possible imperfection of the anastomosis, each with pros and cons. The measures generally used to increase the safety and reliability of the colorectal anastomosis are to evaluate the blood supply of the tissues anastomosed with indocyanine green, or to test the mechanical integrity of the anastomosis for leakage by employing air, methylene blue, or tension.

Intraoperative Ultrasound in Colorectal Surgery


Intraoperative ultrasound (IOUS) in colorectal surgery can be used both in benign and in malignant lesions. In benign cases, such as Crohn’s disease and diverticulitis, it can orient toward the extension of the surgical intervention. In malignant cases, such as colorectal cancer with liver metastases, IOUS/CE-IOUS (contrast-enhanced) improved the intraoperative management of liver metastases by dictating the resection margins in relation to the tumor extension. The IOUS method allows for exact tumor location, intestinal wall visualization, and malignant tumor penetration. The IOUS revealed the tumor and its margin in rectal lesions, making the sphincter-sparing operation easier to perform. In patients with small polyps and early colon and rectum cancers, IOUS works well as a one-of-a-kind intraoperative localization technique. In comparison with IOUS, CE-IOUS offered better detection and resection guidance. Intraoperative ultrasound enables surgeons to easily localize small, non-palpable lesions of the large bowel. Furthermore, it can determine even the aggressive potential of these lesions with high precision.

Surgical Oncology in Romania: An Analysis of Research and Impact Based on Literature Search in PubMed and Web of Science


Background. With a long tradition and outstanding contributions over time, medical scientific research in Romania has experienced major changes in the last two decades, marked by an increase in scientific publications, originating especially from university centers and fostered by national regulations on publication standards required for professional promotion. This study is aimed at assessing the literature on surgical oncology in Romania, published by Romanian authors in journals indexed in international databases. Materials and Methods. A literature search was performed, focused on surgical oncology performed in Romania. Two databases, PubMed and Web of Science (WoS), were finally selected and included in the study, which included bibliometric parameters and subject analysis. Results. The PubMed search retrieved 464,295 articles being published in only 3 Romanian journals, Chirurgia, The Medical-Surgical Journal (Iasi), and Romanian Journal of Morphology and Embryology. The search of the Web of Science retrieved 494 records on the subject of surgical oncology in Romania, 449 of which were published after 1989. The 494 articles received 2,102 citations, 4.26 per year, and an overall Hirsch index of 21. Most articles were published in the same 3 Romanian journals as in PubMed. Neoplasms of the digestive system prevailed, followed by articles on general surgical oncology issues, cancer research, and therapy. Bucharest has the highest number of authors, followed by Cluj-Napoca and Iasi. Conclusion. Research originating from Romania in the field of surgical oncology is present and visible at an international level mainly through Romanian journals. Sustained effort is required from surgical oncology authors to be published in international journals on this subject, as it is the only way to increase global visibility and impact.

Giant testicular tumor- a case presentation


Background. Testicular cancer is the most common cancer in men 15 to 35 years old. Histological subtypes are seminoma, non-seminoma and mixed tumours (partly seminoma and partly non-seminoma). Seminomas are more sensitive to radiation therapy and are easier to cure than non-seminomas. The surgical treatment is either orchiectomy, either orchiectomy plus lymph node dissection of the involved ganglia.

Case presentation. We present the case of a 42-year-old man with scrotal pain, important swelling and erythema admitted into our surgical unit. Clinical exam and ultrasound revealed a testicular augmentation of 6/15 cm. Radical orchiectomy was performed and the patient was further referred to the oncology department.

Conclusions. Even though the common causes of scrotal erythema with local swelling and pain are orchiepididimitis and testicular torsion, a careful examination followed by a precise ultrasound can reveal a developing testicular tumor, which was complicated by inflammation. Moreover, a careful anamnesis hints to the development of a tumor as the patient was operated on for cryptorchidism in childhood. Orchiectomy followed by radiotherapy in seminomas, has a cure rate of 70 to 100%.

Keywords: seminoma, orchiectomy, acute scrotum

Sofia Ionescu-Ogrezeanu (1920-2008), First female neurosurgeon in Romania and first female neurosurgeon in South-Eastern Europe


Dr Sofia Ionescu (1920-2008) started performingsurgical interventions during her years as a student in 1944 when she performed a trepanation to save the life of a child. She obtained her PhD thesis in medicine and surgery in 1945, and it is in the next year when she becomes a certified surgeon, and, later on, in 1954,she becomes a consultant in neurosurgery. She worked in the surgical team of Dr Constantin Arseni (1912-1994), the most famous neurosurgeon in Romania at that time. She practiced for 47 years, bringing new contributions, innovations and resourceful medical solutions; in neurosurgery, mostly in the fields of the spine, and also of the brain. Furthermore, her papers appeared and were cited in famous international surgery magazines. She was the first female neurosurgeon in Romania and also the first female neurosurgeon in South-Eastern Europe. She had numerous famous patients such as singers, spouses of political leaders, wives of Princes, and also poets. Dr Sofia Ionescu was a professor at the University, a Member of the Romanian Society of The History of Medicine, a Member of the Academy of Medical Sciences and she was declared a HERO DOCTOR by the World Health Organisation, next to other 65 greatdoctors.

Surgical Treatment in Stenosing Rectal Cancer


Introduction: Rectal cancer represents an important healthissue, which involves multidisciplinary treatment, posing amajor surgical challenge, both in terms of diagnosis andtreatment. Material and Method:Between 2009-2013, we analysed 83patients with stenosing rectal cancer operated on at theClinic of General Surgery II of Colentina Clinical Hospitaland at the Clinic of General Surgery I of “Prof. Dr. Al.Trestioreanu” Oncology Institute, in Bucharest. Gender distribution was: 51 males and 32 females. Average age was65 years old. The most frequently encountered symptomswere colicky abdominal pain and rectorrhagia. 25 patientspresented intestinal occlusion phenomena at admission, theother 58 cases being in subocclusive stage. Results:In occlusive stages: 17 patients presented withresectable tumour, while 8 patients had locally advanced neo-plastic forms (“frozen pelvis”), left iliac colostomy with tumour biopsy being the chosen approach. In subocclusive stages: 5cases had unresectable tumours for which left iliac anus withtumour biopsy was performed; 53 cases presented withresectable tumour, for which the Hartmann procedure (12patients) and left iliac colostomy with tumour biopsy (41patients) were performed. Depending on the histopathologicalresult, patients were submitted to radio- and chemotherapy.Tumour resection was possible in 70 cases (84.33%), only 34 ofthese (40.96%) being with radical intent.Conclusions:Treatment for stenosing rectal cancer is multi-modal, represented by surgical approach, radio- andchemotherapy. The rationality behind surgery as a first therapeutic gesture in the given study group was represented bythe need to treat occlusive type complications, patients benefitting subsequently from radio- and chemotherapy. Theopportunity of a second surgical intervention, with the objective to remove the tumour, was established based on thetherapeutic response to radio- and chemotherapy.

Key words: rectal cancer, stenosis, occlusion

Cellular Interactions in the Human Fatty Liver


Non-alcoholic steatohepatitis morbidity and mortality is on the rise due to the obesity pandemic. Its pathophysiology is not well understood and implies complex interactions between local hepatic cells populations, adipocytes, immune effectors that lead to hepatic lipid excess, lipotoxicity, cellular stress and inflammation, as well as programmed cell death. A better understanding of these pathogenic interactions would allow better identification of therapeutic targets in a disease that has no known pharmacological therapy until now.

Keywords: NAFLD, NASH, steatohepatitis, genetics, pathophysiology, natural history

The 10 years’ experience in the laparoscopic treatment of benign pathology of the eso gastric junction


In the era of mini invasive surgery, the surgical approach of the esogastric junction occupies an important role, which regards both the results and the complete, long-term patient satisfaction.

The main benign pathology of the esogastric pole includes hiatal hernia, gastroesophageal reflux disease, cardiospasm, oesophageal diverticula. The present study is based on the experience of our clinic in the laparoscopic treatment of esogastric pathology that contains 85 patients in 10 years. Out of these, 15 were operated on for cardiospasm, 29 for hiatal hernia and 41 for gastroesophageal reflux disease (GERD). The investigation protocol consisted in barium swallows and endoscopy, both pre and postoperatively. The results obtained allowed us to underline the superiority of the surgical treatment over the medical one. Likewise, medical literature reports rates of success of 90% in antireflux surgery. The latter is conditioned by correct determination of the reflux causes and by the choice of the adequate time to perform the surgery, in concordance with the local anatomical conditions. As far as the two techniques used (complete or partial fundoplication) are concerned, there were no significant differences in the postoperative evolution of the patients, but we have to mention, nevertheless, the increased incidence of dysphagia after Nissen. The data presented confirm the superiority of laparoscopic surgery over the classic one, due to the superior aesthetic result, the shortened admission time –with reduced costs and rapid social reinsertion.

AbbreviationsGERD – gastroesophageal reflux disease, LES – lower esophagian sphincter

Keywords: GERD, cardiospasm, Nissen fundoplication, Toupet fundoplication, esocardiomiotomy

Evaluating the treatment of metastatic colorectal cancer with monoclonal antibodies


The ability to tailor biologic therapy based on the status of tumor biomarkers and monoclonal antibodies has become very important in the last years. The role of tumor biomarkers in treating colorectal cancer, specifically the K-RAS gene, was identified. K-RAS had a higher interest after Lievre and colleagues reported at the 2008 American Society of Clinical Oncology (ASCO) meeting, their analysis of K-RAS mutations in tumors from patients who did not appear to benefit from cetuximab therapy, providing additional data involving K-RAS mutant tumors and their lack of response to cetuximab, as part of first-line therapy for metastatic colorectal cancer. Furthermore, other trials evaluated the K-RAS status and the first-line treatment of metastatic colorectal cancer, the treatment of refractory metastatic cancer and dual-antibody therapy in the first-line treatment of colorectal cancer. Patients with mutant K-RAS colorectal tumors have no benefit from cetuximab, no matter the type of chemotherapy regimen.

Keywords: biologic therapy, tumor biomarkers, monoclonal antibodies, K-RAS mutations, metastatic colorectal cancer

Morphological and Immunohistochemical Criteria of Tissue Response to Radiotherapy in Rectal Cancer


Aim: Given the context that rectal tumours respond to a certain degree to radiotherapy, a necessity arises for estimatinga tumour’s capacity to react to radiation from the very momentof diagnostic biopsy.Material and Methods:We have histologically and immuno-histochemically analysed tissues coming from 52 patientswith rectal adenocarcinomas.Results: Of the studied parameters, the ones presenting signifi-cant variation under radiotherapy in terms of statistics(p<0.05) were: colloid type (p=0.001), EGFR in the tumour(p=0.00045), EGFR in the normal epithelium (p=0.0017),VEGF in the tumour (p=0.0132) and VEGF in the tumourstroma (p=0.030).Conclusions:Our study follows the same trends as the medicalliterature we have consulted regarding the variation of EGFRand VEGF with radiotherapy, and the distinct note of our studyrelies in the observation that normal stroma in case of rectal tumors also reacts to radiotherapy, sometimes more aggressivelythan the tumor itself, especially in which concerns the nerveand muscle fibers.

Keywords: rectal cancer, radiotherapy, EGFR, VEGF

Pancreaticojejunostomy – Risk Anastomosis after CephalicPancreaticoduodenectomy


Introduction: The authors bring to attention pancreaticojejunalanastomosis (PJA) performed after cephalic pancreatico-duodenectomy (CPD). This type of anastomosis is renowned for its high risk of complications. Among these complications,pancreatic fistula (PF) is distinguishable due to a significant frequency, averaging 10%. It is perhaps the most unsafe type of anastomosis in digestive surgery, due to its pancreatic partner-ship. Performing a sealed APJ can be considered a great achievement: a digestive lumen is set in contact with a brittleparenchymal structure, centred by a delicate excretory channel,difficult to anastomose in itself.Material and methods:We studied two distinct groups of patients undergoing CPD. A first group – 58 cases operated on between 1967 and 1983, and the second one – 70 cases operated on between 1984 – 2013. In all cases we performed PJA; by in-continuity loop technique in the first group, and with separate loop in the second group. In the second groupwe used a variant own technique that does not allow anastomotic loss of pancreatic fluid. Thus, a decline in theincidence of PF from 20% to 8% was obtained, the final percentage corresponding to group two. Of the 8% of patientswith PF losses were recorded strictly at pancreatic level, with no bile or food contamination. Stenting was recorded for biliary- and pancreaticojejunal anastomoses in group two.Discussions: The percentage of PF after CPD did not show anynotable revival when comparing the 1980s period to the present. Also, mortality due to FP is approaching 40%, adaunting figure. The multitude of technical options for restoring bowel movement after CPD, over 80 procedures, further confirms the lack of safety and trust in relation to PJA.The authors bring forward several surgical gestures addressing PJA, gestures capable of providing an 8% frequency of PF, percentage which we consider to be reasonable.Conclusions:The authors consider PJA stenting mandatory.Placing an isolated PJA on the short branch of the “Y”, sepa-rate from the biliary and food flow, prevents the formation of acomplex fistula. The proposed technique does not require a”duct – to – mucosa” type or “telescoping” type pancreatico-jejunal anastomosis.

Keywords: Pancreaticojejunostomy, cephalic pancreatico-duodenectomy, pancreatic fistula

A Primary Hydatid Cyst in the Abdominal Wall – Case Report


Introduction:A solitary primary hydatid cyst in the abdominal wall is an exceptional entity, even in countries where the Echinococcus infection has a high rate, being considered anendemic disease.Case presentation:We report a case of a 70-year-old Caucasian man who presented to our clinic with a slow-growing painless parietal mass in the abdominal wall, right flank area. The diagnosis of cystic mass was established at the ultrasound exam.There were no findings that could describe a hydatic cyst. The punction at the surgical intervention revealed a “clear, stone liquid like”; due to the high risk of major injury of the abdominal wall, we performed partial resection of the outercystic wall, proligerous membrane removal and drainage. The patient had an uneventful post-operative recovery. The histopathology confirmed the suspected diagnosis. Conclusion: Hydatid cyst should be considered in the differential diagnosis of every abdominal intraparietal cystic mass, especially in regions where the disease is endemic. The best treatment is the total excision of the cyst preserving anintact wall (complete cystectomy). Otherwise, removing the proligerous membrane with partial pericyst’s resection (partialpericystectomy) and drainage should be considered.

Keywords: hydatid cysts, intraparietal hydatidosis, cystectomy,pericystectomy

Morbidity after Ultra Low Anterior Resection of the Rectum


Anterior resections of the rectum, used as an alternative to amputation of the rectum, are performed more and more frequently, being presently indicated for neoplasms located at a distance of 7 to 4 cm from the anus. Complications of low and ultra low anterior resections are not at all negligible, and local neoplastic recurrence rate is significantly higher than after amputation of the rectum. However, literature data recommends low and ultra low anterior rectal resections, even if sometimes the method indications are pushed to the limit or the interventions are performed at the patient’s request, in order to avoid permanent colostomy. The authors of this article aim to outline a true picture of the changes caused by anterior resections of the rectum, low and ultra low, so that,without denying the merits of these resections, the entire post-operative pathology that occurs in these patients is depicted and understood. Ultra low rectal resections, up to 3-4 cm from the anus, bring important morphological and functional changes to the act of defecation and to anal continence. These changes in colo-anal bowel movement have a much higher incidence than postoperative genitourinary disorders.Another important aspect emerging from the present study is related to the increased incidence of anastomotic disunity,stenosis and various degrees of incontinence, complications that often can only be solved by completion of rectum ampu-tation and permanent colostomy. In addition, the functional outcomes of these ultra low resections are not always at the level expected by the patient. Also, in terms of surgical performance, the higher share of specific complications of the procedure raises questions with regard to the technique. For all these reasons the authors consider it necessary to review the lower limit to which an anterior rectal resection can descend.

Keywords: rectum, neoplasm, anterior resection, ultra low,limit

Clinical and Paraclinical Criteria of Patient Selection for the Non-operativeTreatment in Completely Responsive Rectal Cancer (after NeoadjuvantRadiochemotherapy)


Introduction: Neoadjuvant radiotherapy is included in the treatment protocols for rectal tumors in stages ė T3. The useof neoadjuvant radiotherapy allowed the limit of surgical oncologic safety margin to decrease with 1-2 cm and the abdominoperineal resection to be able to be performed in tumors situated at 4 cm from the anal verge. This modification of the treatment strategy increased the use of low, ultra low andcolo-anal anastomoses. Goal:Through the analysis of these types of anastomoses and of the disadvantages of the abdomino-perineal resection, we aimed at performing a study on the patients which responded completely to radiotherapy by taking into account the criteria of oncologic safety and the sparing of the patients from surgical complications. Material and method: We performed a retrospective study on171 patients with rectal cancer treated in the 1st Clinic of Surgery from the Bucharest Oncology Institute between October 2007 and December 2013.Results: 141 patients received radiotherapy, out of which 9 responded completely. 5 of those 9 were not operated on and after variable clinical and paraclinical follow up (2-6 years),they did not present with local recurrence.Conclusions:Not performing surgery in the patients with rectal cancer with a complete response to radiotherapy is a good solution and must be taken after a correct information of the patient about rectal surgery with the condition of strictly observing the selection criteria of the patients.

Keywords: rectal cancer, neoadjuvant radiochemotherapy,post radiotherapy regression

The Place of Radiofrequency Ablation in the Multimodal Treatment of Cervical Cancer. Our Experience


Introduction: Genital cancers benefit from standardized treat-ment plans which include: surgery and radio/chemotherapy.Lately, treatments involving thermal ablations have entered the clinical use, as they destroy the tumors by the use of different energy sources. Our study aims at establishing aprecise role of RFA in current treatment protocols of cancer of the uterine cervix.Material and method: We performed a 5-year (2008-2013)prospective study in which we analyzed the use of RFA inpatients treated for cancer of the uterine cervix at our clinic.RFA was used, on selective criteria, in bleeding tumors of theuterine cervix in patients with acute secondary anaemia(Hb=7-11g/dl). The results revealed the haemostatic role ofthe method, RFA being the only non surgical method through which one can achieve quick haemostasis (20 min.). 61patients were clinically observed, with ages between 39 and73, and the number of procedures performed was 61.Conclusion: RFA is useful in the treatment of cancers of the uterine cervix, in all stages of the disease, and it achieves quick haemostasis. RFA can be considered an additional treatment option in neoadjuvant tumor palliation. The method can be associated with surgery and radio/chemotherapy. Its assets are low specific morbidity (1,6%) and mortality (0%). We consider that RFA is on its way to an important place in oncology treatment protocols.

Keywords: radiofrequency (RFA), haemostasis, uterinecervix cancer

Therapeutic approach in locally advanced colon tumours (T4NxM0) – clinical experience in 18 consecutive cases


Introduction: Surgery holds a central seat in the treatment of colon cancer, its objective being R0 resection. Chemotherapy and an appropriate oncological follow-up complete the treatment. Aim: To establish an adequate therapeutic conduct in patients with advanced colon tumours, with no hepatic metastases. Material and method: retrospective study on a group of 150 patients with colon neoplasm treated in the First Surgery Clinic of the Bucharest Oncology Institute in Bucharest,between 01 01 2008 -01 03 2013. Results: 18 patients presented locally extended colon tumours which required multivisceral resections. Patients with hepatic metastases were excluded from the study. The most frequently affected organs were: the small bowel and the internal genital organs, followed by the urinary bladder, spleen, duodenum and diaphragm muscle. Patients were oncologically followed-up according to current protocols and submitted to chemotherapy.When a maximum response was reached in R2 patients or when recurrence occurred in R0 and R1 patients, surgical intervention was required. When necessary, the operation was performed by multidisciplinary teams. 5 patients died due to local recurrence, disease progression, metastatic disease, and also due to comorbidities. Conclusion: Treatment applied by oncological committees and multidisciplinary surgical teams, along with correct oncological follow-up and surgical reintervention when maximum response to chemotherapy was reached in R2 or when recurrences occurred in R0 and R1 patients represents the adequate therapeutic conduct in patients with locally advanced colon tumours.

A Rare Case of a Testicular Teratoma Associated with a Neuroendocrine Tumour


Introduction: We report a rare case of testicular teratoma combined with a neuroendocrine tumour,emphasizing the difficulty of the following aspects: the clinical and laboratory diagnosis, the treatment options and the evolution of patients suffering from this disease. Case presentation: The patients with testicular neuroendocrine tumours represent a rarity, considering that as of 2017, only 22 cases had been reported in the literature. The case operated on in our clinic presents an association between a testicular teratoma and a neuroendocrinetumour. A 39-year-old patient was admitted in our Department for a non-painful abdominal tumour and concomitant testicular tumour. The serum tumour markers (β-human chorionicgonadotropin, α-phetoprotein and lactate dehydrogenase) were within normal limits. Lung andbone metastases were diagnosed CT scan. The histopathological diagnosis consisted of immuno-histochemical study of the orchidectomy specimen as well as of the bi optic material from bone marrow puncture.Conclusions: The diagnosis of testicular carcinoids is based on immunohistochemistry study. Radicalorchidectomy is the only potentially curative treatment for this type of malignancy. Adjuvant chemotherapy determined size reduction of the lung and bone metastases and the disappearance of the lymph node metastases.

Keywords: testicular cancer, neuroendocrine tumours

“Difficult” Colorectal Polyps – Therapeutic Approach


Introduction: Endoscopic polypectomy is the gold standard inthe treatment of colorectal polyps. The importance of polypec-tomy rests primarily on the fact that polyp-type lesions present a high risk of malignant degeneration, colorectal polyps beingable, if left unattended therapeutically, to generate a colorectal cancer (CRC) – a lesion with a far more negative prognosis. Although preferable, endoscopic polypectomy of colorectal polyps is not always possible, multiple factors generating difficulties in performing this therapeutic measure.Material and Method: We performed a retrospective study inthe First Surgical Clinic of the “Prof. Dr. AlexanduTrestioreanu” Bucharest Oncology Institute, spanning a period of 3 years (2008-2011), in which time 224 patients were diagnosed by colonoscopy with colorectal polyps, of whom 222 patients benefited from endoscopic polypectomy.The aim of the study was to identify “difficult” polyps and to identify the criteria for endoscopic surgery versus classic surgery as a therapeutic indication.Results: Presence of “difficult” polyps was observed in 37.56% of the patients diagnosed with colorectal polyps. In over 88%of cases endoscopic polypectomy was possible, and for the remaining patients classic surgery was the therapeutic solution opted for.Conclusions: Presence of “difficult” polyps generates inconven-iences in performing endoscopic polypectomy, increasing th erisk of postoperative complication occurrence, as well as th eduration of the operation. If the criteria for characterizing polyps as “difficult” are relatively well-established, the choice between endoscopic and classic surgery as a therapeutic measure is left at the free will of the operating surgeon, with the exception of situations in which classic surgery is resorted to for oncological reasons.

Keywords: colorectal polyp, colorectal cancer, polypectomy

Types of Polymeric Meshes Used to Repair Abdominal Wall Defects


The development of new polymeric materials –either synthetic or biologic- for the surgical repair of abdomina lwall primary or incisional defects (one of the most frequent surgical procedures performed in a clinic of general surgery) dates back from the 1950s; inspiration for developing new materials came from several sources, such as the evolution of the surgical techniques, the emergence of laparoscopy and the technologic revolution of the past years. The history of the meshes began with Usher’s polypropylene mesh; curently used meshes basically contain polypropylene, polyester and ePTFE, used per se or in different combinations(composite meshes) with various additional materials (omega 3, titan, monocryl, PVDF, hyaluronate). The most important features of the meshes used in the surgical process are: the type of material used, its porosity and its resistance, elements which determine its weight and ability to integrate into the recipient body. The use of meshes allows the repair of many types of abdominal wall defects of various dimensions and the substitution of the areas with lack of substance, as the prostheses stimulate the collagen synthesis.The present article envisages the review of the meshes which have been used more often in our clinic during he past year, and also their features and indications.

Keywords: substitution materials, abdominal wall defects, types of prostheses

Case Presentation: Three Cancers (Cervix, Ovary, Rectal) And One Patient with Multiple Surgical Interventions


The Introduction starts with the unusual case of three consecutive cancers (uterine cervix, ovarian and rectal) and their relapses in one patient, requiring several surgical procedures, sometimes in emergency settings. Methods We drew a minute analysis of this case, which was operated on in the First Clinic of General Surgery and Surgical Oncology of the Bucharest Oncology Institute, and we looked into the details and examined the clinical context in which a series of surgeries were needed: at first, in the beginning of the disease process, for surgical oncologic reasons – and, further on, in the case of tumour relapse, in order to perform life-saving interventions. Results The surgical personal patient history, in this case, is impressive: the patient was initially histerectomised for a cervical tumour, a few years after she presented with an intraabdominal cystic tumour, which was diagnosed as ovarian cancer relapse, and after that she underwent further chemotherapy and, afterwards, a rectal tumour was diagnosed and treated with preoperative radiotherapy and abdomino-perineal resection. This year she presented with a bleeding tumour at the level of the vagina which was biopsied and treated with radiofrequency ablation and afterwards the patient addressed the hospital in intestinal obstruction with an enterovaginal fistula. The fistular path was found, it was in strict adherence to the pelvic floor, and the lesional process was shunted by an ileocaecal anastomosis. In the postoperative period, the patient developed an anastomotic leak, and a median ileostomy was performed. Conclusion of this retrospective case analysis would lead towards the fact that, in such unusual cases, in which the surgeon must deal with several complications from cancer and cancer relapse, in the context of multiple primary tumours, it becomes imperative to try to solve the surgical emergency setting and not to try in vain to cure the advanced stage of disease through extensive and dangerous resections in a frail patient.

The Establishment of Civil Hospital Administration

The beginning of hospital care in Romania was due to the initiatives of several foundations: the St. Spyridon Ward of Iaşifor the Principality of Moldavia and the Civil Hospitals Administration for the Principality of Wallachia. The St.Spyridon General Ward of the House of Hospitals emerged as aresult of the efforts of Dimitrie Bosie and his son Stefan Bosie,who created the first infirmary (“bolniţă”) in 1752. In 1757,under the rule of Constantin Cehan Racoviţă, the establishment was granted institutional legitimacy and was given substantial real estate from the sovereign’s property. In this presentation,we aim at tackling only the hospital institution created in the Principality of Wallachia, leaving the St. Spyridon Ward foranother presentation which will be included in the Chirurgia journal.

The Value of C Reactive Protein and the Leukocytes in the Peritoneal Fluid in the Predicting PostoperativeDigestive Fistulas


Anastomotic fistulas in digestive surgery are a severe complication of the patient. The identification of paraclinical laboratory investigations which would allow an early diagnosis of fistulas would lead to the optimization of patient’s management.We have performed a retrospective study on 100 cancer patients, with digestive tract surgeries, between May 2016 and December 2017, in the First Clinic of General surgery and Surgical Oncology from the Bucharest Oncology Institute. The postoperative follow-up included: the testing of the C reactive protein (CRP ), and also the monitoring of the number of leukocytes (Ld)from the abdominal cavity, with probes taken from the drainage tube, all in association with the number of leukocytes in the blood (Ls) in all patients (with or without digestive fistula). By calculating the values of these tests and comparing them always with the clinical evolution of the patients, and sometimes with other tests as well, one would confirm an early diagnosis of fistula.The data obtained have shown that in patients with digestive fistulae there is a rapid growth and maintaining of increased values of serum PCR and of the leukocytes from the peritoneal cavity, values to which we associated also an increase in blood leukocytes. The modifications appear with approx. two days before the appearance of clinical signs or their confirmation through imagery(ultrasound, computed tomography).The regular and standardized follow-up in days 1, 3 and 5 post operatively of the PCRvalue in blood, of the number of leukocytes in the abdominal cavity and of the serum leucocytosis,increasing the value of these parameters, could allow the early identification of the patients with a risk of fistula and the rapid selection of those which need supplementary investigations and/or surgical intervention.

Keywords: C reactive protein, peritoneum leukocytes, leukocytosis, digestive surgery, postoperative complications, anastomotic fistula

The Importance of the Nutritional Factor and the Stageof the Disease in Postoperative Fistula in Patients with Gastric Cancer


Introduction:In gastric cancer there are multiple local and general risk factors for the occurrence of postoperative fistulas. In the present study, we proposed to analyse the role of the preoperative nutritional state and nutritional therapy along with the disease stage, the age and the sex of patients in the occurrence of fistulas.Material and method:This retrospective study included 158 patients operated for gastric cancer in Surgery Department of Bucharest Oncology institute between January 2010 and December 2016 in which we analysed the incidence of anastomotic fistula according to the nutritional status, disease status, age and sex of the patients. Results:The global incidence of fistulas was of 11%, out of which 8 % were fistulas of the duodenal stump and 3.19% fistulas of the eso-jejunal anastomosis. Out of the 30 patients with weight loss and parenteral nutrition in the preop period, we had 4 fistulas (13%), and out of the 36 patients with weight loss and nutritional measures in the postop we had 5 fistulas (14%), also, out of the 24patients with weight loss and without nutritional intervention, we had 5 fistulas (21%), finally, out of the 68 patients without weight loss we had fistulas in 4 patients (6%).. The incidence of fistulas was 5% in patients with stage I, II and III and 24% in stage IV patients. The distribution of fistulas according to the age of the patients showed a much higher incidence of fistulae in patients over 70 years old.Conclusions: − The number of postoperative fistulas was higher in the advanced stages of the disease (p=0.027) and in patients over 70 years old (p=0.047) and the differences were statistically significant. − The difference between the number of fistulae occurred in patients who had weight loss but did not receive nutritional support from those who received this support was not statisti-cally significant (p<0.001).

Keywords: gastric cancer, preoperative nutritional balance, fistulae, disease stage, age

The choice of performing a stoma versus an anastomosis in immune-compromised colo-rectal cancer patients : old age, chemotherapy , radiotherapy and low protein levels as prognostic factors for the surgical outcome

Postoperative Investigations Resulting in Cost Reductionin Oncological Patients Undergoing Major Abdominal and Pelvic Surgery


Aim: Rising costs in health care are of progressively growing interest and a major factor affecting hospitalization costs is represented by postoperative complications. Complications of Major Abdominal Surgery (MAS) are associated with increased morbidity and mortality. This study estimates the costs of postoperative care associated with complications.Material and Methods: We performed a retrospective study on 254 patients admitted to the 1stGeneral and Oncological Surgery Clinic of the Bucharest Oncology Institute who were submitted to MAS. The total hospitalization, complications and treatment costs were analysed.Results: For a patient undergoing MAS, the average costs for surgery without complications are5,791.3 RON and reach an average of 20,806 RON after major complications.Conclusion:The results provide insight into the costs of hospitalization for oncology patients submitted to surgical interventions. Complications occur in 20.86% of patients undergoing MAS and account for 50% of total care costs. Establishing and implementing a protocol aimed at early diagnosis and treatment of specific complications could lead to a decrease in morbidity and mortality, as well as of the costs of hospitalization.

Keywords: genital and digestive oncological surgery, postoperative complications, patient hospitalization costs

Histology parameters and their variation with preoperative radiotherapy in rectal cancers

Immunohistochemistry as a measurement tool for various aspects of the tumour response to radiotherapy in rectal cancer


Background: As rectal tumors answer in different grades to radiotherapy, we aim at evaluating–right from the moment of the biopsy-the capacity of the tumor to react or not to this treatment option. We find the immunohistochemical evaluation of the tumor to be of crucial importance and we highly recommend it to be done on the biopsy before radiotherapy.Material and methods: We examined immunohistochemical parameters from tissue samples using paraffin blocks from 52 patients. The examinations were done comparatively, both: before radiotherapy (tissues from diagnostic biopsy), as after radiotherapy (tissues from abdomino-perineal resection).Results: out of the 12 biomarkers studied, the ones with statistical importance (which varied with radiotherapy) were: EGFR in the tumor (p= 0.00045), EGFR in the normal epithelium (p= 0.0017), VEGF in the tumor (p= 0, 0132), VEGF in the tumor stroma (p= 0,030)

Rectal Cancer: Measurement of the Tissue Response to Preoperative Radiotherapy


Background: The purpose of the study is to quantify by means of histology and immunohistochemistry the response to preoperative radiotherapy in rectal tumors, in order to decide when and where radiotherapy is likely to result helpful and when it only delays time until surgery. Different tissue responses to irradiation were examined in previous studies, for instance, Bazzetti mentions, in 1996, that there are five grades of response, which vary from complete to absent.Material and methods: The study is meant to be prospective, non randomized and multi-centered. The stages followed in our study are: 1) evaluation of the lesion (rectal tumor) and staging, 2) rectal tumor biopsy with histology and/or immunohistochemistry, 3) start of the radiotherapy when indicated, 4) the surgical procedure, 5) the histology and immunohistochemistry from the rectum excised by the surgeon

The Use of Prostheses Techniques in Bilio- and Pancreatico-jejunal Anastomoses After Cephalic Duodenopancreatectomy


Background: Arterial anomalies near the pancreas and liver are an especially important consideration during pancreaticoduodenectomy (PD), with aberrant right hepatic arterial anatomy (ARHAA) being the most common and relevant anomaly. Variations in arterial blood supply in this region occur in up to 15% of donor livers3 and in 17% of preoperative visceral angiograms. The most common anomalies, according to the Hiatt classification, 3 involve a replaced or accessory right hepatic artery without (type III, 10.6%) or with (type IV, 2.3%) an accessory or replaced left hepatic artery. The common hepatic artery may originate from the SMA (type V) or the aorta (type VI), but, together, they account for only 1.7% of deviations. Normal hepatic arterial anatomy is seen in 75.7% of all patients. Objective: To describe five cases of variants in visceral hepato-biliopancreatic after duodenopancreatectomy.

True and False Incomplete Duplications of the Common Bile Duct and Their Impact on Therapy


The congenital anomalies of the common bile duct (CBD) represent a real challenge for the surgeon, and not recognizing them may have two consequences: either generate incomplete or incorrect surgical solutions, or, even worse, lead to iatrogenic pathology. The association between the anomalies of the CBD and biliary lithiasis, biliary cancer or other hepato-biliopancreatic pathology may lead to a pre/perioperative diag-nosis; frequently, the incertitude persists. We present 2 cases:one with an incomplete duplication of the CBD and the other with a false duplication. We wish to underline the sovereign value of cholangio-MRI with 3 D reconstructions in the diagnosis and description of the anatomy of the biliary ducts,superior, in some cases, to the intraoperative cholangiographyor ERCP.

Keywords: duplication of the CBD, cholangio-MRI with 3 Dreconstructions, endoscopic retrograde cholangiopancreato-graphy (ERCP)