Laparoscopic cholecystectomy (LC) has become the gold standard in the treatment of symptomatic cholelithiasis. Some patients require conversion to open surgery and several preoperative variables have been identified as risk factors that are helpful in predicting the probability of conversion. The aim of this study was to analyze the factors that make LC difficult and determine conversion to open approach: Our study includes: 6985 cases which underwent LC and 1430 cases with open cholecystectomy, between March 1993 and April 2005 in our clinic of general surgery. The overall conversion rate was 5.1% (deliberate conversion--299 cases, conversion of necessity--62 cases). The conversion rate has decreased from 17.5% in 1993 to 3.2% in recent years. The most conversion happen after a simple inspection or a minimal dissection caused by the existence of perforation (105 cases), the discovery of a difficult anatomic situation (63 cases) or of another pathology (14 cases); more rarely, the conversion was necessary in the principal time, doing to hemorrhage (26 cases), impossible dissection (41 cases), visceral injury (1 case) or even at the end of the operation, doing to hemorrhage, loss piece or stone (10 cases), and other situations (101 cases). Significant predictors of conversion were acute cholecystitis , choledocholithiasis, past history of acute cholecystitis, male gender, gall bladder wall thickness exceeding 6 mm. In conclusion, based on our experience, we suggest limiting OC to patients with proven contraindications to LC (i.e., Mirizzi syndrome or systemic illness incompatible with general anesthesia or pneumoperitoneum), attempting LC in all other cases. Decision to convert to open approach is a proven of surgical maturity. Conversion must be decided from the beginning, in the moment of the recognition of a difficult situation and not after the occurrence of a complication.

Adult↗

PubMedDate not supplied

[Hydatic cyst of the liver. Considerations on 337 cases].

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.

Adolescent↗

PubMedDate not supplied

[Pancreatic endocrine tumors].

Incidence of the endocrine tumors of the pancreas is about 4 to 10/1.000.000 peoples. We present 10 cases of endocrine pancreatic tumors which were operated in the First Surgical Clinic Iaşi in the last 20 years (1984-2003); these cases represent about 2.21% from all the pancreatic tumors (454 cases). It was 4 insulinoma, 2 gastrinoma, 2 gastrinoma associated with other endocrine neoplasia (Wermer syndrome) and 2 non-functioning endocrine pancreatic tumors. Female/men ratio was 9/1 and median age was about 41.9 yo (27-67 yo). In the four cases of insulinoma (all females) the diagnosis was delayed by two to five years due to misinterpretation of neurological symptoms generated by hypoglycemia. The diagnosis of insulinoma was based on Whipple triad, high plasma insulin levels associated with low plasma glucose levels, as well as the symptomatic relief after intravenous glucose injection. The surgical option was based on biological data, ultrasonography, computed tomography and arteriography. In two cases the localization of the insulinoma was established only by intraoperative ultrasonography. All tumors were localized in the tail of pancreas. In three cases we decided for a distal pancreatic resection with splenectomy and in one case for spleen preserving left pancreatectomy. Postoperative course was uneventful and all the symptoms disappeared. The diagnosis was confirmed on pathological examination in all cases. We also present two cases of gastrinoma with multiple ulcers and multiple surgical interventions for haemorrhage and perforation with peritonitis. Both patients died and diagnosis of pancreatic endocrine tumors was post-mortem. The two patients with Wermer syndrome also had ulcers complicated with haemorrhage and peritonitis and parathyroid adenoma. One case also had ante-hypophyseal and pituitary adenoma and the other had thyroid colloid hypertrophy. We performed left pancreatectomy with spleen preservation in one case and enucleation associated with total gastrectomy in the second case. The two cases of non-functioning pancreatic endocrine tumors had a non-specific symptoms. Diagnostic was established by abdominal ultrasound exam. We performed spleno-pancreatectomy in one case and pancreatectomy with spleen preservation in the other patient. Postoperative course was un-eventful.

Adult↗

PubMedDate not supplied

[Incidence and management of the ovarian fibroma and thecoma. Experience of The First Surgical Clinic Iaşi].

The ovarian fibroma, thecoma and fibro-thecoma are a rare benign tumors growing from the connective tissue of the ovarian cortex. The general surgeon may confront in his practice solid ovarian mass, sometimes in emergency. Between 1995 and 2005, we report thirteen cases of ovarian fibroma (two bilateral) and two ovarian thecoma with mean age 53 years operated in First Surgical Clinic Iasi. Four of them were operated on as emergencies. Clinical ascites are found in three patients with large tumors. The early symptoms were pelvic pain and abnormal uterine bleeding. Patients with large tumors or ascites were admitted with compression symptoms or abdominal distension. Ultrasonography showed a solid uniformly hypo-echogenic mass, with very marked sound attenuation. We performed oophorectomy in six cases (laparoscopic approach in four cases) and salpingo-oophorectomy in nine cases (using laparoscopic stapler in three cases). There were no conversions to laparotomy. In all cases the diagnosis was established by histological examination. Laparoscopic approach is associated with significantly less operative morbidity, less postoperative pain, shorter hospital stays and shorter recovery periods, best cosmetic results.

Adult↗

PubMedDate not supplied

[Cholecystosis, the diagnostic and treatment problems].

In the interval 1981-1989 at the Ist Clinic of Surgery of Iaşi 230 cases of chronic cholecystitis were admitted and operated upon (cholesterolosis--24 cases, dysmorphosis--84 cases, dysplasia--22 cases). Most cases had a morphologic--dysmetabolic substrate--strawberry gallbladder, alone or associated with other lesions (lithiasis, cirrhosis, pancreatitis), rare cases being also found (porcelain gallbladder--1 case, calcium bile--2 cases, gallbladder diverticulosis--3 cases, longitudinal complete obstruction of cystic duct by gallstone--2 cases). This condition is more frequent in women in the 3rd dad 4th decade, the symptoms being discrete, uncharacteristic, but persistent. The diagnosis is based on duodenal catheterization, cholecysto-cholangiography and ultrasonography, the intraoperative and histo-pathologic confirmations being required. The increasing frequency of chronic cholecystitis makes necessary a more minute diagnosis and exigent surgical indication, pledges for long-term favourable results.

Adult↗

PubMedDate not supplied

[Differentiated thyroid cancer].

In the interval 1979-1988, out of 1070 operated goiters 77 malignant thyroid tumors were recorded, 60 of them being differentiated: papillary--32 (53.4%), vesicular--12 (20%), mixed forms--16 (26.7%). The differentiated thyroid carcinomas had peculiar clinical biological and prognostic features and were framed: stage I--60%, stage II--23.4% and state III-IV--16.6%. Only 15 cases presented lymph node metastases. In 16 cases the thyroid tumor was associated with another thyropathy: Hashimoto's thyroiditis--5 cases, Basedow's disease--1 case. The surgical intervention was performed in two times: first total lobectomy or total lobo-isthmectomy [correction of lobioistectomy] with contralateral subtotal exeresis, then total thyroidectomy. It is insisted upon a careful surveillance of postoperative evolution (clinical, biological, scintigraphy) in order to detect the recurrence and apply a proper treatment.

Adult↗

PubMedDate not supplied

Specific antibodies and mycobacterial antigens in pulmonary tuberculosis patients sera. Note I.

206 sera collected from different groups of subjects were analyzed by immunoenzymatic methods regarding the content of Mycobacterium tuberculosis specific antibodies and mycobacterial antigens. The results underlined that two assays offered improved serologic diagnosis of tuberculosis over a single antibody test. BCG vaccination interferes with serologic tests for tuberculosis when polyspecific antibodies or mixture of common and specific antigens are used as immunologic reagents. A mycobacterial antigens circadian variation in correlation with vesperal fever in tuberculous patients was not revealed. The mycobacterial antigens seem to become undetectable, in sera, after 6 months of efficient treatment.

Adult↗

PubMedDate not supplied

Specific antibodies and mycobacterial antigens in patient sera with pulmonary tuberculous and nontuberculous diseases. Note II.

"Two-assay" tests (TAT), immunoenzymatic determination of both specific antibodies and mycobacterial antigens in sera of tuberculous and non-tuberculous subjects, was undertaken in our territorial conditions, where BCG vaccination is systematically applied and the prevalence of tuberculous infection is relatively high. The sensitivity of the method, calculated on 42 patients with active pulmonary tuberculosis and on 39 patients with post-tuberculosis syndromes is high, i.e. 0.952. The specificity of the method separately calculated for 44 young subjects (under 21 years old), for 78 healthy adults and for 201 lung diseased patients, bacteriologically not ascertained as tuberculosis at the moment of sera prelevation, varied between 0.830 and 0.489. "TAT", performed with crude immunologic reagents, produces false-positive reactions in early BCG vaccinated subjects. Method specificity low values in pulmonary non-tuberculous patients group may be partially explained by the difficulty in establishing the real relationships, in time, between host and mycobacteria, by the bacteriological method imperfections or sample prelevating methods. Our results certainly underestimate the diagnosis value of "TAT".

Adult↗

PubMedDate not supplied

[Clinical and therapeutic aspects of some rare forms of pancreatic tumors].

A total of 198 tumours of the pancreas have been hospitalized between 1972 and 1987 in the 1st Surgical Clinic from Jassy. Only 10 of these tumours were benign, and these included: 2 gastrinomas, 2 insulinomas, 2 cystadenomas, one fibrolipoma, 1 lymphangioma, one hydatic cyst and a Wermer's syndrome. The particularities are analysed, of these 10 cases of benign tumours of the pancreas, and it is stressed that most of the clinical and therapeutic problems are determined by tumours of the endocrine pancreas, and especially those which are hormonally active. Thus the symptomatology of these last tumours which is difficult to evaluate, especially at the onset of the symptoms will determine a considerable delay in the surgical diagnosis, many of the patients being hospitalized in other departments before reaching the surgeon. Present possibilities for diagnosis and treatment have kept pace with progresses achieved in the field of investigations, which provide useful data from the morphological and functional viewpoints. All the 10 cases mentioned above have benefited from the surgical treatment, that was adapted according to particularities of each patient. The authors stress the importance of the extemporaneous morpho-histologic examination (with serial slides) and when the tumours are difficult to identify by direct macroscopic examination they recommend intraoperative echography and direct hormonal dosages on samples obtained from the portal circulation before and during surgery.

Adult↗

PubMedDate not supplied

[The surgery of intestinal obstruction in the elderly].

Out of 301 intestinal obstructions treated at the 1st Surgical Clinic of Iaşi in the interval 1970-1987, 58 patients aged between 70 and 90 years (mean age 75 years) were recorded. Anatomo-clinically these 58 cases presented: strangulated hernia (19 cases), strangulated eventration (2 cases), strangulations on cords (4 cases), small intestine volvulus (8 cases), sigmoid colon volvulus (6 cases), volvulus of cecum (1 case), intestinal investigation (1 case), colorectal neoplasm (15 cases), peritoneal carcinomatosis (2 cases). The clinical and therapeutical aspects of these particular forms of obstruction in the elderly are discussed and the severity of their prognosis, given the terrain and late admission of such patients which sometimes make impossible a surgical intervention, is underlined. Ten deaths (17.1%) were recorded, representing a lower percentage as compared to other statistics published in the literature.

Acute Disease↗

PubMedDate not supplied

The presence and significance of some anti-enzyme antibodies (anti-plasminogen, anti-trypsin, anti-phospholipase C) in rheumatoid arthritis (RA) and reactive arthritis (rA).

It is a well known fact that during the course of RA and rA, due to some cellular and molecular mechanisms, a number of proteolytic enzymes and membranal phospholipases are either activated or their concentration rises significantly. With this aim in view in the present work we have aimed to investigate if, in an inflammatory process associated to RA and rA, the human organism produces or not anti-enzyme antibodies. Using an enzyme-linked immunosorbent assay (ELISA), in the sera of 19 patients of RA and 19 of rA, the presence of the following antibodies has been ascertained: antiplasminogen (antiPAb), antitrypsin (antiTAb) and antiphospholipase C (antiPLCAb). Out of RA cases, 47.3% presented antiPAb, 36.8% antiTAb and 26.3% antiPLCAb. As it was expected, in the rA cases, these antibodies were found in a higher proportion of cases, i.e.: 85.7%, 71.4% and 57.1% respectively. When following the same cases before and during or after the treatment with nonsteroidal antiinflammatory agents (NSAIAs), the antibodies levels were significantly decreased especially in the RA cases. The results obtained indicated a significant rise of seric concentration of antiPAb, antiTAb and antiPLCAb, as well in RA as in rA. While the rise of antiPLCAb in RA and especially in rA could be explained due to microbial infections, the rise of the antiproteolytic enzymes antibody levels as well as the decrease of the antibody titres during or after NSAIAs treatment could be explained, in our opinion, on the basis of some autoimmune processes.

Antibody Specificity↗

PubMedDate not supplied

[Perforated gastric ulcer].

Out of 603 patients with perforated ulcer, 40 clinical cases with type I perforated gastric ulcers (this particular anatomo-clinical form being distinguished from the perforated duodenal ulcer) were selected. The perforated gastric ulcer type I, less common, is usually found in the patients over 45 years, with old, callous ulcers; in general, when the perforations are large, a malignancy is suspected, the removal of the lesion and the systemic control of the resected specimen being required. The primary radical surgical treatment is performed only in the patients in good general state, the excision of the ulcer followed by suture being reserved to the cases at high risk, with increased mortality (10%).

Adult↗

PubMedDate not supplied

[Problems of therapeutic management of cancer of the superior pole of the stomach].

This cancer is rare (17-30%) and has the worst prognosis. In the interval 1970-1987 to the I-st Surgical Clinic of Iaşi were admitted and treated 648 patients with gastric cancers of which 98 (15.2%) with adenocarcinomas of the cardiac end of the stomach. In most patients the diagnosis was late: stage II and III-40 patients; stage IV-58 patients. Given the extension of the tumoral process, the exeresis was possible but in 36 cases (36.7%), as compared to 26-70% mentioned in the literature. The therapeutical management of these cases and the obtained results are presented.

Adenocarcinoma↗

PubMedDate not supplied

[Immunologic and ultrastructural analysis of lymphocytes in rheumatoid synovial fluid].

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Arthritis, Rheumatoid↗