A particular case of a "captive forceps" in the esophagus

We present a particular case of a "captive" forceps in the esophagus in an attempt to remove a foreign body in a patient with previous esophageal post-caustic stenosis. The mechanism of incarceration and the surgical therapeutic option consisting of open thoracic surgery are detailed and argumented. Postoperative course was favorable, though the patient developed a small esophageal fistula visible at radiology without any clinical expression. This case emphasizes the difficulties that may occur but in the management of esophageal foreign bodies in patients with esophageal post-caustic stenosis, which may lead finally to open surgery.     

Locoregionally advanced rectosigmoid cancer: diagnosis, surgical approach, late results

The colorectal cancer continues to be diagnosed in advanced stages in our country, mainly due to unapplying of a programmer of active diagnosis through screening on the population with risk for colorectal cancer, and inefficiency of primary care system. In the department of General Surgery CFR Craiova Hospital between 1991-2001 were operated a number of 231 patients with colon cancer and 104 patients with rectal cancer. The results, showing an increased number of recurrences in cases of resection performed for advanced loco-regional tumors of rectosigmoid, made us to reconsider the attitude of avoiding the abdominoperineal resection even when the distance between the inferior limits of the tumors and the anal edge exceeded the distance considered being standard for a low anastomosis performing. The follow-up of the patients with paraclinic technique that didn't prove efficient led in the most cases to a delaying in diagnosis of local recurrences until the moment of resectability was exceeded. The applying of efficient methods in early diagnosis of colorectal cancer and follow-up could provide in the future better results for anterior resections with low anastomosis.     

Ileosigmoid fistula due to an abscess of a periappendicular mass

The paper debates the subject of the undiagnosed acute appendicitis. The formation of a complex ileosigmoid fistula due to an abscess of the periappendicular mass and the three steps peritonitis determined a particular approach in solving the case.     

Ovarian cancer--diagnostic dilemmas and unusual therapeutic response

The aims of this paper are both to highlight some dilemmas concerning the diagnosis of primary epithelial ovarian carcinoma mainly in its early stages and to underline the capricious responses of this type of malignancy to an otherwise well coded modern management. This study is based on the analysis of the records of 78 patients with ovarian carcinoma admitted for diagnosis and surgical treatment to the Department of General Surgery of Craiova C.F.R. Clinic from 1993 through 2003. The results of this analysis are difficult to interpret due to loss to follow up (in terms of response rates) of some of our 78 operated on ovarian carcinoma patients who went on with their platinum-based chemotherapy (following surgical cytoreduction) under the supervision of different Oncology Departments nationwide. Nevertheless, it is worth mentioning that most of this study patients (71.9%) presented with advanced-stage (III and IV) ovarian carcinoma which sometimes seemed quite confusing by its clinical polymorphism but its prognosis was very much related to both the degree of surgical cytoreduction accomplished and tumor sensitivity to chemotherapy. Finally, although this study does not allow us to draw firm conclusions it is an attempt to share out our current perception on the primary epithelial ovarian cancer management.     

The modulator role of the hypothalamic paraventricular nucleus on immune responsiveness

Role of the paraventricular nucleus of the hypothalamus (PVH) upon immune modulation was studied by either mechanically destroying the PVH (PVHL) or by isolating the PVH (PVHI) with a knife-cut. PVHL or PVHI manipulations induced significant leukopenia characterized by a decrease in the number of neutrophils and lymphocytes two weeks post surgery. The numbers of circulating monocytes and eosinophils were not affected by PVH interventions. In addition, PVHL and PVHI were also associated with a reduction, relative to controls, in the phagocytosis by neutrophils and an increase in blastic transformation of T lymphocytes induced by phytohemagglutinin-M (PHA-M). Antibody titers rose against sheep red blood cells (SRBC) after either PVHL or PVHI were reduced. The magnitude of the SRBC antibody reduction after PVH manipulations was similar to that observed in rats that received a peripheral chemical sympathectomy two hrs prior immunization. Comparison of thyroid hormones blood levels two weeks after PVHL or PVHI revealed significant reductions in comparison with sham-operated group (SO), whereas blood corticosterone was not significantly altered. In summary, we provide evidence that lesion or isolation of the PVH selectively reduces circulating white blood cells and the primary immune response, while it enhances the cell-mediated immune function. Taken together our data showed that PVH modulates immune functions by altering both the peripheral sympathetic tone and thyroid hormone secretion.     

Accuracy of office hysteroscopy in the diagnosis of endometrial hyperplasia

In the last decade the advantages of office hysteroscopy performed without cervical dilatation and/or anaesthesia were fully demonstrated. Many authors consider office hysteroscopy the gold standard diagnostic method in the diagnosis of intrauterine pathology, with high accuracy and compliance. The best sensitivity and specificity are reached in the diagnosis of focal lesions as submucous myomas and polyps but controversy still persists regarding hysteroscopic accuracy in the definition of endometrial hyperplasia. The aim of this prospective study was to evaluate the efficacy of outpatient hysteroscopy in the diagnosis of endometrial hyperplasia and to compare hysteroscopic findings with histology. From April 2000 to May 2002, 145 diagnostic office hysteroscopies were performed at the Euganea Medica clinic. Sensitivity in the detection of endometrial hyperplasia was 89.36%, specificity 91.96%, positive predictive value (PPV) 82.36% while negative predictive value (NPV) reached 95.37%. Uniformity of histology associated with outpatient mini-invasivity and high compliance favour office hysteroscopy and represent important elements in its diffusion as a first level diagnostic method even in the diagnosis of hyperplasia.     

Structure and function evaluation (SAFE): II. Comparison of optic disk and visual field characteristics

PURPOSE: To evaluate the relationship between glaucomatous structural damage to the optic nerve and development of visual field loss with standard automated perimetry (SAP) and short wavelength automated perimetry (SWAP). DESIGN: Cohort study. METHODS: Patients with elevated intraocular pressure and normal SAP visual fields were enrolled in this prospective study. Stereo optic disk photographs, SAP, and SWAP visual fields were obtained annually over a period of 4 or more years. Trained readers evaluated baseline and follow-up optic disk photographs for evidence of glaucomatous damage. Standard automated perimetry and SWAP examinations were evaluated according to previously validated criteria for development of confirmed visual field changes. RESULTS: Two-hundred ninety-five subjects (479 eyes) were enrolled. Following masked assessment of stereo photographs by an optic disk reading center, 272 of the 479 eyes were judged to have glaucomatous optic neuropathy at the time of study entry. Depending on the criteria employed, approximately 10% to 17.5% of all eyes developed confirmed visual field loss for SAP (conversions). Of the conversions, 75% to 80% had baseline glaucomatous optic disk damage, whereas normal and glaucomatous optic disks were equally divided (50%) among the nonconversion eyes. This difference was statistically significant (P <.003). Depending on the criteria employed, 4% to 12% of the eyes had confirmed SWAP deficits at baseline, and 4% to 8% developed confirmed SWAP defects at a follow-up examination. There was a greater percentage of eyes with a glaucomatous optic neuropathy in the group with SWAP deficits (75%-100%) than for those eyes in which SWAP remained normal (45%-60%). Some of these differences were statistically significant (P <.05). CONCLUSIONS: A strong relationship exists between glaucomatous optic disk damage at study entry and the subsequent development of a confirmed glaucomatous SAP visual field defect. A higher percentage of glaucomatous optic disks were also found in patients with SWAP deficits at baseline and in those who later developed SWAP deficits. These findings support the premise that a glaucomatous optic disk is predictive of the subsequent development of glaucomatous visual field loss.     

Phase II Study of Lonidamine and Diazepam in the Treatment of Recurrent Glioblastoma Multiforme

Recurrent glioblastoma multiforme (GBM) is resistant to most therapeutic endeavours, with low response rates and survival rarely exceeding 6 months. There are no standard chemotherapeutic regimens and new therapeutic approaches have to be found. We report an open-label, uncontrolled, multicentre phase II trial of lonidamine (LND) and diazepam in 16 patients with GBM at first relapse and a Karnofsky performance status 70. The treatment regimen consisted of LND 450mg/day and diazepam 15mg/day orally of every 28-day cycle until progression or unacceptable toxicity. Patients received a median of three cycles (range, 1–12). No complete or partial response was observed. Therefore, according to the design of the study, no additional patients were enrolled and the trial was closed. Nevertheless, seven stabilizations (50%) were observed. Median time to progression was 8 weeks (range, 5–19 weeks). Median overall survival from recurrence was 15 weeks (range, 14–61 weeks). No grade 3–4 toxicity, except somnolence, was observed and there were no therapy-related deaths. Dose reduction for diazepam due to somnolence (grade III) was performed in 9 patients. The combination of LND and diazepam is well tolerated. LND and diazepam, acting on two distinct mitochondrial sites involved in cellular energy metabolism, may exert a cytostatic effect on tumour growth as shown by the high percentage of stable patients. The LND–diazepam at the used dosing schedule did not show a complete or partial response. LND plus diazepam may be interesting in the adjuvant setting or associated to chemotherapy to act on different targets and increase the therapeutic index.     

Breast conserving surgery --7 years of experience

The breast cancer treatment is based nowadays on a new surgical option: breast-conserving surgery, which is reliable at least for the first and second stage of cancer, with radical intention, obviously. We have started to practice the breast-conserving surgery in our surgical clinic (at CFR Hospital, from Craiova) for 7 years; until now we have performed 159 breast-conserving operation and, as results, we have recorded 3 local recurrences (2.12%) and 1 death due to cancer evolution. Our protocol includes removal of the primary tumor with enough surrounding tissue to ensure negative margins of resectable specimen, associated with total axillary lymph-node dissection and postoperative breast irradiation. Our oncologist on different postoperative conditions indicated the chemotherapy: tumor size, axillary lymph node involvement, patient age, etc. The purpose of this paper is to emphasize our unassuming experience but especially to draw attention on important results, obtained by long-term monitoring the patient who underwent breast-conserving surgery, in a two prospective protocols, which demonstrate the importance and applicability of breast-conserving therapy. The conclusion of this study is that breast-conserving surgery followed by breast irradiation is reliable, as the results are similar with the radical mastectomies; the main objective is to obtain a good cosmetic result, which depends on tumor size/size of the breast ratio.