Journal of Surgery

Journal of Surgery [Jurnalul de chirurgie] is now at its 10th anniversary. It was developed after the success of the first Romanian medical e-teaching/e-learning platform, www.laparosurg.ro. The mains goals of the new journal were to ensure a powerful platform for medical information/education and to allow to the residents and young doctors to publish and share their research work. Even from its first volume Journal of Surgery was included in DOAJ (Directory of Open Access Journals) a worldwide data base developed by Lund University from Sweden. Then, the journal was included in other prestigious international databases as Index Copernicus and EBSCO Academic. During the last 9th volumes, Journal of Surgery published 547 scientific articles that means 60.77 ± 13.07 articles yearly (median 55; range 44 to 86) distributed in 4175 pages (463.89 ± 117.23 pages/year, median 421, range: 372 to 721). The overall tendency was to slightly increase the number of articles. It is important to note the stability of published editorials, multimedia, case reports, surgical technique notes and history of surgery articles; furthermore due to the tightening of the peer review process we noted a bipolar tendency regarding original papers and review type articles: to increase the number of original paper and, respectively, to decrease the number of reviews. In this way the review type articles decreased from over ten articles per year (the first 4 issues) to 5 and respectively, 7 in the last two years, and the original articles increased from about 12/year in the first 4 years to over 20 in the last three years. The citation of Journal of Surgery’s articles is also on an increasing tendency. A brief electronic data research revealed 142 citations (from 386 articles studied). The other overall scientific data measurements are: 0.37 cites/paper, 15.78 cites/year an h-index of 5 and a g-index of 9. In this era of globalization, of open access, of “impact factor”, of performance and “performance” classifications, the surgical journals are “under pressure”. The only way to evolve, to improve the scientific content and to be “more international” is to open all the barriers and misconceptions. In this way, Journal of Surgery has joined to OMICS group. This new collaboration allows us to further develop the Journal (with a primary objective to be included in PubMed and then in ISI) and to widely open the Romanian surgery to the world. Furthermore we want to offer to the young doctors a powerful surgical education platform and a real chance to share their work to their colleagues from all-around the world.

However, our goal to represent Romanian surgery is not forgotten; so, Journal of Surgery will preserve a Romanian language section for the articles submitted in Romanian. We want to warmly thank to all our readers, editors, members of scientific committee and especially to our contributors who helped us during the years to develop Journal of Surgery. We’ll remain your true fellows and we invite you to further collaborate with Journal of Surgery.

This paper aims to update certain aspects of the therapeutic attitude on cervical cancer, a disease that currently is, worldwide, the second leading cause of cancer death in women and thus has increasingly come to the attention of general surgeons. The obvious clinical forms of cervical cancer are brought into discussion, meaning those in the FIGO IB1, IB2 and IIA stages, these being, by far, the most numerous cases we meet in the clinic. Unlike early cervical neoplastic lesions (stages 0 and IA) where the therapeutic attitude is relatively well codified and uniform, in obvious clinical forms there is a great variability of therapeutic approaches, with results that are close to those from the studied literature, indicating according to various statistics a survival rate at 5 years of 80% and 90% for stage I disease and between 60% and 80% for stage II patients.

Background: Cholelithiasis is very common in cirrhotic patients (15-30%), occurring 1 to 3 times more often than in general population. The presence of cirrhosis, hepatocellular failure and/or portal hypertension increases the risk of postoperative complications in any type of surgery, especially biliary.

Methods: A review of the literature over the last 8 years (2005-2013) was performed by searching the Medline database using the following keywords “Laparoscopic Cholecystectomy” and “cirrhosis”. We selected 11 studies that were considered well-documented and contained comparable data. We analyze the demographics, cholecystectomy indication and duration, incidence of perioperative complications and time of hospitalization in cirrhotic and noncirrhotic patients.

Results: Analysis of the literature revealed a total of 842 cirrhotic patients that undergone laparoscopic cholecystectomy in group of 11 published studies. The incidence of acute cholecystitis as indication for LC (Laparoscopic Cholecystectomy) was extremely variable (3.6% to 52.38%). The ratio women to men were 1.06: 407 patients (48.34%) were men and 435 were women (51.66%). Mean of mean age reported by each series was of 53.77 years (range 21-86). Child-Pugh class was reported by 10 studies for a total of 577 patients, most of them being Child-Pugh class A (443 cases, 76.78%) and B (119 cases, 23.22%). The average operating time of reported mean values was of 94.14 minutes. Average overall morbidity rate was of 24.87%; a single study reported 75% morbidity, all other studies indicating rates of maximum 35%. The length of hospital stay was of 3.47 days (range: 1.87 to 7.2).

Conclusions: LC, although initially contraindicated in cirrhotic patients, has gradually replaced open cholecystectomy as standard surgical procedure. The operative risk in patients with liver disease depends on the degree of preexistent hepatic dysfunction, nature of the procedure and comorbid conditions.

Objective: Non-steroid anti-inflammatory drugs can change serum thyroid hormone concentrations by binding to serum proteins. If misunderstood, this situation can give way to inappropriate diagnoses and faulty treatment planning for thyroid diseases in clinical practice. The purpose of our study was to investigate the effects of ketoprofen, lornoxicam, and etofenamate, which are frequently used in clinical practice, on thyroid function tests.

Methodology: The study covered 28 rabbits divided into 4 groups. Groups were administered intramuscular injections daily for 10 days. Thyroid hormones concentrations were tested in the blood samples end of day 10.

Results: An increase in free thyroxin level in the lornoxicam group was recorded on day 7 in comparison to other groups (p=0.015). There was a statistical decrease regarding thyroid stimulant hormone concentration after day 5 in all three groups (Day 5 p=0.000, day 7 p=0.003, day 10 p=0.00).

Conclusion: We believe that previous history of non-steroid anti-inflammatory drug use should be taken into consideration within the scope of patients’ anamneses because non-steroid anti-inflammatory drug use can change the results of thyroid function tests and this change may lead to misevaluations and mistreatment not only for patients with thyroid diseases but also for normal patients.

Background: Despite general anesthesia with one-lung ventilation represents the standard to perform thoracic surgery operations, there is an increasing interest toward alternative methods, such as the use of local or neuroaxial analgesia alone in fully alert or mildly sedated patients. These can be applied to perform a series of videothoracoscopic procedures.

Material and Methods: We reviewed our own institutional experience with this kind of surgery, as well as the most relevant literature findings available on this topic at the usual search websites (PubMed, Scopus, EMBASE). We focused on more recent advances regarding indications, expected advantages, possible pitfalls and implications for future research.

Results: Such an operative modality can be safely and successfully adopted to manage a series of common malignant and non-malignant diseases. In thoracic oncology, it is mainly employed to treat malignant pleural effusion, to remove of pulmonary lesions of any origin, and to perform mediastinal biopsies. Furthermore, even complex procedures such anatomic lung resections and thymectomy are now being performed in this way. When taking into the account just intermediate to major surgeries, reported conversion rates to general anesthesia range between 2.8 and 9%. Despite the lack of randomized controlled trial, there is a general perception that non-intubated videothoracoscopic operation may translate into a lower morbidity rate, better hematosis, and preserved perioperative immunosurveillance. No sufficient data is available as far as long-term outcomes are concerned.

Conclusions: Non-intubated videthoracoscopic operations may be as effective as the equivalent procedures performed with general anesthesia, while providing advantages in terms of cost and postoperative morbidity. This surgical practice should thus be included in the armamentarium of modern era thoracic surgeons, and appropriately designed studies should be undertaken to better define its merits and limitations.

Background: Patients with pancreatic cancer frequently suffer from thrombosis as a consequence of excess thrombin generation. In addition to its role in the plasmatic coagulation cascade, thrombin induces numerous cellular effects by activating a unique group of G-protein-coupled receptors on the cell membrane, the proteinase-activated receptors (PARs). At present, PAR-1, PAR-3 and PAR-4 are known to be activated by thrombin. We previously demonstrated a putative role for PAR-1 in pancreatic cancer progression, but little is known about the physiological and pathophysiological roles of PAR-3 and PAR-4. In the present study, we examined the expression patterns of PAR-3 and PAR-4 in pancreatic tissue and pancreatic cancer cells.

Methods: Tissue samples from three patients with pancreatic adenocarcinoma and six human pancreatic carcinoma cell lines were examined. Gene expression was analysed by RT-PCR and quantified by HPLC. Protein expression was determined by Western blot analysis. Data analysis was performed using ANOVA in SPSS.

Results and Conclusion: In contrast to PAR-1, both PAR-3 and PAR-4 were expressed in healthy pancreases but downregulated in pancreatic cancer. The contrasting expression patterns of PAR-3 and PAR-4 compared with PAR-1 indicate that the mechanism that regulates the cellular effects of thrombin on tumor progression remains to be fully elucidated.

Background and Aim: Breast cancer shows poor prognosis when tied with chronic inflammation mediated by tumor associated macrophages (TAM). However, TAM’s multiple role, localization and prognosis are still debatable. Our study aims to quantify macrophage area and compare defined tumor morphological compartments: tumor associated stroma (TAS), tumor parenchyma and invasive front.

Material and Methods: Automated digital macrophage area quantification was standardized using a tissue cytometry system (TissueFAXS) on slides originated from 50 patients with invasive breast carcinoma. Macrophages were stained using immunohistochemistry with anti-CD68 marker. The three tumor compartments were manually delineated on the digital slides.

Results: Macrophage area was 3 times higher in lymph node-negative metastasis patients (pN0 group) when compared to lymph node-positive group in tumor and invasive front compartments. Highly significant strong correlations were found between the three compartments only in pN0 group (i.e. R >0.90, P<0.001) while pN+ group showed weak ones suggesting various macrophage roles.

Conclusion: Compartment-specific automatic quantification of macrophages in invasive breast carcinoma provides more insight on their role in tumor outcome. The new method applied in our study shows compartments’ variability of local macrophage density and highlights behavior differentiated by the presence of metastasis.

Background: Chronic pancreatitis has been shown to have potential benefit in pancreatic resections by reducing postoperative pancreatic fistula. We sought to investigate the impact of chronic pancreatitis on oncologic surgical outcomes. Materials and Methods: Consecutive partial pancreatectomies performed for malignant disease from 2005-2011 were reviewed. Patients were divided for analysis based on the presence of chronic pancreatitis. The primary outcome measures were need for intraoperative re-excision of margins and final margin status. Secondary outcome measures included pancreatic fistula rate and overall morbidity which were graded in standardized fashion. Significance was assessed for p<0.05. Results: One hundred fifty-four patients met criteria for study, 48 of which had chronic pancreatitis. Demographics, co-morbidities, diagnoses, and surgical technique were equivalent between groups. Though there was a trend towards increased re-excision of margins in the chronic pancreatitis group (p<0.08), there were no significant differences in any surgical outcome measures between groups including final margin status, pancreatic fistula rate, and overall morbidity. Multivariate analysis failed to identify chronic pancreatitis as a predictive factor for any of the chosen outcome variables. Conclusion: Despite potential for difficult dissection due to inflammatory changes in chronic pancreatitis, we found no differences in oncologic outcomes in patients undergoing pancreatectomy.

Introduction: The current trend for the modern treatment of gastric cancer it is represented by radical surgery with extended lymphadenectomy. The lymphadenectomy, as defined by the Japanese surgeons, is an important, already proved, marker for the overall and disease free survival, but is associated with a risk of postoperative morbidity and mortality. Aim: The aim of the study was to analyze the gastric cancer surgery evaluating the postoperative morbidity and mortality. Material and Method: We performed an observational study, on 110 patients with gastric cancer operated in the Emergency Clinical Hospital București. We also included in our study the tumors located at the gastro-oesophageal junction (that proved by histopathology exam to be of gastric origin) and the tumors of the remnant stomach. RESULTS: The men to women ratio was 1.5 and the mean age was 65.02 ± 11.04 years old. The gastric cancer is located in the 1/3rd upper part in 20.90% cases, and on the distal 2/3rd in 68.17%. Almost half of the patients (48.18%) were admitted with complications (bleeding, stenosis and/or perforation). 25.54% from the patients had distant metastasis (liver, peritoneum, pulmonary, or/and lymphnodes). All the cases were advanced or locally advanced gastric cancer and no case of early gastric cancer has been noted. Most of our surgical interventions were standard resections: total or distal gastrectomy associated with D1 lymphadenectomy in 64 cases and D2 in 32 cases. The mean operative time was 182.3 ± 99 minutes. The overall mortality rate was of 4.5%. The type of lymphadenectomy wasn’t a risk factor for postoperative mortality. Conclusions: The gastric cancer is diagnosed, most commonly, in an advance stage. However, the trend is to perform radical or potentially radical gastrectomies associated with D1 or D2 lymphadenectomy. The type of lymphadenectomy is not a risk factor for postoperative morbidity and mortality.

Background: A long-term follow-up of inguinal hernia operated patients is mandatory in order to evaluate the efficiency of the surgical procedures. AIM: The aim of this study is to evaluate a personal follow-up procedure for the operated inguinal hernia patients. Material and Methods: A prospective study including the patients who underwent Lichtenstein tension-free procedure was performed. A prospective follow-up to 1, 6 and 12 months using a Quality of Life (QoL) questionnaire was performed, and the results were carefully analyzed. Results: 44 consecutive patients operated from June 2011 until May 2012 was included in the study. The median age was 60 years old and men to women ratio were 43 to 44. To 1 month postoperative check-up, 88.63% of the patients were presented and at 6 months only 31.81% from the patients were presented to the postoperative check-up, and after 12 months 58.13% of the patients answered to QoL questionnaire. In term of QoL, 76% of the patients had “excellent result” and 24% “very good result” one year after the procedure. We recorded no recurrence one year after the procedure to the patients who underwent the check-up physical exam. Even the postoperative results are outstanding, the follow-up is only satisfactory from multiple reasons, equally related to doctors, patients and medical system as well. Conclusions: In our conditions the long term follow-up of the inguinal hernia operated patients is more likely a goal than a routine activity. Further studies and activities (e.g. a National Hernia Registry) will be necessary to improve the patients’ follow-up procedure.

Introduction: Critically ill patients develop anemia due to several reasons: bleeding prior or during intensive care unit (ICU) stay, frequent flebotomies, hemodilution and inflammatory status with altered erythropoiesis. The aim of this study was to assess the trend of hemoglobin (Hb) level during long ICU stay (more than 7 days) in transfused and nontransfused patients. Materials and Methods: We conducted a prospective observational study that included all patients with long ICU length of stay (LOS) admitted during 1 year in a 19-beds mixed ICU of a tertiary care university hospital. Patients were divided into two groups: never transfused (NT) and ever transfused (ET) according to their transfusional status during ICU stay. Collected data: demographic data, severity scores, Hb values during ICU stay transfusion status and outcome. Statistical analysis was conducted with SPSS 15.0. Results: 132 patients (54 NT, 78 ET) were enrolled in the study. On ICU admission, overall mean Hb level was 9.2 g% (95%CI 8.72-9.72) with a significant difference between NT and ET group (10.1 g% versus 8.5 g%; p<0.01). By the day 7 there was little change in overall mean Hb value (9.1 g%; 95%CI 8.85-9.43) as in NT group the Hb values continued to drop while in ET group raised as a result of transfusions. However, at two weeks after ICU admission there was a significant decrease in mean Hb value, from 9.2 g% in day 1 to 8.1 g% (95%CI 7.71-8.49) in day 14. The variance also had a significant decrease over time (8.94 in day 1; 1.58 in day 14) indicating a convergence of Hb values in studied patients, regardless of their transfusion status. Conclusions: Despite the fact that Hb values on ICU admission may vary widely, after 14 days of ICU stay the Hb values tend to converge. The Hb level in critically ill patients with long ICU stays decreases stadly over time no matter the transfused or non-transfused status.

Abdominal Cocoon Syndrome (ACS) or sclerosing encapsulating peritonitis is characterized by intestinal obstruction and ileus as a result of encasement of small intestines totally or partially by a thick fibrous sac. We herein present a patient undergoing Continuous Ambulatory Peritoneal Dialysis (CAPD) therapy for chronic renal failure for 3 years who developed intestinal obstruction and perforation and was subsequently diagnosed with abdominal cocoon syndrome. Abdominal cocoon should be remembered in patients on CAPD therapy. One should also be aware that clinical signs of peritonitis may not become evident in the case of intestinal perforation in patients with ACS. In such cases, computed tomography has an important role in making the diagnosis.

Vesico-amniotic shunt is one of the methods used to relieve fetal bladder obstruction in some cases of lower urinary tract obstruction. We highlight a 35 week gestation baby boy, who developed acquired abdominal wall defect following placement of the antenatal vesico-amniotic shunt. It is one of the rare complications of placement of vesico- amniotic shunt.

A 16 year old male presented with Ewing’s sarcoma of the sternum which extended into the anterior mediastinum. At presentation, there was no evidence of metastatic disease. The patient was initially treated with chemotherapy. The residual tumor was subsequently resected and the sternal defect was repaired with a polyprolene mesh and a muscle flap. Post-operatively, the patient did well and was discharged home. The patient has been seen in the clinic and is doing well post-operatively. Although extremely rare, Ewing’s sarcoma occurs in the sternum. A combined effort between oncology, thoracic surgery and plastic surgery for single excision and reconstruction is optimal for the patient.

We present the case of a 74 year-old male with delayed diagnosis of post-traumatic thoracic esophageal perforation that occurred secondary to thoracic vertebral fracture in an ankylosed spine. The injury resulted after a fall from chair secondary to an unconscious collapse due to Ventricular Fibrillation (VF). At 8 days after the injury, the patient was diagnosed with esophageal perforation, secondary to fourth thoracic vertebral fracture without neurological deficit. The esophageal laceration was complicated by sepsis with bacteremia, pleural empyema and mediastinal abscess. Non-surgical management for the esophageal perforation, chest complications and thoracic spine fracture resulted in complete recovery. A case report and review of the literature is presented. We report the first case of post-traumatic thoracic esophageal perforation secondary to thoracic T4 vertebral fracture, in a patient with an ankylosed spine that survived neurologically intact after successful conservative management.

Background: Gastrointestinal Stromal Tumors (GIST) are rare neoplasms, with sever prognosis in advanced cases. Until the discovery of Tyrosin Kinase Inhibitors (TKI), the life expectancy was very poor for patient with metastatic tumors, postoperative relapses or unresectable disease. Introduction of TKI therapy provided an unexpected survival rate, controlling the disease with very good tolerance. Method: We present a case report representative for GIST pathology. It is the first case of our GIST series of patients, operated in General and Esophageal Surgery Clinic of “St. Mary” Hospital Bucharest. A multidisciplinary approach and a complex, multimodal, surgical and oncological treatment was applied, with good response confirmed by the long-term follow-up. A 79 years old patient was diagnosed in 2004 (at the age of 70 years) with giant gastric GIST. He underwent a total gastrectomy, splenectomy and left pancreatectomy; the resection was considered as R1 because the tumor capsule was not complete. The adjuvant treatment with TKI was started postoperatively for 2 years. The recurrence was noted one year after the adjuvant therapy stop. Then the TKI treatment was restarted with very good tolerance and control of disease at 9 years. Conclusion: The TKI therapy allows long-term control of the malignant GISTs in term of overall survival and quality of life, even when the surgical procedure is not optimal.

Background: Orchitis tumor incidence is rare, about 2% of male malignancies. The pathology of tumoral orchitis has a maximum incidence between the ages 20-35, in children being more frequent the embryonal carcinoma and teratoma, in adult are met all types and in elderly predominates the seminoma. About 25% has endocrine secretory capacity. The incidence of gynaecomastia in adult men is reported as being 35-65%, depending on the criteria for diagnosing gynaecomastia and the age group. However, only 2% of men presenting with gynaecomastia are founded to have testicular tumours. Case Report: We present the case of a 27 years old patient, diagnosed two years ago with testicular tumor. In diagnosis, the first sign was the unilateral gynaecomastia then neoplastic transformation of the left testicle was noted. The diagnosis was confirmed by ultrasound exam and tumoral markers (β human chorionic gonadotrophin over 5000 mUI/mL; alpha-fetoprotein at 12.3 UI/mL; lactate dehydrogenase at 1840 U/L). Left orchiectomy was performed. The pathological report showed a mixed tumor with germinal cells: embryonal carcinoma, teratoma and choriocarcinoma. The patient refuse adjuvant therapy and two months postoperatively pulmonary and vertebral metastasis were revealed. He followed radiotherapy, chemotherapy and neurosurgical treatment with complete remission. Conclusion: We emphasize the importance of complete physical exam and testicular ultrasonography in any case of suspicion of testicular tumor. The multidisciplinary approach and treatment allows good results in advanced testicular tumors.

Splenic cysts are uncommon, not frequently encountered in surgical practice. Generally, they are considered to be either parasitic or non-parasitic. We report the case of a young woman who presented with pain in the left upper abdomen quadrant and nausea. Ultrasonography and CT scan revealed a giant cystic lesion arising from the splenic hilum compressing the stomach and pancreas. At laparotomy a huge cyst was found which was affecting also the splenic vein and artery. Through a meticulous surgical technique it was possible to preserve the spleen in this particular case. Cystectomy with spleen preservation is the treatment of choice for spleen cystic lesions, especially in young patients, due to its immunologic functions.

Background: Desmoid tumors are rare neoplasms of uncertain etiology arising from fascial or deep musculoaponeurotic structures. Although with benign histological appearance and no metastatic potential, desmoid tumors are locally aggressive tumors with a high rate of local recurrence. Case Report: The case of a 47 years old woman repeatedly operated for a recurrent desmoid tumor of the right thigh is presented. The initial radical excision was followed by adjuvant radiotherapy but local recurrence was diagnosed one year after. The pathology report revealed aspects of desmoid tumor. The patient was reoperated and subsequently referred for chemo- and hormonal therapy. A second recurrence occurred 20 months later and the patient was again operated with microscopic tumor free margins and positive long term outcome. Conclusion: Desmoid tumors are benign tumors with unpredictable natural history. Best management involves a multidisciplinary approach. Concerning diagnosis, the best approach is performing a MRI examination. Wide surgical resection with adjuvant radiation therapy remains the main treatment option for local control.

Primary hyperparathyroidism (pHPT) is a common disease, in the majority of cases determined by a single solitary parathyroid adenoma; it is more frequently encountered among older women, between 50-60 years. Due to advances in imaging, preoperative localization of the hyperfunctioning or enlarged gland is almost always possible. In this perspective the classic bilateral neck exploration shifted to limited (focused) surgical approaches i.e. minimally invasive parathyroidectomy (MIP). The aim of this study is to do a short literature review of MIP surgical techniques and to present the surgical procedure we have used, along with our initial experience, respectively.

The thumb accounts for almost 50% of hand function, the pulp having a major role in ensuring it. Pulp injuries lead to marked disability, so preserve length, position, mobility, sensitivity thumb are just some of the goals that must be met for the techniques used in reconstruction of the thumb and its pulp. To rebuild the thumb pulp, Littler describes the technique that bears his name in 1953, using a neurovascular flap harvested from the cubital board of the third finger. Immediately after describing it, his technique proved to be successful as it brings the thumb pulp a sensitive tissue. As time has proved Littler flap attached advantages and some disadvantages. These have been linked mainly to the difficult and often incomplete cortical integration of the new pulp and donor site morbidity. The purpose of this article is to bring to attention the technique that should be considered whenever we face a thumb trauma with loss of the pulp region and exposure of the underlying structures.

Background: Laparoscopic approach for ventral hernias is associated with decreased hospital stay, reduced risk of infection and low recurrence rate compared with the open repair techniques. However, these good outcomes depend of several surgical techniques related key points. Aim: The aim of this paper is to present and highlight these “critical” key points. Method: The paper presents the procedure in a step-by-step manner; operative room set-up, peritoneal access and trocars placement, abdominal wall defect exploration, accurate mesh placement with a minimum 4 to 5 cm mesh overlap of the hernia defect and an adequate mesh fixation. The different key points as mesh insertion and unrolling as well as mesh placement and fixation are highlighted. Several data from literature were also discussed. Conclusion: The laparoscopic ventral hernia repair is a feasible and safe procedure. The respect of procedure’s “critical” key points allows the best outcomes in term of hospital stay, postoperative pain and morbidity