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Tumors in the pandemic era: giant ovarian mucinous cystadenoma. Mucinous cystadenoma is a benign tumor of the ovary originating from the surface epithelium of the ovary, characterized by mucin production. They represent 10-15% of ovarian tumors. The borderline variety represents 10% of mucinous cystadenomas. They can reach very large sizes. We present the case of a patient, aged 65, hospitalized at the end of pandemics with a giant abdominal cystic tumor (diameter 40 cm) with compression disorders. He had a subtotal hysterectomy for uterine fibroids at the age of 25. Laboratory tests are within normal limits except CA19-9 = 398 IU / ml. Abdomino-pelvic ultrasound shows a mid-abdominal liquid formation, inhomogeneous with septa inside that exceeds 30 cm. CT with the contrast substance highlights a multiloculated formation, developed from the left ovary to with iodophilic septa, with mass effect on anatomical elements, with overall dimensions of approx. 230/300/350 mm. With the suspicion of a giant left ovarian cyst suspected of being malignant, a median xipho-umbilical laparotomy was performed and a giant cystic tumor of the left ovary weighing 13 kg, reaching the supramesocolic floor without adhesions, with an ovarian pedicle one cm thick, was removed. Anexectomy was performed on the right side without complications. The postoperative evolution was simple. Histopathological examination determined the diagnosis of borderline mucinous cystadenoma. The epidemiology, clinical signs and imaging diagnosis and surgical treatment of these rare tumors with favorable evolution are discussed.

The thyroglossal duct cyst (TDC) results from a failure in obliterating the embryogenic duct produced during thyroid migration and it represents the most common type of developmental cyst encountered in the neck region. Material and methods: In the First Surgical Clinic from “Sf. Spiridon” County Clinical Emergency Hospital Iasi, Iasi, between 1998 to 2021, 21 patients with thyroglossal duct cyst were diagnosed and treated. All medical records were reviewed. Results: The thyroglossal duct cysts are located as midline cysts of the neck in all cases. The mean age was 39.2 years (13-66 years). The treatment performed was a variant of Sistrunk’s procedure in which the thyroglossal tract was excised to a variable extent, with central hyoidectomy. The size of the cyst ranged from 1.2 to 4 cm (mean 2.6 cm). Postoperative course was uneventful in all cases. No recurrence was recorded in this series. We describe a case, a 42 years old women, with asymptomatic mass in the anterior part of the neck found a 6 months before, when the patient was referred us with lithiasic obstructive jaundice (we performed ERCP + laparoscopic cholecystectomy). The treatment performed was a variant of Sistrunk’s procedure in which the thyroglossal tract was excised by minimally invasive video-assisted approach, variation of Miccoli’s technique. Postoperative course was uneventful. The follow-up 1 and 2 years no recorded recurrence and thyroid scintigraphy was normal. Conclusions: The standard surgical approach to TDC is Sistrunk’s operation with low recurrence rates. Although the results and the operative time are the same as in traditional surgery, minimally invasive video-assisted approach has better cosmetic result and a less painful course.

Background and Objectives: Postoperative pancreatic fistula after cephalic pancreatoduodenectomy (CPD) is still the leading cause of postoperative morbidity, entailing long hospital stay and costs or even death. The aim of this study was to propose the use of morphologic parameters based on a preoperative multisequence computer tomography (CT) scan in predicting the clinically relevant postoperative pancreatic fistula (CRPF) and a risk score based on a multiple regression analysis. Materials and Methods: For 78 consecutive patients with CPD, we measured the following parameters on the preoperative CT scans: the density of the pancreas on the unenhanced, arterial, portal and delayed phases, the unenhanced density of the liver, the caliber of the main pancreatic duct (MPD), the preoperatively estimated pancreatic remnant volume (ERPV) and the total pancreatic volume. We assessed the correlation of the parameters with the clinically relevant pancreatic fistula using a univariate analysis and formulated a score using the strongest correlated parameters, the validity of the score was appreciated using logistic regression models and an ROC analysis. Results: When comparing the CRPF group (28.2%) to the non-CRPF group, we found significant differences of the values of unenhanced pancreatic density (UPD) (44.09 ± 6.8 HU vs. 50.4 ± 6.31 HU, p = 0.008), delayed density of the pancreas (48.67 ± 18.05 HU vs. 61.28 ± 16.55, p = 0.045), unenhanced density of the liver (UDL) (44.09 ± 6.8 HU vs. 50.54 ± 6.31 HU, p = 0.008), MPD (0.93 ± 0.35 mm vs. 3.14 ± 2.95 mm, p = 0.02) and ERPV (46.37 ± 10.39 cm3 vs. 34.87 ± 12.35 cm3, p = 0.01). Based on the odds ratio from the multiple regression analysis and after calculating the optimum cut-off values of the variables, we proposed two scores that both used the MPD and the ERPV and differing in the third variable, either including the UPD or the UDL, producing values for the area under the receiver operating characteristic curve (AUC) of 0.846 (95% CI 0.694–0.941) and 0.774 (95% CI 0.599–0.850), respectively. Conclusions: A preoperative CT scan can be a useful tool in predicting the risk of clinically relevant pancreatic fistula.

Introduction: Caustic gastric stenosis is relatively rare complications after voluntary or accidental ingestion of caustic substances.Methods: They analyzed all the medical recordings of the patients operated in First Surgical Clinic, “St Spiridon” Emergency Hospital Iasi during 2004-2017 (6 cases - lot A) for caustic gastric stenosis presented comparatively with a lot of 46 patients with caustic gastric stenosis (lot B) operated in the same clinic between 1990 and 2003.Results: The most frequently used substance was the caustic soda in group B and detartrant (surface cleaning product – a descaling agent) in group A. The most common site of stenosis was antral, prepyloric; this is explained by the prolonged contact of the caustic with this declivity area and by the spasm of the ankle muscles secondary to caustic action. In the period of establishment of esophageal and/or gastric stenosis, in all cases of group A, esophageal dilation with endoscopic pneumatic balloon probe was started early for both esophageal and gastric stenosis and in group B only in 19 cases. Surgical treatment depended on the extent of the corrosive lesions. In most cases, with limited antral stenosis, we performed distal gastrectomy with gastroduodenal anastomosis. In the combined lesions (esophageal and gastric stenosis) we preferred surgical interventions in two or three steps.Conclusion: Associated gastric and esophageal lesions form a distinct subgroup that often requires complex surgical resolution through laborious procedures. It is advisable to perform endoscopic dilation procedures, both esophageal and pyloric lesions, before attempting surgical treatment. Postoperative morbidity and mortality decreased over the time, through a personalized, differentiated approach to each case, into a multidisciplinary team.

Hematoma of the graft is a life threatening complication of liver transplantation (LT) and there has been no overt conclusion in the literature about optimal management except in scarcely reported cases. It may be either intrahepatic or subcapsular, then again it may develop spontaneously or following parenchimal injuries or transhepatic percutaneous invasive manoeuvers. In this report we describe a rare case of large spontaneous graft intra- and perihepatic hematoma. A 62 year-old man underwent a whole graft orthotopic liver transplantation (OLT) for decompensated chronic liver disease due to alcoholic cirrhosis. The surgical procedure was uneventful. During the early postoperative course, routine Doppler ultrasound examination and CT-scan revealed an extrahepatic paracaval hematoma, 7 days after transplantation, which was stable and conservatively managed until the 18-th postoperative day, when rapidly expanding intraparenchimal hematoma involving the right hemiliver, several other perihepatic hematomas, significant right pleural effusion and hemorrhagic ascites were described. The patient was successfully treated conservatively (nonsurgically) with slow recovery of the liver allograft and discharged one month later in good general status.

MORGAGNI HERNIA – LAPAROSCOPIC APPROACH (Abstract): INTRODUCTION: Morgagni hernia is due to a diaphragmatic defect, retrosternal congenital hernia being a rare form of hernie. The diagnosis is usually in childhood but there are cases that are found in adult or as a intraoperative surprise. The condition is asymptomatic or has nonspecific clinical manifestations or clinical dressing of often occlusive complications. The diagnosis is established by Rx thoracic imaging, barium enema or computed tomography (CT) eso-gastro-duodenal passage. Treatment consists of reducing the hernia with or without dissection and resection of the hernia sac and diaphragmatic defect closure by suture the fascia endotoracica retrosternal and retrocostala or rectus abdominis sheath or plastic bag. CASE PRESENTATION: We present a case of a 49 years old woman admitted in our department for an insidious onset, several months ago, with postprandial upper abdominal pain, flatulence and nausea. CT scan revealed a mass of 95 / 130 / 80 mm, narrowly defined with homogeneous structure and negative densities (fat) in the lower and middle mediastinum, outlining opacity described in cardiofrenic sinus radiography. The aspect was characteristic for a Morgagni hiatus hernia. Exploratory laparoscopy was performed using a 30o laparoscope inserted through a 10 mm supraombilical trocar; it revealed the parietal defect (Morgagni hernia) and the herniation of greater omentum. Two additional 5 mm trocars are then inserted; the escaped great omentum was reintegrated and the parietal defect was laparoscopically sutured. To note, the peritoneal hernia sac was abandoned. Postoperative course was uneventful. A review of the literature data was also performed. CONCLUSION: Minimally invasive surgery is feasible, safe and tends to become “gold standard” therapeutic approach for the treatment of Morgagni hernia.

Malignant melanomas have a predilection to metastasize to the small bowel. Three patients with malignant melanoma involving the small bowel are reported. Two patients were operated on for small bowel obstruction and the third for gastrointestinal bleeding with anemia. Two patients remained well 6 month and 2 years, respectively, after surgery. One patient died of metastatic cerebral melanoma 6 months postoperatively. One should suspect small bowel metastasis in every patient with malignant melanoma in his past medical history, who presents with recent changes in bowel habits, intestinal obstruction or gastrointestinal bleeding. Preoperative assessment can only raise the suspicion, even with advanced imaging methods: capsule endoscopy, enteroscopy, CT or PET-CT. The only therapeutic procedure is surgical resection, offering both short term survival as well as an improvement in the quality of life. Although prognosis is dismal there are factors associated with prolonged survival: complete surgical resection with no residual primary or metastatic tumor, so-called primary small bowel tumors in patients aged more then 60 years, LDH < 200 U/L, lack of tumor spread in mesenteric lymph nodes.

Background: Breast cancer in men is rare (1% of all breast cancers) and shows some particularities. Methods: We performed a retrospective study analyzing patients admitted and treated in First Surgical Clinic, Emergency Hospital “St. Spiridon” Iasi from 1 January 2008 to 31 December 2015 with malignant breast tumors. Patients included in the study were diagnosed with breast cancer after pathological examination. We followed the clinical data, laboratory and postoperative follow-up of patients. Results: Between 2008 to 2015 in our clinic were treated 319 breast cancers, of which only 11 men, so 3.4%, higher rate to literature data. Most of the patients were aged and with an advance clinical stage. The mean age of men with breast cancer was 67 years, ten years older than women with same disease. The favoring factors in the study group, were smoking, alcohol consumption in 10 patients, obesity present in 9 patients, blood type IIA, Rh + in 8 patients, periurethral adenoma in 7 patients, diabetes in 6 patients. Neoplastic family histories were recorded in 3 patients, one of Lynch syndrome type II, with BRCA2 mutation. In three cases the breast cancer was the 2nd or 3rd cancer after skin cancer after cancer urothelium and sarcoma soft tissue and in one case with colon cancer, 4 years after breast cancer surgery, with chemotherapy and radiotherapy (Lynch syndrome). We performed radical mastectomy with axillar lymphadenectomy in 9 cases and whiteout lymphadenectomy (sentinel lymphnode negative) in 2 cases. Median survival was 4.2 years (range 1-8 years). Conclusion: Men have a particular form of breast cancer. Unlike women, this cancer is found in men at an older age, with a higher rate of lymphatic invasion and hormone receptor positivity. Treatment should be personalized by a multidisciplinary team.

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal malignancies of the digestive tract. We present the case of a 61-year-old male patient liver metastasis of a GIST with primary location at the level of sigmoid colon. Like in the majority of cases, the symptomatology in this patient has long been faint and when it became manifest, it was nonspecific. Imagery wise, the computer tomography (CT) scan was the most efficient, showing the origin of the tumor from large bowel, its dimensions, as well as the relations with the other abdominal viscera and the liver metastasis. Surgery in this patient was en-bloc, according to the principles of GIST and for the metastasis he followed treatment with Imatinib. The histological aspect is characterized by a proliferation of spindle cells positive for CD117 and CD34. Despite complete microscopic resection, the exhibit of liver metastasis remains an important relapse factor.

The term of retrosternal or substernal goiter means that more than 50% of thyroid gland descends in the thorax.There is a retrospective study on retrosternal and substernal goiter and its patological features among 2482 patients who underwent thyroidectomy between 2000 and 2010 in the First Surgery Clinic of Iaşi. Retrosternal goiter was identified 54 patients (2.17%). All patients were refered to surgery from the Clinic of Endocrinology.Mean age at diagnosis was 55.3 +/- 3.58 years, and most cases were found in women (83.3%). The clinical pictures of retrosternal goiter was dominated by compressive disorders. Thyroid function abormalities were identified by hormonal assays performed on Endocrinology Clinic lasi in 15 cases (27.7%). The diagnosis of retrosternal goiter was suggested by clinical examination and confirmed by imagery: thorax X ray, ultrasonography, CT scan. The cervical approach was being safely performed. Only in 8 cases (14,8%), sternotomy was necessary. There was no mortality and morbidity was 5.5% (3 cases). The length of stay in the hospital was 4.3 days. We compared our recent data with a previous report on retrosternal and thoracic goiter treated in First Surgery Clinic of lasi during 1950 to 1979 and published in the journal "Chirurgia" in 1981.Retrosternal goiter is a particular form of thyroid surgical pathology presentation with declining incidence. Diagnosis and treatment of retrosternal goiter involve a multidisciplinary team. The endocrinologist has an important role in diagnosis and postoperative follow-up. Surgery is the treatment of choice for substernal goiters, but there are still some controversies on surgical approach, and complication rate. The cervical approach can be safely performed in almost all cases but when required, sternotomy should be performed without hesitation.

Multiple endocrine neoplasias are syndromes characterized by the involvement of at least two endocrine glands. Parathyroid gland involvement is usually noted in Multiple Endocrine Neoplasia (MEN) type I and type II. Parathyroid glands tumor associated with endocrine pancreatic tumor, as well as pituitary tumors is the typical pattern of MEN I. The parathyroid gland is the most frequent abnormality in MEN I.We presented five cases with MEN I and parathyroid glands involvement. In three cases with young ages (28-33 years old) and familial setting, the MEN I syndrome was "complete" (parathyroid adenoma, gastrinoma or insulinoma and pituitary adenoma--prolactinoma or GH-secreting tumors), and, in the other two cases, with 57 and 68 years old respectively, the MEN I syndrome was "incomplete" with parathyroid glands and pituitary gland involvement. The cases with gastrinomas were operated in emergency for complication of peptic ulcer (perforation associated with peritonitis and gastro-intestinal bleeding); then the pancreatic tumors were diagnosed and left pancreatectomy with spleen preservation and respectively, tumor resection have been performed. Hyperparathyrodism was then diagnosed and subtotal parathyroidectomy has been performed in both cases. Unfortunately one patients died due to severe endocrine disorder. During the necropsy, the pituitary adenoma has been diagnosed. The third case with "complete" MEN was a women of 33 years old, admitted for severe hypoglycemia. The imagistic and laboratory test diagnosed a tumor situated into the pancreatic body, and an parathyroid adenoma. The resection of pancreatic tumor associated with resection of the parathyroid adenoma, in the same time, were performed. The other two cases with "incomplete" MEN were older then the first patients, and were diagnosed with hyperparathyrodism and pituitary gland tumor. The resection of parathyroid gland adenoma has been performed in both cases, with uneventful postoperative course. The literature data was also discussed.The parathyroid glands involvement in MEN is common. There are two kinds of MEN associated with parathyroid gland involvement: the "complete" form, especially in young patients, with diffuse involvement of the parathyroid glands, and the subtotal parathyroidy is the best choice, and the "incomplete" form, especially in elderly, with the involvement of a single parathyroid gland; in this way, the resection of the adenoma associated with biopsy from the other parathyroid gland is the best approach. The presence of gastrinomas, complicate the disease prognosis and the surgical approach. The treatment of these patients is challenging and has to be done in multidisciplinary team.

Multiple focal liver lesions can generate diagnosis difficulties in daily practice. This paper present the case of a 53 years old patient with multiple hyperechoic liver lesions suggestive for hepatic hemangiomas, detected during the ultrasonographic exam. Contrast enhanced ultrasonography indicated focal hepatic steatosis, while computed tomography proposed possible liver metastasis. The histological diagnosis was focal nodular hyperplasia associated with hepatic steatosis. The peculiarity of the case was the association of multiple focal nodular hyperplasia lesions with hepatic steatosis and atypical imaging findings that required histological confirmation.

The use of self expandable metallic stents (SEMS) in the palliation of dysphagia due to malignant esophageal stenosis is a gold standard. Covered stents are used in all cases with overt air-digestive fistula or high potential for fistula development. The procedure is associated with a low incidence of procedure-related complications. We present a case with a major accident which developed during stent deployment. The delivery system became blocked and we found it impossible to fully deploy the stent, which remained attached to the introductory system. The stent was forcefully removed and replaced later on with a new stent. This is the first report of a SEMS related accident due to malfunction of the stent deployment system. Stent malfunction is unusual and unlikely to happen, but one should be aware and prepared for such unusual situations.

Gynecomastia describes a benign increase of the mammary gland in men. When medical treatment fails, the surgical procedure is the treatment of choice. There are two main surgical procedures: subdermal mastectomy and liposuction.To evaluate the results after surgical treatment (mastectomy) performed in a general surgery unit.We performed a retrospective study; all the patients operated for gynecomastia were reviewed. The clinical, imaging, biological, intraoperative and histological data were included into a MS Access database and statistical analyzed.From 1990-2007, 114 patients were admitted in the First Surgical Clinic Iaşi for gynecomastia. Only 12.6% from the patients were with bilateral gynecomastia. The mean age was 40.54 +/- 1.83 years old (range 12-84). Mean body mass was 26.72 +/- 0.46 kg/m2 (range 18.5-41), and about 20% from the patients had a BMI of over 30 kg/m2. We also noted that 46.5% were smokers. Simon classification was used for preoperative staging: 2.6% from the cases (N = 3) were included in stage I, 16.7% (N = 19) in stage IIa, 50% (N = 57) in stage IIb and 30.7% in stage III. The patients included in stages IIa and I are younger then the patients included in stage III (p = 0.024). Mastodynia was noted in 46 cases (40.4%). Ultrasound exam was performed in all the cases, and the larger diameter of the nodule measured was 3.75 +/- 0.18 cm (range 0.5-9.7). Only three cases were preoperatively treated with tamoxifen. Most of the cases were operated using general anesthesia (53.5%). Mastectomy was performed by peri-areolar (70.2%), elliptical (28.9%) or radial (0.9%) incisions. The subdermal mastectomy using peri-areolar approach was performed especially for the cases included in stages I, IIa and IIb--p10(-3). The epi-pectoral vacuum drainage has been used in 79.8%. The postoperative morbidity rate was 15.8%--4 cases of hematoma, 13 cases of seroma and 1 case complicated with skin necrosis. No specific risk factors for postoperative complications were found by univariate and multivariate statistical analysis. The pathological exam revealed pseudo-gynecomastia in 6 cases; the other cases presented dilated ducts. We also noted intraductal papillary hyperplasia in 87 cases and chronic inflammation in 35 cases. The histological exam also revealed intraductal papilloma--9 cases, fibro-adenoma--1 case, papillary ductal carcinoma--1 case and mucinous carcinoma--1 case. From all these data, the etiological diagnosis in presented series was: pseudo-gynecomastia--5.3% (N = 6), idiopathic--64.9% (N = 73), endocrine--7.9% (N = 9), drug induce--5.3% (N = 6), metabolic--7.9% (N = 9), tumoral--8.8% (N = 10). The postoperative hospital stay was 4.04 +/- 0.26 days (range 1-12). A literature review has also been performed.The management of gynecomastia has to be performed by a multidisciplinary team. Gynecomastia it is possible to be associated with a breast cancer, even in younger people. The surgical treatment, especially the type of incision, will be chosen from point of view of Simon stages. Liposuction can be associated in selected cases.

Pyogenic liver abscesses were a relative rare disease. In the last decades the management of the liver abscesses was changed due to the new imaging and surgical techniques.To evaluate the clinical features, imaging techniques and treatment of the liver abscesses.We performed a retrospective study during the last twenty years (1987-2007). The patients were divided in two groups: group I treated during the period 1997-2007 and group II, 1987-1996. We compare the clinical features, biological tests, imaging techniques and the treatment.Of the 71 patients with liver abscesses, 39 (54.9%) were included in group I and 32 (45.1%) in group II. The male/female ratio was 49/22; liver abscesses were more frequent to the males, in group I (63.3%) and more frequent to the women, in group II (63.6%) (p = 0.035). The mean age was 47.49 +/- 2.09 years old (range 18-85) with no difference between the groups (p = 0.059). The symptoms were similar in the two groups. We noted, as associated disease: diabetes--16% (N = 12), liver cirrhosis--7% (N = 5), malignancies--4.2% (N = 3). White blood cells were higher than 10000/mm3 in 51 patients (71.83%); a severe anemia with hemoglobin levels less than 10 g/dL was found in 25 cases (35.21%). All cases were investigated by ultrasound exam, but CT scan was performed in only 25 cases (19.71%). The abscesses were situated into the right lobe in 53 cases (74.6%), into the left lobe in 13 cases (18.3%) and into the both lobes in 5 patients (7%). The etiology was diverse: 25.4% after hepatic hydatid cysts, 12.7% with biliary origin, 22.5% with hematogenous and phlebitis origin and 39.4% with unknown origin (cryptogenetic). Treatment of the liver abscesses was surgical, by open (87.3%) or laparoscopic approach (8.5%), and percutaneous (ultrasound guided punction)--2.8%. One case was medical treated (antibiotherapy). Bacteriological exam found aerobic germs in 45 patients (64.28%), anaerobic germs in 3 patients (4.28%); the pus was sterile in 22 patients (31.43%). The intraoperative mean dimension of the liver abscesses was 74.26 +/- 4.35 mm (range 30-160), similar with dimensions measured by echography 72.29 +/- 4.84 mm (range 12-179)--p10(-3). Intraoperative bleeding was noted in 29 patients (40.8%). Univariate analysis revealed as prognosis factors for intraoperative bleeding, diameter of the liver abscess (p10(-3)), dimension of the residual cavity (p10(-3)) and the pus volume (p10(-3)). The multivariate analysis, by logistic regression, revealed as prognosis factors for intraoperative bleeding, pus volume (p = 0.006) and hemoglobin level (p = 0.035). Postoperative morbidity was 43.7%. Univariate analysis and logistic regression revealed the pleural effusion as prognosis factors for postoperative complications (p = 0.046) and, respectively, intraoperative hemorrhage (p = 0.010) and splenomegaly (p = 0.007). Postoperative mortality rate was 2.81%.Pyogenic liver abscess is a challenging disease with high rate of postoperative morbidity. Most of the abscesses are unique and situated in the right lobe of the liver. The imaging techniques, especially ultrasound exam and CT-scan, are essential for the diagnosis and the treatment of liver abscesses. The treatment is usually surgical, by open or laparoscopic approach; in selected patients the percutaneous approach can be performed.

We performed a retrospective study to assess the postoperative results, long-term survival and quality of life after pylorus preserving pancreaticoduodenectomy (PPPD) versus standard Whipple pancreaticoduodenectomy (WPD).A retrospective study was performed in a nonselected series of 137 patients who were operated in the Surgical Clinics of "St. Spiridon" University Hospital Iaşi, Romania, from January 1st, 1995 till December 31, 2005. Demographics, preoperative and intraoperative data, as well as postoperative morbidity, mortality and follow-up were analyzed. Quality of life, after to at least six months after discharge, was also studied.There were no significant differences noted in demographics data. Jaundice was more frequent in the PPPD group as for WPD patients (p=0.047). For the most patients the digestive reconstruction after resection were performed as in Child technique: the first anastomosis was pancreaticojejunostomy (end-to-end or end-to-side), the second anastomosis was hepaticojejunostomy (end-to-side) and the last anastomosis was gastrojejunostomy end-to-side (duodenojejunostomy in PPPD group). For 31 cases a pancreatico-gastrostomy were performed. We also noted 14 cases with pancreatico-gastrostomy and duodenojejunostomy end-to-end, and a Roux jejunal loop for 3 patients with previous gastrectomy and gastrojejunostomy (Reichel-Polya). The operating time was shorter in the PPPD group as in WPD (p10-3), but the mean blood loss was the same. Postoperative morbidity rate was 46.8% in PPPD group vs 39.2% in WPD (p0.05), but the reintervention rate was significant higher in PPPD group (30.6% vs 15%; p = 0.027). We also noted no significant differences of Delayed Gastric Emptying, postoperative mortality rate (14.5% in PPPD group vs 10.1% in WPD group) and mean survival time (42.42 months (24.94 - 59.89; 95% CI) in PPPD group vs 46.78 months (28.07 - 61.50; 95% CI) in WPD group; log rank test p = 0.643). Pathological exam diagnosed a malignancy in 109 cases (54 cases with pancreatic cancer); we noted chronic pancreatitis in 22 cases. Quality of life was also the same in the two groups.PPPD and WPD were associated with comparable results, but, there is a tendency of increase rate of postoperative morbidity and mortality for PPPD patients. We also noted that postoperative quality of life is the same for both procedures.

Pancreatic cancer has an increase rate in western countries. From the first pancreaticoduodenectomy (PD) performed by Kausch in 1909, the value of the resection in the treatment of pancreatic head cancer was disputed.To assess the PD with or without pylorus preservation as surgical treatment for pancreatic cancer.Retrospective review of the clinical records of patients undergoing PD for pancreatic cancer.From January 1995 till December 2005, in the First and Third Surgical Units, "St. Spiridon" University Hospital Iaşi, Romania, were performed 137 PD. From these, 54 cases were histologic diagnosed with pancreatic cancer; 23 cases underwent pylorus preserving pancreatico-duodenectomy (PPPD) and 31 patients, classical Whipple procedure (PDW). Mean age was 59.07 +/- 1.42 years old (26-75 years old), and male to female ratio was 29 to 25. Jaundice was presented in 51 cases (94.4%), abdominal pain at 39 patients (72.2%) and Curvoisier-Terrier sign at 37 cases (68.7%). Fever was observe only in 4 cases (7.4%). Other biological and imaging parameters (e.g. main diameter of the biliary duct, tumor and wirsung ) were also discussed, but no significant difference was found between PPPD and PDW. Pancreatico-jejunostomy was performed in 41 cases (28 during the PDW and 13 in PPPD) and 13 pancreatico-gastrostomy (3 during PDW and 10 during PPPD). Mean operating time and mean blood loss in the PDW group were 358.22 +/- 10.53 minutes and 587.74 +/- 60.87 mL. After PPPD, these figures were 326.08 +/- 15.04 minutes and 571.74 +/- 90.50 mL, but no significant difference was noted. Delayed Gastric Emptying (DGE) was presented at 15 patients: 8 in PPPD group and 7 in PDW group (p=0.322). Postoperative morbidity rate (excluding DGE) was 33.33% (8 cases in PDW group and 10 in PPPD group). Pancreatic leak has a rate of 5.55% (3 cases--one in PPPD group vs two in PDW group), biliary leak has a rate of 12.96% (4 in PPPD group vs 3 in PDW group)and duodeno-jejunal anastomotic fistula appeared in one cases (PPPD). Acute postoperative pancreatitis is presented in one case (PPPD group) and postoperative hemorrhage appeared in 4 cases (2 in PPPD and 2 after PDW). Hospital stay was 19.91 +/- 2.28 days in PPPD group vs 18.87 +/- 2.24 days in PDW group (p = 0.751). Postoperative mortality rate was 5.5% (one case after PPD and 3 cases after PDW). Histological exam diagnosed ductal pancreatic adenocarcinoma in 51 cases (94.44%). Mean long-term survival rate was 20.98 months (10.52-31.45 months; 95 CI) and no difference was revealed between PPPD and PDW (log rank test - p = 0.796).PD should be performed for any pancreatic tumor even without preoperative histologic confirmation. The results after PPPD (postoperative morbidity and mortality, long-term survival) are similar to that following conventional Whipple procedure, if the principles of viable and tumor free margins are observed.

Anatomical abnormalities of the liver are extremely rare. We report a case of a 32 year old female who has admitted with acute epigastric pain and vomiting. Physical exam revealed a mobile mass in right middle abdominal quadrant. Ultrasound and contrast--enhanced CT demonstrated a heterogeneous vascular left mass. Small bowel enema shows left jejunal loops displacement. Surgical findings: twisted, congested swelling, attached by a long pedicle to the liver's third segment. Histological examination showed recent hepatic infarction.

Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors of the gastro intestinal tract and express the c-kit proto-oncogene protein (CD-117). We report herein a case of a 58 years old male with upper abdominal pain and anaemia. Preoperative endoscopic and barium meal exams showed a submucosal tumor in the gastric fornix. Endoscopic biopsy revealed spindle-shaped cells with elongated nuclei specific of GIST. We performed a stapled resection of the gastric fornix associated with Hiss angle reconstruction. Postoperative histologic exam revealed the same spindle-shape cells characteristic of GIST with 2-5 mitosis/50HPF. Almost all of the cells showed immunoreactivity for c-kit, CD-34 and a Ki-67 labeling index of 30%. Postoperative course was non eventful and after 3 month the patient has no recurrence.GIST are rare gastric tumors and are usually associated with bleeding and abdominal pain. The preoperative diagnosis is usually established by endoscopy with biopsy or endoscopic ultrasonography fine needle aspiration and barium meal exam. Only immunoreactivity is able to differentiate GIST from other mesenchymal tumors. Surgical resection is a safe and effective treatment. The chemotherapy with tyrosine kinases competitive inhibitors (e.g. imatinib mesylate) is also recommended.

We analyze the experience in laparoscopic hepatic surgery of the Research Center of Laparoscopic and Open Surgery from Iaşi between 1993-2006. This study includes 92 patients (0.9% from 10,367 laparoscopic operations) with liver pathology considered for laparoscopic treatment. We performed 42 Lin procedures (wide fenestration technique) for serous hepatic cysts, 32 cystectomies for hepatic hydatid disease, 10 non-anatomical hepatic resections (for 2 adenomas, 4 haemangiomas, 4 metastasis) and 8 steam water thermo-necrosis (for multiple hepatic metastasis). Conversion to open surgery rate was 8.7% (hepatic hydatid cysts--6 cases, serous hepatic cyst--1 case with associated acute cholecystitis, thermo-necrosis--1 case). We had no postoperative mortality and morbidity rate was 6.5%. The follow-up was available in all patients for a mean time of 12 months, by abdominal ultrasound exam and/or computed tomography. No evidence of disease recurrence was registered. We are at the beginning of the laparoscopic hepatic surgery and these results need to be confirmed. For the hepatic serous cysts the laparoscopic fenestration is the best treatment, but for the hepatic hydatid cyst, the laparoscopic approach is indicated only in selected cases: uni-vesicular hydatid cyst, noncomplicated, localised into the "laparoscopic" segments of the liver. Albendazole treatment is also necessary in these cases. For all types of benign liver tumours, the best indication remains small, superficial lesions, located in the anterior or the lateral segments of the liver. When performed by expert liver and laparoscopic surgeons using an adequate surgical technique, the laparoscopic approach is safe for performing minor liver resection for malignant tumours and is accompanied by the usual postoperative benefits of laparoscopic surgery.

We report the 19 months followup results after thermo-necrosis with steam water of non-resectable colorectal liver metastases. The studied group included 24 (18 men + 6 women) cases, aged 39-85 (mean age = 61), that were subjected to thermo-necrosis procedure between 2004-2006. Thermo-necrosis was performed per primam (1 case with non-resectable primary tumor), or either synchronous (8 cases) or at up to 53 months (15 cases) after primary tumor resection, and implied delivering of 6.7 - 87 kiloJoules to targeted lesions (for a median of 5 targets per patient liver). Concomitant with thermo-necrosis, in 8 cases some metastatic lesions were also resected (for tumor mass reduction). Followup consisted in echographic, CT, clinical and laboratory evaluation each 1-2 month.The thermo-necrosis procedure was completed within 3 to 20 (median = 10) minutes, and no peri-operatory deaths or complication were recorded. After procedure, the treated lesions either shrunken or were stationary under imaging explorations; increasing images marked the time to tumor progression. Tumor progression was recorded in 12 cases, time to tumor progression ranging from 1 to 14 (median = 5) months; the follow up time for the remaining 12 cases ranging 3 - 18 (median = 8) months. Nine cases died at 6-15 (median = 9) months after thermo-necrosis; for the remaining 15 cases the followup time ranged 4-19 (median= 10) months. One year survival was 61%; median survival (50%) time was 9 months.Thermo-necrosis with steam water of non-resectable colorectal liver metastases associate low invasiveness, good compliance, and time interval for tumor progression and survival comparable or better than other thermo-necrosis techniques, representing a promising palliative therapy in secondary liver cancer.

Three years after right nephrectomy for stage II (T2N0) clear cell carcinoma, a 51-year old man presented with upper digestive tract bleeding. Endoscopic examination revealed a duodenal mass. Imaging modalities showed the lesion in the head of the pancreas, with duodenal wall invasion, and raise the question of a pancreatic metastasis. The anatomopathology result of the resection specimen confirms the imaging diagnosis.

The aim of this study was to assess breast cancer incidence, diagnostic possibilities in clinical treatable stages and the prognosis in a series of breast cancer patients repeatedly treated in the same unit, by the same team. Diagnostic difficulties in the early stage of the contralateral cancer constitute a proven reality even in our cases. The detection of the second metachronous breast tumor was done and evaluated mostly in an more advanced stage than the initial tumours. This might be explained by the delayed visit to the doctor. Most BBC were lobular carcinoma. Adjuvant therapy--chemotherapy, antiestrogens, ovariectomy--do not prevent the appearance of the second tumoral site.

We report the peculiar case of a young woman with hepatic hydatid cysts, with numerous peritoneal disseminations (56 cysts) incidentally diagnosed during a caesarian section. The case was managed, surgically preceded and followed by systemic treatment with albendazole. Surgical treatment addressed both the hepatic cyst and the peritoneal hydatid disease aiming to preserve involved abdominal organs. The diagnosis of peritoneal hydatid disease is today more accurate due to the new imaging techniques and the surgical procedure should be tailored to each patient depending on size, location and complications of each cyst. Radical treatment is the best and represents a goal, but with multiple disease, a staged treatment and special care for organ preservation should prevail as recurrences are not unusual.

Superior mesenteric artery (SMA) syndrome is an uncommon cause of proximal intestinal obstruction, frequently occurring in patients who have had an important weight loss. The diagnosis can be difficult and usually is made by exclusion. The most characteristic symptoms are postprandial epigastric pain, fullness, voluminous vomiting and eructation. These symptoms are due to the compression of the third portion of the duodenum against the posterior structures by a narrow-angled SMA and surgical management is necessary. We report a case of SMA syndrome in a 23 year old patient, with a long history (since childhood) of voluminous vomiting, epigastric pain and an important weight loss. We performed small bowel enteroclysis, upper gastrointestinal series and endoscopy, biopsy of gastric and duodenal mucosa, abdominal computer tomography and ultrasonography to establish the diagnosis. Finally, the patient successfully underwent duodenojejunal anastomosis with a postoperative favourable outcome.

The incidence of hepatocellular carcinoma (HCC) in cirrhotic patients is increasing. Despite advances in imaging and laboratory screening which allow earlier diagnosis, the surgeon is all too often confronted with an HCC of advanced stage or arising in the setting of severe cirrhosis. Hepatic resection is still considered the treatment of choice for hepatocellular carcinoma in patients with liver cirrhosis. From 1998 to 2005, 6 patients (5 males, 1 female, age 52-70 years, mean age 64.1 years) with HCC associated severe, but well compensated liver cirrhosis (Child A-- 4 patients, Child B--2 patients) underwent 9 hepatic resection in our department. Mean tumor size was 56 mm (range 23-86 mm). Two of these lesions were in the left liver and four in the right lobe. Doppler ultrasonography was performed in all cases and CT in 3 cases to confirm the extension of the lesions. Laparoscopy was performed in 3 patients under CO2 pneumoperitoneum. The Pringle maneuver was not used. The transection of the liver parenchyma was obtained by the use of Ligasure and harmonic scalpel. Nine hepatic resections were performed: 7 segmentectomy and 2 non-anatomical resections. The resection margin was 1 cm. The mean operative time was 90 minutes (range 60-120). Mean blood loss was 250 ml and 2 patients required blood transfusion. One patient died on the tenth postoperative day from a severe respiratory distress syndrome and hepatic failure. Major morbidities occurred in three patients who developed moderate postoperative ascites, which resolved successfully with conservative treatment in two patients. Limited liver resection in cirrhotic patients with HCC is feasible with a low complication rate when careful selection criteria are followed (tumor size smaller than 8 cm, Child-Pugh A class and the good general conditions of the patients). Other medical and interventional treatments (chemoembolization, chemotherapy) can only slow the progress of HCC.

Hydatid disease of the liver is still endemic in certain parts of the world. The modern treatment of hydatid cyst of the liver varies from surgical intervention to percutaneous drainage or medical therapy. Surgery is still the treatment of choice and can be performed by the conventional or laparoscopic approach. The aim of the study is to analyze the results of the surgical treatment in hydatid disease of the liver in First Surgical Clinic, Iaşi. The study concerned a period of 12.5 years (1992 - 31.07.2004) and it included 337 cases. There were performed radical procedures (ideal cystectomy - 17 cases - 5.04%, hepatic segmentectomy - 8 cases - 1.48%, atypical hepatectomy - 10 cases - 2.96%) or conservative procedures (de-roofing - 37 cases - 10.97%, subtotal pericystectomy - 34 cases -10.80%, total pericystectomy - 19 cases - 5.63%, partial pericystectomy - 212 cases -62.90%). In 35 cases (10.38%) the operation was started laparoscopically and 12 cases needed conversion. Postoperative course was complicated in 112 cases (33.32%) (external biliary fistula, cavity suppuration, residual cavity hydatid relapse). Radical methods constituted operations that had excellent results, but they are feasible in few cases. Conservative procedures, relatively simple and still accepted, have a higher rate of morbidity. The laparoscopic approach is more and more used, with good results.

Hydatid cyst is a parasitosis caused by Taenia Echinococcus. In the last 10 years, new methods of treatment of the hydatid cyst have been proposed (percutaneous or laparoscopic).This retrospective study includes 24 patients with hepatic hydatid cyst (HHC) who were treated by a minimally invasive approach, 18 women and 6 men (average age 49.3 years), representing 10% of all patients with HHC.The average operative time was shortened to about 70 minutes. The conversion rate was 25%. In all cases managed laparoscopically, the prophylactic flooding of the peritoneal cavity was realized with peroxide solution 10 per thousand or with hypertonic saline 30%. The inactivation of the cyst was performed with hypertonic saline in most of the cases. Most cysts were univesicular (62.5%), but there were also multivesicular cysts (37.5%). In two cases patients presented hepatic and pulmonary hydatid disease which were also approached in a minimally invasive manner. The average postoperative period of the cases treated laparoscopically was 6 days and for the converted cases it was 13.3 days.The open surgical approach of HHC is highly expensive due to the postoperative period, therefore a laparoscopic approach may be advocated. The minimally invasive method shortens the postoperative hospitalization period, reduces the number of complications as well as the overall costs and facilitates a rapid social reintegration. All these arguments recommend the laparoscopic approach as a standard procedure for hepatic hydatid disease.

Zenker's diverticulum is a protrusion of the posterior mucosal wall of the hypopharynx through the weakened muscular layer, between the oblique fibers of the inferior constrictor of the pharynx and the transverse fibers of the cricopharyngeal muscle (Killian's dehiscence). Pharyngoesophageal pulsion diverticulum is the most common of all the oesophageal diverticuli and is characterised by dysphagia, regurgitation, gurling sounds in the neck and aspiration. The current principles of surgical management includes a pharyngoesophageal myotomy accompanied by a diverticulectomy or a diverticulopexy. The same principles apply in both open approach and the endoscopic methods.

Hydatid disease is relatively frequently encountered in general surgery services (4-5% of the total operated cases). The association of the hepatic and pulmonary localizations is quite common, but the involvement of more organs is rare. The asymptomatic rupture of the hydatid cyst in the peritoneal cavity is exceptional. We present the case of a 69-year old female patient who was hospitalized in the 1st Surgical Clinic for irritative dry cough, loss of weight (4 kg in the last 3 months), fatigue, itching and dyspnea. She had been hospitalized in a department of internal medicine for respiratory symptoms when, during X-ray investigation, an opacity was observed, which was suggestive for a pulmonary hydatid cyst. The abdominal ultrasound revealed a multiple hydatid localization (liver, spleen, lower right abdominal quadrant and hypogastrium) and the patient was sent to our clinic. The patient was treated with albendazole 10 mg/kg/day for 10 days before surgery. Surgery was performed by a minimally invasive approach, first by thoracoscopy and, in the same operative session, the other hydatid localizations were approached by laparoscopy. The parasiticide treatment was continued about 3 months after surgery, when the patient was hospitalized again in order to cure the splenic hydatid cyst. Postoperative evolution was complicated by a biliary fistula which resolved spontaneously in 10 days after the intervention. The postoperative hospital stay was 14 days. This case was unusual because of the paucity of symptoms in spite of the multiple abdominal cysts and because it was cured by a modern, minimally invasive approach.

The incidence of hydatid disease is increased in Balkan region and Eastern Europe. The global incidence in Romania is 5-6 cases of 100,000 populations. The etiological agent is Taenia echinococcus. The pulmonary localization is about 30% from all cases with hydatic disease. The only efficient treatment is represented by surgical intervention with minimal visceral and parietal destruction. We will present 4 cases with pulmonary and pleural hydatic cysts that were treated with minimally invasive techniques. New minimally invasive approaches are developed to reduce physical discomfort, to offer a better intraoperative visibility, for the esthetic aspect of incisions, shorten hospitalization and quick socio-professional reintegration. The mean duration of hospitalization in these 4 cases was 8.5 days (limits between 7-12 days). The rate of complication and the necessary of analgesics were reduced. The medical treatment with Albendazole 10 mg/kg/day, 14 days in preoperative and 3 months postoperative period was followed in all patients. After discharge, imaging evaluation in the first 24 months is very important. The obtained results were excellent and we conclude that minimally invasive surgery in pulmonary hydatid disease represent a better method of surgical treatment.

Congenital cystic disease of the biliary system is a complex syndrome of ectasies of the intra-, extra- or both situation of biliary tree. This disease has an unsure etiopathogeny. It is uncommon through the third age, with a greater incidence in child, teen-ager and young adult. The goal of our study is to evaluate the symptoms, diagnosis, treatment and histological aspects of the congenital biliary cysts. We performed a retrospective study from March 1988 to July 2003 about 11 patients with this disease treated in our surgical clinic. Clinical features, methods of diagnosis and surgical treatment were assessed. All patients were females with mean age 51 years (extreme 26-77 years). The symptoms were: right upper quadrant pain--11 cases (100%), jaundice--6 cases (54.5%), fever--3 cases (27%), palpable abdominal mass--2 cases (18%), weight loss--1 case (9%). The imaging diagnosis was helpful (ultrasonography, CT, ERCP, percutaneous cholangiography and preoperative cholangiography). In concordance with Todani classification the patients were included in the following types: Ia--3 cases (27%), I b--1 case (9%), I c--3 cases (27%), IV a--2 cases (18%), IV b--1 case (9%), V--1 case (9%). All patients were operated on: after cholecystectomy and transcystic cholangiography (11 cases--100%) we performed the total excision of the cyst--9 cases (82%) with choledochal jejunostomy (Roux-en-Y)--6 cases (54.5%), choledochal jejunostomy (omega)--1 case (9%) and choledochal duodenostomy--2 cases (18%). In one case of neoplasic cyst with portal invasion we performed a cyst-jejunostomy (omega) and in one case of Caroli disease with total obstruction of the distal choledoc, the solution of choice was choledocal-duodenostomy. The microscopic pathology of the cyst wall showed: chronic intramural inflammation--9 cases (82%) and the absence of the nervous intramural terminations--1 case (9%). The additional lesions was: hepatic cirrhosis--1 case (9%) and hepatic fibrosis--3 cases (27%). We found three cases with neoplasia: malign cyst with advanced local invasion--1 case (9%), pancreatic carcinoma--1 case (9%) and gallbladder carcinoma (microscopic finding)--1 case (9%). The postoperative morbidity includes biliary fistula--2 cases (18%) and wound infection--2 cases (18%). Long-term follow-up revealed cholangitis in one case--9%. The cystic dilatations of the common bile duct is an exclusive indication for surgery as soon as it was discovered.

A number of 1031 patients with gastric cancer have been admitted in the First Surgical Clinic of Iasi between 1986-2001. The operability index was 86%, 52% being resectable and 36% having potential curative resection. In this group, 222 patients benefited from total gastrectomies. We consider the introduction of stapled eso-jejunal anastomosis (38 patients) as the most important moment in this development, as the manual performance anastomosis is considered difficult due to the problems imposed by suturing in a deep space. Postoperative course of patients who benefited from stapled anastomosis was simple although many patients had a poor biological status. We encountered only one small fistula, which was dealt with conservative. Patients in this group had immediate postoperative results significantly better than the comparative group with manually performed anastomosis. Introduction of stapler techniques increased the proportions of patients who benefited from palative total gastrectomies for advanced gastric cancer. We consider that a method to solve the frequent complications, insured an increased intraoperative comfort, reduced the number of postoperative complications, increased survival and improved patients quality of life.

We present a rare entity of colonic pseudo-obstruction, characterised by severe colonic dilatation in absence of any organic obstacle. Clinical symptoms, diagnostic approach, and therapeutic measures are analysed and discussed. Many factors have been associated with this syndrome which include electrolyte imbalance, systemic infection, drugs, and occasionally, neurologic disease. Reported here is a case of acute colonic pseudo-obstruction which developed in a patient with restrictive respiratory dysfunction. Colonic decompression by means of colonoscopy, the most effective therapeutic approach for pseudo - obstruction failed, and surgical cecostomy was required. The acute colonic pseudo-obstruction, Ogilvie's Syndrome, most often appears as a complication of other clinical conditions. It is characterized by massive colonic dilatation in the absence of a mechanical cause and may lead to cecal perforation in absence of treatment. When colonic obstruction is suspected, one should always consider the possibility of the occurrence of Ogilvie's syndrome

We present three rare entities of mucinous tumors: appendiceal mucinous adenomas, enteroid mucinous cyst and pseudomyxoma peritonei, the latter as a developmental course or separate idiopathic etiology of mucinous tumors. We attempted to clarify the term of pseudomyxoma peritonei, a poorly understood condition, characterized by a diffuse intraperitoneal collection of gelatinous fluid with mucinous tumoral implants on the peritoneal surfaces. With this rare condition it is often difficult to establish the histological and developmental malignant or benign characteristics. We analyzed 4 patients admitted during the period of February 2000 - February 2002 in the First Surgical Clinic of St. Spiridon Hospital and in addition we referred to the current approach in the recent literature. In three of the four patients the diagnosis was possible preoperatively by imaging techniques and consequently they were operated by laparoscopic procedure for the complete removal of tumor cells at macroscopic level. We preferred to administrate chemotherapy accordingly to the malignant/ benign aspect, choosing the long term follow up of the patients to ward off the eventual relapse. We considered the future state of these cases to be uneventful, with a real chance of long term survival. In conclusion, the symptoms are not always specific, allowing errors in diagnosis. Imaging techniques offer real elements of diagnosis. Laparoscopic techniques could offer an oncologic approach with no less benefit compared to open surgery. This methodology also allows different surgery for a different pathology at the same time. The origin of these tumors is more frequently digestive and less ovarian.

Esophago-respiratory neoplastic fistulas present serious problems of management, mostly because of the severe status of the patient. The authors present the case of a 49-year-old patient with a malignant eso-tracheal fistula manifesting as mild dysphagia and dyspnoea. An endoscopic palliative treatment of the fistula was performed introducing a metallic coated stent into the esophagus. The multiple stent displacement required a definitive, very high positioning of the stent in the lower pharynx, with significant discomfort. Severe respiratory conditions regressed and the patient survived 6 months after the initial placement. The authors suggest endoscopic palliation with esophageal prosthesis as the therapeutic choice in those cases not amenable to surgery.