Mircea Gherghinescu, Călin Molnar, Daniel Popa, Cristian Russu, Alexandra Lazăr and Constantin Copotoiu
Background: Hepatitis C prevalence in Romania is 3.5%. Nowadays, the treatment of this condition comprise of interferon. One of the interferon’s side effects is the reduction of collagen synthesis, substance that is necessary in the process of abdominal wall healing.
Case report: We report the case of a 56 years old female patient, admitted in our Clinic for a giant, recurrent incisional hernia. The patient’s history was eventful: a hysterectomy for uterine fibroma in 2009, incisional hernia repair in 2010, the treatment with Interferon in 2011 and 2012 for viral hepatitis C. A well represented subcutaneous tissue is observed intraoperator, a wall defect of 15 cm in diameter with a 5 mm thick muscle aponeurosis lay. We performed abdominal wall plasty by components separation technique, reinforced with a polypropylene mesh disposed on lay. Postoperative analgesia was provided by inserting a wound catheter through which Ropivacaine 0,5% was continuously injected for 72 hours. The postoperative evolution was uneventful, the patient being discharged 7 days after the surgical intervention.
Conclusions: The treatment with Interferon of hepatitis C can favor the recurrence of an incisional hernia. The Oscar Ramirez procedure seemed to be the best choice for surgical treatment of this giant incisional hernia. Postoperative analgesia can be accomplished by a wound catheter through which Ropivacaine 5% is continuously infiltrated.
Cristian Russu, Călin Molnar, Sanda Maria Copotoiu, Claudiu Sărăcuț, Mircea Gherghinescu, Varlam Claudiu Molnar and Constantin Copotoiu
Introduction: Surgical treatment for low rectal cancer represents a challenge: to perform a radical resection and to preserve the sphincter’s function. We report a case of intersphincteric resection in a combined multimodality treatment for low rectal cancer, with good oncologic and functional outcome. Case presentation: We report a case of a 73 years old woman admitted in April 2014 in surgery, for low rectal cancer. The diagnostic was established by colonoscopy and malignancy confirmed by biopsy. Complete imaging was done using computed tomography and magnetic resonance to establish the exact stage of the disease. The interdisciplinary individualized treatment began with radiotherapy (total dose of 50 Gy, administered in 25 fractions) followed by surgery after eight weeks. We performed intersphincteric rectal resection by a modified Schiessel technique. There were no postoperative complications and the oncologic and functional results were very good at one year follow up. Conclusions: Intersphincteric resection, in this selected case of low rectal cancer, represented an efficient surgical treatment, with good functional results and quality of life for the patient. A multidisciplinary team is an invaluable means of assessing and further managing the appropriate, tailored to the case, treatment in the aim of achieving best results.
Saracut Claudiu, Molnar Calin, L Farczádi, L Vlase, Tero-Vescan Amelia, Todoran Nicoleta and Copotoiu Constantin
Objectives: The aim of the study was to determine the level of secondary bile acids (SBA) in the diets and feces of mice and the variation of amount ingested/excreted if these SBA are administered as monotherapy or in 1:1 dose.
Methods: The mice were divided into 4 groups and fed for 140 days with different diets. The control lot received a normal diet and the others received diets supplemented with 0.25% deoxycholic acid (DCA), 0.25% lithocholic acid (LCA) and 0.125% DCA+0.125% LCA. After 140 days, the mice feces were collected and homogenized to obtain a mixture for each lot from which the determinations of the studied SBA were performed. For the mice food evaluation, portions of 10 g from each of the 4 diets were subjected to the SBA determination.
Results: The daily ingestion over more than 4 months of DCA or LCA added to the diet and administered as monotherapy determine a significantly increase of the SBA eliminated into the feces (the DCA level was 11x higher, and of the LCA 233x higher). If half of the LCA dose is replaced with DCA, the level of LCA in the feces gets comparable with that of the DCA (their combined amounts represents only 13x higher increase of these two bile acids in feces).
Conclusions: The simultaneous ingestion and excretion of DCA and LCA can be considered as a particular situation ruled by endogenous mechanisms. This behavior represents an important observation, knowing that the bile acids effects in the colorectal cancer are dose dependent.
Marian Botoncea, Claudiu Molnar Varlam, Adrian Chiujdea and Călin Molnar
Background: Pelvic exenteration is an ultra-radical surgical procedure described by Brunschwig in 1948, which attempts to surgically cure patients with recurrent pelvic cancer after radiotherapy. Several variants of pelvic exenteration are described that allow a more limited or extensive resection, depending on the stage of the disease.
Case report: We report the case of a 54-year-old woman, who was diagnosed with a tumoral rectovaginal fistula after a recurrent cervical cancer that had been treated with a total hysterectomy with bilateral adnexectomy and a left percutaneous nephrostomy, as well as interaortocaval lymph node resection. The patient had undergone a supralevator total pelvic exenteration with pelvic and interaortocaval lymphadenectomy. The reconstruction process included right ureterostomy, left nephrostomy, and colocutaneous anal anastomosis (Parks procedure).
Conclusions: Supralevator total pelvic exenteration provides hope for cure in patients with pelvic malignancies that reappear after radiotherapy. The restoration of the digestive tract and avoiding colostomy with a colocutaneous anastomosis increases the quality of life in these cases.
M. Gherghinescu, C. Molnar, D. Popa, C. Russu and C. Copotoiu
Background: The incisional hernias are frequent complications after laparotomy. Extended subcutaneous tissue dissection is often necessary for the treatment of large incisional hernias, and this procedure is frequently followed by a high intensity pain in the postoperative period. The aim of this study was to assess the postoperative patient comfort without using major analgesics.
Material and method: we present the preliminary results of an ongoing study from Surgery Clinic 1 of Emergency Clinical County Hospital of Târgu Mures, University of Medicine and Pharmacy Târgu Mures. The study comprises in the intraoperative insertion of a subcutaneous catheter (Pajunk InfiltraLong) placed on lay, through which we administered continuously Ropivacaine 0,5%.
Results: Ten patients have been included in the study by now. For 5 of the patients the wound infiltration was started with 7 ml/h in the first 6 postoperative hours, after which the rate decreased to 5 ml/h until the end of the 72 hours, when the catheter was removed. For 2 patients the wound infiltration was started with 10ml/h in the first 6 postoperative hours, after which the rate decreased to 7 ml/h in the first day, followed by 5 ml/h for the next two days. Two patients needed a minor analgesic in the immediate postoperative period and one patient needed major analgesia in the first 24 hours.
Conclusions: By using this method, postoperative analgesia can be achieved without using major systemic analgesics and a superior patient comfort can be achieved simply by adjusting the infusion rate
Călin Molnar, Octavian-Sabin Tătaru, Vlad-Olimpiu Butiurcă and Varlam-Claudiu Molnar
Introduction: Pelvic floor hernias are encountered especially in elderly women. A combined genital, bladder, and rectal prolapse poses treatment challenges in aged women.
Case presentation: We present the case of an 88 year-old patient, complaining of an intravaginal mass protruding for the last 3 months, rectal prolapse that occurred two weeks before admittance, accompanied by stress incontinence of urine and chronic constipation. Examination revealed a uterine prolapse with cystocele and a fourth grade rectal prolapse. We decided on a perianal and transvaginal approach, performing preliminary dilatation and curettage, cervix amputation, anterior colporrhaphy and colpoperineorrhaphy (Manchester procedure) with perineal rectosigmoidectomy using the LigaSure™ device, and coloanal manual anastomosis. Postoperatively the patient had no symptoms of stress urinary incontinence, bowel movement resumed in the fourth postoperative day, and the patient was discharged after seven days. One month after surgery the patient has both urinary and fecal continence, with no relapse in pelvic organ prolapse.
Conclusions: Encountering genital, bladder, and rectal prolapse in the same patient is quite rare, and its treatment can be difficult in aged women. Therefore, a less invasive surgical procedure, using the transvaginal approach, and a genital sparing surgery could be the key in cases like this.
C. Molnar, C. Silaghi, C. Rosca, L. Marginean, V.O. Butiurca, A. Tudor and C. Copotoiu
Introduction: Hepatocellular carcinoma is the most frequent primary malignant tumor of the liver, being linked in 80% of cases with viral hepatitis ”B” or “C”. Treatment remains a challenge especially in cases with associated hepatic cirrhosis, where preoperative arterial chemoembolization followed by liver resection is recommended.
Case report: We discuss the case of a 64 years old cirrhotic patient, diagnosed by echography, computed tomography, magnetic resonance cholangiography with hepatocellular carcinoma (64x52x46 mm). Preoperative chemoembolization was performed with Lipiodol and 5-FU by supra-selective catheterization of left hepatic artery, followed by favorable radiologic response. Two weeks after embolization, the patient was admitted in Surgical Clinic No. 1 Targu Mures where an atypical resection of the left hepatic lobe (bisegmentectomy II-III) was performed with Harmonic Scalpel. Early and late postoperative evolution was favorable.
Discussions: The principle of arterial chemoembolization is based on the fact that vasculature of primary hepatic tumors is predominantly arterial. Arterial obstruction may lead to ischemic necrosis while tumor embolization combination with a chemotherapeutic agent significantly improves its local concentration. Decrease in tumor size and its vasculature allows for safe hepatic resection especially in the cirrhotic liver.
Conclusion: In case of tumoral cirrhotic liver preoperative chemoembolization decreases intra and postoperative bleeding risk, providing a safe and oncological resection.
A Tudor, C Molnar, C Nicolescu, C Rosca, Bianca Tudor, V.O Tudor and C Copotoiu
Introduction: One of the most feared complications after cephalic duodeno-pancreatectomy remains pancreatic fistula. In recent years, various methods of pancreatico-digestive reconstruction were performed in order to reduce the rate of pancreatic fistula. One of these methods is pancreatico-gastric reconstruction by using two purse string threads.
Case report: We present in this article a patient with jaundice with mixed etiology: tumoral and lithiasic. Subjectively, the patient accused sclerose-skin-jaundice, right upper quadrant and epigastric pain, nausea and vomiting. Computed tomography revealed dilatation of intraand extrahepatic bile ducts, a dilated Wirsung duct and a tumor at the biliopancreatic confluence, leading to a suspicion of vaterian ampulom. Upper endoscopy revealed a tumor protruding in the descending duodenal segment. Intraoperatively a tumor suggestive of vaterian ampulom and duct stones was shown. Surgical treatment consisted of coledocolitotomy, cephalic duodeno-pancreatectomy with pancreatic-gastric anastomosis, performed by using two purse string threads. The postoperative evolution was favorable.
Conclusion: Pancreatico-gastric anastomosis using two purse string threads is a simple, safe and quick procedure, avoiding the application of sutures through the pancreatic parenchyma and thus reducing the rate of pancreatic fistula.
A Tudor, C Molnar, C Copotoiu, VO Butiurca, C Nicolescu, Tudor Bianca and Gurzu Simona
Objectives. The aim of our study is to identify a surgical technical that has the lowest rate of pancreatic fistulas in pancreatico-gastric anastomosis following duodenopancreatectomies. We studied pancreatico-gastric anastomosis performed with stitches compared to the ones performed without stitches.
Methods. Our experimental model is based on ten piglets, which were divided into 2 groups. In the first group (n=5) the pancreatico-gastric anastomosis was done using double purse-string threads one passed through the gastric seromuscular layer and one through the gastric mucosa. In the second group (n=5) the pancreatico-gastric anastomosis was performed using sutures through the stomach and pancreas.
Results. Postoperative amylasemia was higher in the second group. In the first group no pancreatico-gastric fistulas were observed, whereas pancreatic necrosis was observed only at a superficial level of the pancreatic stump. In the second group, two cases had developed fistulas, both bordered by large areas of coagulation necrosis accompanied by pancreatic duct hyperplasia. Duration of the anastomosis was shorter for the first group.
Conclusions. In conclusion, the pancreatico-gastric anastomosis performed using two purse-string suture is a feasible, safe and fast process.