Chirurgia最新文献

Breast cancer (BC) is recognized as one of the leading malignancies affecting women worldwide. Its remarkable heterogeneity is a defining characteristic, contributing to both diverse patterns of disease progression and varied therapeutic responses. This review explores the evolution of breast cancer classifications, focusing on key prognostic and predictive factors. It examines traditional systems, such as the TNM staging and histological differentiation, while also incorporating modern elements like molecular subtypes, genomic alterations, and advanced diagnostic assays. By combining classical clinicopathological insights with cutting-edge molecular genetic technologies, the goal is to refine the precision of treatment strategies, ultimately advancing both our understanding and management of this complex disease. The review also emphasizes the importance of a global perspective, as achieving the primary treatment goals - prolonged survival and enhanced quality of life - requires addressing the disease in a broader, more comprehensive context. Breast cancer's complexity, driven by significant variability both across and within tumors, presents major challenges to conventional diagnostic and therapeutic approaches. However, breakthroughs in genomic research, such as molecular profiling and genetic testing, have deepened our understanding of this cancer's intricate nature. These advances have led to the identification of critical genetic alterations - including mutations in BRCA1/2, TP53, PALB2, PTEN, and PIK3CA - that profoundly impact tumor behavior, treatment efficacy, and patient prognosis. Genomic assays like Oncotype DX, MammaPrint, PROSIGNA, and EndoPredict offer valuable insights into recurrence risks and treatment choices, underscoring the growing importance of precision medicine. Moreover, the implementation of Molecular Tumor Boards further enhances personalized treatment strategies, contributing to improved patient outcomes and survival rates. This review underscores the significance of tailored therapeutic approaches and highlights the dynamic evolution of breast cancer in clinical practice.

video width="640" height="480" controls controlsList="nodownload" poster="https://www.revistachirurgia.ro/pdfs/video/posterior_retroperitoneoscopic_bilateral_adrenalectomy.jpg" style="margin-top: -20px;" source src="https://www.revistachirurgia.ro/pdfs/video/posterior_retroperitoneoscopic_bilateral_adrenalectomy.mov" type="video/mp4" Your browser does not support the video tag. /video Introduction: Bilateral adrenal involvement occurs in about 20% of pheochromocytomas, more commonly in genetic syndromes like MEN2A (Multiple Endocrine Neoplasia 2A). Posterior retroperitoneoscopy surpasses the disadvantages of the other laparoscopic approaches, being particularly useful when bilateral adrenalectomy is indicated. The aim of this study was to present the first published experience in Romania with posterior retroperitoneoscopic bilateral adrenalectomy in the treatment of bilateral pheochromocytoma. Materials and Methods: We report the case of a 47-years-old female referred in Urology department for surgical treatment of bilateral pheochromocytoma in the setting of MEN2A syndrome (her daughter and sister with the "high risk" mutation in RET gene) for which she has been actively screened. The ultrasound of thyroid gland and the significantly increased serum calcitonin were highly suggestive for medullary thyroid carcinoma. The computed tomography of chest/abdomen/pelvis revealed inhomogeneous, contrast-enhancing bilateral adrenal masses, 38/38 mm on the right and 36/26 mm on the left side, respectively. The free plasma metanephrines were significantly increased. After adequate preoperative preparation of the patient, we performed bilateral adrenalectomy using posterior retroperitoneoscopic approach, during the same procedure. Results: The total operative time was 90 minutes. The estimated blood losses were minimal. The postoperative surgical evolution of the patient was uneventful. Major cardiovascular and metabolic perioperative complications were prevented by anesthesia team. The lumbar drain was removed in the postoperative day 1. The pathology results reported negative surgical margins, PASS score of six on the left side and two on the right side, respectively. Three months later, the patient underwent total thyroidectomy with cervical lymph node dissection for medullary thyroid carcinoma (pT1bN0L0V0Mx). The last clinical and imaging evaluation (at 12 months postoperatively) revealed no evidence of tumour recurrence. Conclusion: Posterior retroperitoneoscopic adrenalectomy is a direct, painless, cosmetic and feasible technique and the ideal option when bilateral procedure is considered. To our knowledge, it is the first publication regarding bilateral adrenalectomy in Romania using this approach.

Background: Minimally invasive techniques in gynecological pathology have well-known benefits, the "gold standard" of uterine prolapse being currently managed laparoscopically. Laparoscopic lateral hysteropexy and hysterosacropexy are surgical techniques that can be performed for uterine prolapse. Laparoscopic management of such cases is recommended, but requires well-trained teams in laparoscopic surgery. Methods: This study is a prospective analysis of patients who required surgical treatment for stage III uterine prolapse, hospitalized in the Surgery Department of Constanta County Hospital, for which laparoscopic lateral hysteropexy or laparoscopic hysterosacropexy was performed. Results: Between 2016-2020, 61 patients were hospitalized with stage III uterine prolapse that required surgery. All patients underwent laparoscopic surgery. Symptomatology was dominated by urinary incontinence (50%, 44.89%) and obstructive defecation (16.66%, 18.36%). Intraoperative complications were encountered in 33.3% of cases undergoing laparoscopic hysterosacropexy and in 8.16% undergoing laparoscopic lateral hysteropexy. At one year, the recurrence rate was 2.04% for patients who underwent lateral hysteropexy and 8.33% for patients who underwent hysterosacropexy. No patient had a recurrence at the 3-year visit. Conclusions: Laparoscopic lateral hysteropexy is emerging as an appropriate, safe, and effective procedure to treat advanced apical prolapse that requires further clinical attention and development to fully understand its surgical place in the treatment of pelvic defects.

Background: Gastroesophageal Reflux Disease (GERD) has a persisting high prevalence in western industrial countries and a rising prevalence in some asian industrial societies. Management of the disease, i.e. the multimodal care for the affected patients consists of the application of a definition of GERD to clearly define the cohort, using a systematic and differentiated diagnostic work-up as well as using selection criteria for conservative versus interventional and surgical therapy and long-term accompaniment. The purpose of this manuscript is a review of the information in literature on items involved in the current management of GERD and their clinical application. Methods: A list of items was established with all components necessary for the multimodal management of patients with GERD. A literature search was performed using the term [management of GERD] or [GERDmanagement] in medline pubmed.gov (USA). All abstracts were evaluated for their usefulness regarding the aim of the study, those with a different focus on GERD-issues were excluded. Results: Initially 8 items were identified necessary for the multimodal management of GERD-patients. In total, 2193 abstracts were found between 2017 and 2023, which were evaluated and 53 full articles were analyzed. Out of these 53 publications with the correct focus on GERD-management, 34 were excluded for not providing at least 4 of the available 8 items of the complete spectrum of GERD-management. Finally, 19 reports were selected for final assessment. Remarkably, 16 out of 19 publications used either a symptom questionnaire or the Montreal classification, while others used esophageal acid exposure or esophagitis for defining the presence of GERD. Regarding suggestions for a multimodal therapeutic concept, only 9 publications reported on all available therapeutic management options of GERD. Most publications described conservative therapy, while 9 articles included surgical procedures as an option in the overall GERD-management. Conclusions: GERD cannot be handled as just one disease, but should be considered as a multi-factorial disease consisting of several subgroups of GERD-patients with different phenotypes. All these different sub-groups of the disease may need their individual management options. Only half of publications on GERD-management provided the complete spectrum of involved management components.

Background: Laparoscopic surgery is now widely recognized as a very safe and effective standard treatment for colorectal cancer as compared with laparotomy. Diabetes causes significant mortality and morbidity in the general population, and in particular in patients who associate an oncological pathology. In the postoperative period, diabetic patients have a significantly higher risk of developing important complications. The aim of this study was to analyze the impact of minimally invasive surgery in patients with colorectal cancer and type 2 diabetes mellitus. Methods: Between January 2018-2022, 482 patients diagnosed with colorectal cancer were enrolled in the study, of whom 52 were eligible for inclusion. General characteristics and the presence of diabetes before colon cancer diagnosis were identified. Kaplan-Meier analyses were performed according to type of surgery, gender, stage of disease, and associated comorbidities. Results: Fifty-two patients were included in the study, divided into two groups: 24 underwent laparoscopic surgery and 28 open surgery. Postoperative recovery was faster in patients who underwent laparoscopic surgery, this being also evidenced by a lower number of postoperative hospitalization days (6.67+-1.97 vs 9.21+-2.36, p 0.001). Regarding postoperative complications, patients with open surgery, had higher rate of minor and major complications according to the Clavien-Dindo classification (67.9% vs 25%), and the long-term survival of patients who underwent laparoscopic surgery was higher. Conclusions: Laparoscopic surgery is recommended for patients with colorectal cancer and type 2 diabetes, the patients having minimal postoperative complications and a faster postoperative recovery period.

Rectal cancer is one of the most frequently diagnosed malignancies, associated with high morbidity and mortality, which justify the constant interest in fine-tuning the available therapeutic methods and developing new ones. The preference for one surgical technique over another is highly dependent on the stage, the location of the tumor, other patient-related factors and the experience of the surgical team. This article aims to offer a comprehensive review of the surgical modalities utilized at the present time for the curative treatment of rectal cancer, as well as the future directions in this field, pointing out the latest progress and the most recent shifts in paradigm in the management of rectal cancer. The evolution of open surgery, laparoscopy, robotic surgery, and transanal techniques is described in chronological fashion, highlighting the advantages and disadvantages of each procedure. Although open surgery remains the gold standard for emergency situations such as occlusion or massive bleeding, minimally invasive surgery has gained ground over the past decade due to its benefits - faster discharge, lower infection rates, better short-term outcomes, while demonstrating similar oncological long term outcomes as in the traditional surgical approach. The main disadvantage is strongly connected with the training process, especially with gaining experience in complicated cases, as well as the total cost of equipment and maintenance. While robotic surgery has been lately successfully implemented in advanced or/and recurrent low and medium rectal cancer, laparoscopy remains the most utilized minimally invasive modality which has the undeniable advantage of shorter operating time. Additionally, one of the most discussed topics comprises the newly developed transanal techniques which offer an elegant solution for distal rectal tumors, especially in obese patients or with narrow pelvises. Continuous optimization and new developments of surgical techniques in rectal cancer lead to accomplishing the goals of precision medicine.

Background: Prognostic scoring systems are critical for assessing preoperative risk and forecasting outcomes in rectal cancer surgery. This study evaluates the effectiveness of four scoring systems - Estimation of Physiologic Ability and Surgical Stress (E-PASS), Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM), Colorectal-POSSUM (CR-POSSUM), and the Association of Coloproctology of Great Britain and Ireland (ACPGBI) - in predicting postoperative complications and mortality. Methods: A retrospective study was conducted involving 67 patients who underwent surgery for rectal cancer. The scoring systems were assessed concerning postoperative outcomes, including complications, morbidity, and 30-day mortality rates. Statistical analyses included t-tests, chi-square tests, and logistic regression. Results: Patients with complications (n = 39) demonstrated significantly higher scores across all systems. The Comprehensive Risk Score (CRS) derived from E-PASS (11.43 versus 8.95, p = 0.001) and the ACPGBI score (1.95 versus 1.27, p = 0.0005) demonstrated the most significant correlation with complications. Elevated physiological and operative scores correlated with increased morbidity, underscoring their prognostic importance. Conclusions: Scoring systems such as E-PASS, POSSUM, CR-POSSUM, and ACPGBI effectively stratify the risk associated with rectal cancer surgery. Clinical integration enhances the identification of high-risk patients, which informs interventions designed to optimize outcomes.

Introduction: Pancreatic neuroendocrine tumors (PNETs) are uncommon cancers, but their overall incidence seems to be on the rise, possibly due to better detection with advancements in cross-sectional imaging techniques. Methods: This study consists of a retrospective analysis of PNET patients treated in the First Surgical Oncology Clinic over a period of 10 years. The patient files were evaluated, and the following parameters were taken into consideration: gender, age, primary tumor site, extension of the disease, metastatic sites, the therapeutic approach, type of surgery, histopathological results, postoperative mortality, and morbidity. Results: Over the course of 10 years, there were 16 patients diagnosed with PNETs. Surgical interventions consisted in: pylorus-preserving pancreaticoduodenectomy in 5 cases, distal pancreatectomy in 3 cases, enucleation of the tumor in 4 cases, liver biopsy in 3 patients and one case in which choledochoduodenostomy and a liver biopsy were the treatment option. Mean length of stay was 10.6 days. In the study group, there were 4 cases that presented grade I-II complications (Clavien-Dindo). There was no case of postoperative or 30 days mortality. Conclusion: This study outlines the surgical management and clinicopathological findings of PNETs. Surgical therapy must be tailored to tumor and clinical characteristics.

Introduction: Pancreatic metastases are very rare tumors comprising 2-5 % of all malignant tumors of the pancreas. Colorectal pancreatic metastases are rare - 1.7%. Clinical features: Three patients with colo-rectal pancreatic metastasis were resected in our departament. The immunohsitochemical examination was positive for colorectal origin. Extensive imagistic work-up excluded extrapancreatic disease and allowed the surgical resection. Results: Three patients with personal history of colorectal cancer (2 - colon, 1 -rectal) were diagnosed with isolated pancreatic metastasis (2 in the head and one in body). Standard pancreatic resections were performed (2 pancreatico-duodenectomies and one distal spleno-pancreatectomy). One patient with associated vascular resection died postoperatively. The other two developed extrapancreatic recurrence and only one was resected (alive and disease free); the other died under systemic therapy. Conclusions: Surgical resection is recommended in selected patients, surgically fit, with resectable oligometastatic disease, in high-volume center with experience in pancreatic surgery.

Introduction: we report the case of a recurrent giant pseudopolyp occurring in a patient without a history of inflammatory bowel disease (IBD), with an asymptomatic interval of nine years. Case Presentation: a 51-year-old Caucasian male with no relevant medical history was hospitalized for a subocclusive mass in the right colon, suspected to be neoplastic. He underwent a right hemicolectomy, and the histopathology revealed a giant pseudopolyp without malignancy. Follow-up for IBD was recommended but not completed. Nine years later, the patient presented with a similar clinical picture, and another mass was found at the site of the prior anastomosis. Surgical excision confirmed another giant pseudopolyp with no evidence of neoplasia. Conclusion: giant pseudopolyps, while often associated with IBD, can occur in patients without a prior inflammatory history. This case underscores the need to include pseudopolyps in the differential diagnosis of colonic masses, even in the absence of IBD, to avoid unnecessary surgical morbidity.