Spontaneous esophageal rupture in three patients

Boerhaave's syndrome represents the most severe perforation of the gastrointestinal tract. The typical clinical presentation is by a sudden onset of pain after a vomiting effort on the background of an alimentary and alcoholic abuse. It usually associates the cervicomediastinal emphysema, altogether forming the Mackler triad. The atypical presentation and the rarity of this entity usually lead to the delay in diagnosis in 50% of the cases. The diagnosis requires native and hydrosoluble contrast radiological examination which may reveal, altogether with the esomedistinal or esopleural fistula, pneumomediastinum, cervical subcutaneous emphysema, pleural effusion or hydropneumothorax. The early diagnosis and surgical treatment in the first 24 hours after the perforation offer the best chances for survival. We present and analyze the cases of 3 patients with spontaneous esophageal rupture with their different evolution and the diagnostic and treatment steps in each case.     

Blood pressure homeostasis and microvascular complications in diabetic patients

The retinopathy and nephropathy are among the most prevalent and disabling complications associated to microvascular damage in diabetes mellitus. The severity of hyperglycaemia and the presence of arterial systemic hypertension are among the main risk factors for these complications. The ambulatory blood pressure provided a better understanding of patterns of blood pressure in diabetic patients. There is a growing number of evidence relating diabetic patients with abnormal 24 h blood pressure patterns. Even subtle modifications of these patterns, frequently shown by patients diagnosed as normotensives in office blood pressure measurings, may be implicated in an increased risk of microvascular complications. Hyperglycaemia and these abnormal pressure patterns appear to have a synergistic effect on promoting and aggravating diabetic retinopathy. Impairment of the normal retinal autoregulation is one of the implicated physiopathological mechanisms. Probably, ABP may be useful in predicting an increased risk of microvascular complications on diabetic normotensive patients. The objective of this paper is to provide an updated and clinically oriented review in blood pressure homeostasis and diabetes mellitus.     

Biochemical changes in the rat brain associated with dinitrophenol-induced brain edema.

The present paper was designed to the study of cerebral edema induced by intracarotid infusion of dinitrophenol. The determinations included variations in three lysosomal enzymes (acid phosphatase, cathepsin C and beta-glucuronidase), Na+-K+-ATP-ase, changes in cerebral RNA and protein concentrations and the synthesis of these macromolecules in vitro. In experimental brain edema a drastic drop in the activity of lysosomal enzymes took place. The acid phosphatase decreased to less than 30% of controls. Cathepsin C and beta-glucuronidase were reduced about 30% and 50% of control levels respectively. Protein concentration in the cerebral tissue also decreased by more than 50%. The concentration of RNA, RNA synthesis, and the level of Na+-K+-ATP-ase remained unchanged. Protein synthesis was stimulated by 75% (against controls). All these phenomena were suppressed when the animals subjected to the action of dinitrophenol were concomitantly treated with the antiacidotic substance, tris (hydroxymethyl) aminomethane.     

Colonoscopy in Romania

BACKGROUND: To date, colonoscopy is considered the gold standard for the investigation of the colon and also the gold standard method for colorectal cancer screening. AIM of this paper was to assess if and how is Romania prepared to cope with screening of colon cancer by means of colonoscopy. METHOD: We sent a study-type questionnaire addressed to all the centers in Romania known to perform digestive endoscopy and we inquired about the total number of colonoscopies and flexible sigmoidoscopies performed in 2003 (the questionnaire was sent to 43 centers). RESULTS: Thirty-eight centers responded to the question-naire. The total number of colonoscopies performed in Romania in 2003, obtained by collecting the data from the study centers, was 22,324. The number of sigmoidoscopies performed during the same period was 12,349. The ratio between the number of colonoscopies and sigmoidoscopies was 1.8/1. There were 106.3 colonoscopies /100,000 inhabitants. CONCLUSION: Considering the population of Romania (about 21 million inhabitants), the number of colonoscopies performed is insufficient for our country. The number of centers performing colonoscopy in Romania is also insufficient.     

Proliferative activity of myeloma cells determined by Ki-67 antibody: biological and clinical significance

In this study we analyzed proliferative activity of myeloma cells and a possible correlation with selected clinical data, histological features and survival in 59 patients with newly diagnosed multiple myeloma (27 females and 32 males, mean age 62 years). Imunohistochemical method was applied using Ki-67 antibody on B5-fixed and paraffin-embedded bone marrow specimens to evaluate growth fraction of myeloma cells. Clinical staging was done according to the Durie-Salmon classification (4 patients had stage I disease, 16 patients stage II and 39 patients stage III). The number of Ki-67+ myeloma cells ranged from 1% to 36% (mean value 7%). In 39 of 59 patients (66.1%) number of Ki-67+ cells was less than 10% (cases with low proliferative index). Ki-67 expression significantly correlated with the clinical stage, beta2-microglobulin level, plasma cell morphology, volume of myeloma infiltration and the extent of osteolytic lesions. Patients with increased proliferative index (Ki-67+ cells > or = 10%) showed a significantly shorter survival compared to those with low proliferative index (14 months vs. 36 months, p = 0.023). However, this difference was not shown in multivariate analysis, particularly due to the high correlation between proliferative activity and plasma cell morphology and the volume of myeloma infiltration.     

Use of polypropylene mesh for incisional hernia repair

Incisional hernia is an important complication of abdominal surgery. Procedures for the repair of these hernias with sutures and with mesh have been reported, but there is no consensus about which type of procedure is best. We have performed a retrospective analysis on 1014 patients operated on in our unit between 1994 and 2003 for simple or recurrent incisional hernias. The polypropylene mesh has been used in a number of 107 patients. The mesh has been placed either intraperitoneal, extraperitoneal/subfascial or onlay. Median follow-up was 36 months. There were 1 enterocutaneous fistula and 5 wound sinus developed. The mesh had to be removed in 6 cases. All of these complication developed when the mesh has been placed either extraperitoneal/subfascial or onlay. We note 5 recurrent incisional hernias after a period of up to 24 months. The recurrence rates after open mesh repair are less then after primary closure. The intraperitoneal use of polypropylene mesh with omental coverage is a good procedure with less complications.     

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.     

Carcinoid tumors, leiomyosarcoma and invasive adenocarcinoma metastasis of the Treitz angle

Our paper studies the quite rare occurrence of the digestive superior occlusive pathology, namely some causes which might induce partial or even total obstruction of the digestive tract, at the distal anatomical limits of the duodenum, also known as the Treitz angle. The first two described cases were carcinoid tumors, obstructive and ulcerated in the lumen of the same angle. The last two cases were an obstructive leiomyosarcoma and an invasive mesenteric metastasis from a right colon cancer, which cause a total external compression of the Treitz angle, clinically manifested as a complete food intolerance, as a first symptom. Concerning the clinical evolution, these are totally different lesions, malign, metastasis and neuroendocrine tumors, which occurred at the same level, had a totally different clinical evolution and surgical approach, only three of them developing at good postoperative course. The imaging, clinical and pathological diagnosis problems, the different specific surgical solutions, the postoperative care and finally the rarity of this level of obstruction of the small bowel, are the aim of this paper.     

Minimally invasive approach of the cervical endocrine glands

Improved preoperative functional and topographic diagnostic techniques and availability of intra-operative hormone monitoring, stimulated the introduction of video-assisted minimally invasive operations in parathyroid and thyroid surgical pathology. The first cases of such pathology operated on in our clinic are presented. The first one is a 62 year old man with renal hyperparathyroidism consecutive to a chronic renal insufficiency and hemodialysis from five and three years respectively. The technique of a minimally invasive gapless resection of all four "adenomised" parathyroid glands using laparoscopic and classic instruments is described. Fragments of one gland are implanted in the left forearm musculature. The second case was a 48 year old woman with a three cm diameter right toxic adenoma. With a lateral 15 mm incision, dissociation of the musculature and adequate moving of the retractors the excision of the thyroid nodule was done in 25'. The video-assisted minimally invasive approach allows magnification and adequate identification and removal of endocrine secreting tissues in thyroid and parathyroid pathology. The authors believe that these techniques represent a feasible and attractive alternative to conventional surgery.     

Superoxide dismutase entrapped-liposomes restore the impaired endothelium-dependent relaxation of resistance arteries in experimental diabetes

Diabetes is associated with impaired endothelium-dependent relaxation. We questioned whether administration of superoxide dismutase (superoxide: superoxide oxidoreductase, EC 1.15.1.1) entrapped in long-circulating liposomes improves the vascular reactivity of the resistance arteries. Using the myograph technique, the vasodilation in response to acetylcholine was measured in mesenteric resistance arteries isolated from diabetic or normal hamsters treated for 3 days with superoxide dismutase entrapped in liposomes, with the same concentrations of free superoxide dismutase and plain liposomes, or untreated. Superoxide dismutase activity and nitric oxide (NO) levels were assayed by spectrophotometry, superoxide dismutase levels by Western blot and the role of N(pi)-nitro-L-arginine ethylester (L-NAME) on vasodilation by the myograph technique. Our data revealed that: (i) superoxide dismutase entrapped in liposomes restored to a great extent the endothelium-dependent relaxation of diabetic hamster resistance arteries; (ii) in superoxide dismutase entrapped in liposomes-treated diabetic animals, the activity and the level of superoxide dismutase in arterial homogenates as well as the serum nitrite levels were significantly higher than those in untreated hamsters or hamsters treated with free superoxide dismutase and plain liposomes: (iii) L-NAME inhibited the response of arteries to acetylcholine in superoxide dismutase entrapped in liposomes-treated diabetic hamsters. These results suggest that superoxide dismutase entrapped in liposomes is effective in scavenging superoxide anions, increases nitric oxide bioactivity and improves the vasorelaxation of resistance arteries in diabetic hamsters.