Recurrence of clonal hematopoiesis after discontinuing pegylated recombinant interferon-alpha 2a in a patient with polycythemia vera.
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Amino Acid Substitution↗
Biomedical subjects
S Ciurea
Publications and source records attributed to S Ciurea.
The use of blood conservation methods in addition to erythropoietin allows myeloablative allogeneic stem cell transplantation without the use of blood products.
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Adult↗
Liver hemangioma revisited: current surgical indications, technical aspects, results.
BACKGROUND/AIMS: New developments regarding the diagnosis of liver hemangiomas, surgical indication and therapeutic options emerged recently. We reviewed our experience from the point of view of these modern developments. METHODOLOGY: Fifty-seven patients with liver hemangiomas were retrospectively studied. The relationship between size, symptoms and treatment was assessed. RESULTS: Indication for surgery was the size of the lesion in 5 patients, symptomatology in 48 and uncertain diagnosis in 4. Increase in size was noted in four patients. Six patients had associated intraabdominal benign or malignant pathology. The treatment of choice was enucleation. Postoperative complications were noted in 6 patients and mortality was nil. In 3 patients the hemangiomas recurred and were reresected in 2. CONCLUSIONS: Hemangiomas should be resected when larger than 10 cm and when they become symptomatic. With the modern diagnostic work-up, uncertainty of diagnosis as an indication for surgery should be rare. Surgery remains the main treatment, with a low morbidity and mortality if performed in a specialized hepatobiliary unit. Enucleation is the surgical option of choice. In selected cases laparoscopic enucleation can be performed with good results.
Adult↗
[Palliative total gastrectomy in advanced malignancies of the stomach].
The diagnosis of the malignancies of the stomach is generally late (stages III and IV to a medium value of 80% of patients). Therefore it is necessary a surgical treatment in order to effectuate the extirpation of the lesions and to warn or to treat the complications in course of the neoplastic disease. The indications and the results of the palliative total gastrectomy (PTG) are analyzed in the present study. Between 1992 and 1999 there were studied retrospectively and prospectively during three successive periods of time, 217 patients (pts.) with PTG. This group of pts. represents 22.1% of the total number of pts. operated on for gastric malignancies (carcinoma particularly). The indication of PTG was established only after one complex evaluation of the every patient from the point of view of his general and biological status. 142 (65.4%/217) of the analyzed pts. presented at the admission in the hospital various complications of the malignant disease (gastric different stenosis, digestive hemorrhages, loco-regional invasion). The lymph nodes metastases and the systemic metastases (in the liver especially) as well as the invasion in the neighbouring viscera imposed sometimes the extension of the PTG with partial or total extirpation of the invaded organs. A proportion of 61% pts. were submitted to those type of enlarged surgical interventions without radical intentions; all the operated pts. remained by necessity in R1 or R2 types of operations. The reconstructive preferred anastomosis was effectuated with an Y jejunal ansa à la Roux completed or not by a "J" reservoir. Microscopically pathologic lesions were: adenocarcinoma and carcinoma (82%), followed by primitive lymphoma (11.5%), and others malignant forms of lesions (approximately 6%). The general perioperative morbidity was 32.5% divided in: 12.3% having a surgical cause (the majority anastomotic leakages +/- septically complications or precocious occlusions); 20.2% complications depending by the general status and altered biology of the patients. Perioperative mortality was 10.1% (22 pts.) comparable with other experiences published in the international literature in those forms of advanced gastric cancer operated by PTG. The average outcome of the operated followed pts. was 16-18 month (extremes 12 months and 29 months). A better quality of life and a variable disease-free period was obtained. As a conclusion we think that the PTG is a advantageous modality of surgical treatment with an acceptable rate of perioperative morbidity and mortality. The outcome of operated pts. is superior comparable with that of nonoperated pts. or with that secondary to other palliative surgical interventions. The importance of adjuvant treatment (chimeo- or radiotherapy) remain to be appreciated in the future.
Adenocarcinoma↗
[Laparoscopic splenectomy--lessons learned from a series of 40 cases. The advantages of the postero-lateral approach].
Until October 2000 in our surgical department 40 patients underwent laparoscopic splenectomy. Seven patients were converted to laparotomy for completion of splenectomy. All of these occurred in the first 20 patients and were due to bleeding. There was no postoperative mortality. Postoperative complications occurred in two patients: one abdominal wall hematoma and a postoperative hernia. Indications were idiopathic thrombocytopenic purpura, hereditary spheocytosis, autoimmune hemolytic anemia and others. In the last 30 cases we used the postero-lateral approach, that results in reduced blood loss, fewer patients that needed to be converted to open surgery and shorter postoperative stay. Accessory spleens can be successfully localized and with a carefull technique the capsular fractures can be minimized reducing the risk of splenosis.
Adult↗
[Liver transplantation--considerations over 8 cases operated in the year 2000].
In the year 2000, at the Department for General Surgery and Liver Transplantation from The Fundeni Clinical Institute Bucharest, seven OLTs and one living-related transplantation were performed in 6 adults and 2 children. Postoperative complications were: bile leakage, hemoperitoneum, lower gastrointestinal hemorrhage, parietoabdominal hematoma. There was only one postoperative death due to septic complications in the 18th p.o.d. and one late death due to pneumonia of unknown origin. After the results in the year 2000 there was an increased number of donors and referrals. We consider that now in Romania this is an established program that will continue depending on the number of donors and financing.
Adult↗
[Hepatic serial resection. Portal vein resection followed by hepatic resection in second time].
Hepatic resection still remains the only potential curative treatment for either primary or secondary malignant liver tumors. In order to increase the resectability of initially considered non-resectable tumors and to decrease the posthepatectomy morbidity and mortality, ligature of a portal branch with consecutive hepatic resection is recommended. The ligature of a portal venous branch was performed in 12 patients with gross hepatic tumor: hepatocellular carcinoma (2), peripheral cholangiocarcinoma (5), hepatic metastases from colorectal cancer (5). Two-stage hepatectomy was performed in 5 patients. The interval between the two operations ranged between 4 weeks and 6 months. Hepatic resection could not be performed in 7 cases due to the loco-regional progression of the disease (4 cases) or to the absence of the hypertrophy-atrophy process (3 cases). Hepatic failure occurred posthepatectomy in 2 patients, resulting in the death of one of the patients. Two patients died at 5 and 10 months respectively while two other patients are still alive, free of recurrence at 6 and 12 months respectively. In conclusion, portal vein ligature can be considered in selected cases of unresectable gross hepatic tumors that can be eventually, resected in a second operation. The two-staged hepatectomy is not always feasible. Moreover, the hypertrophy of the controlateral lobe does not always prevent the postoperative hepatic failure..
Aged↗
[Video-assisted thoracoscopic thymectomy--preliminary results].
Video-assisted thoracoscopic surgery (VATS) provides a new approach to thymectomy. From April 1999 to December 1999, we performed a total of 10 video-assisted thoracoscopic thymectomies for myasthenia gravis (MG). There were one male and nine female patients with ages ranging from 8 to 59 years. Thymoma was present in one of the ten patients. We considered that complete thymectomy was accomplished in all cases by examination of the thymic bed and of the resected specimen. There was no mortality or intraoperative complications. The median postoperative hospital stay was 4 days. Clinical improvement was observed in all patients after this short follow-up. Compared with a similar historical group of patients with MG who underwent transsternal thymectomy, the VATS group was associated with significantly less analgesic requirement and shortened hospital stay. We conclude that VAT thymectomy is technically feasible and is associated with a favorable postoperative course compared with the transsternal approach. We believe that complete thymectomy can be achieved by this approach. Further investigation with long-term follow-up is needed to further clarify the role of VAT thymectomy in thoracic surgery.
Adult↗
[The periampullary carcinoma. Clinical and therapeutic alternatives].
BACKGROUND AND STUDY AIMS: An analysis of the diagnosis difficulties in periampullary carcinoma (PAC) is done, the consequences being the possible therapeutically insufficiencies. PATIENTS AND METHODS: During 10 years (1990-1998) 54 patients have been operated on for a PAC. Sex ratio: 34 males (63%)/20 females (37%). The pick of frequency was in the decade 61-70 years (20 patients) with extremes ages between 20 and 80 years. The main symptom was the cholestatic progressive jaundice with or without neoplasic pain (39 patients--72%). The intermittent jaundice was present only to 7 patients (13%) and the clinical forms without jaundice were manifested to other 8 (15%); superaded colangitic syndrome was present to 17 patients (31%). Other concomitances manifestations of the neoplasic disease were record to 23 cases (43%). Historical evolution of the illness until the cholestatic jaundice appearance was under 2 month to 23 cases, between 2 and 4 months to 24 patients and not sure determined to other 8. The biological preoperative investigations confirmed the clinically evident biliary retention syndrome in 85% of the cases and not yet clinically visible to other 15% of the cases. The ultrasonography was the most conclusive method from the imaging examinations because it have suggested the diagnostic of PAC to 43.5% from the patients submitted to this exploration. Computed tomography was diagnosis relevant only for the in site-regional invasion of the tumors or for the nodes or systemic metastases. Endoscopy and the endobiopsy proved to be valuable especially associated with ERCP (our experience regarding ERCP is not conclusive yet). Therefore the real preoperative diagnostic was established to 11 patients (20%), and for the rest of the cases there have been another presumptive preoperative diagnosis: cancer of the pancreatic head (11 patients), retentive jaundice without determined origin (24 patients), others (8 patients). Intraoperative exploration detected the periampullary tumor through palpation in 30 (55%) cases, through palpation and exploratory duodenectomy in 8 (15%) cases and/or by accessory signs (hydropic gallbladder, dilatation of the main biliary duct etc.). Organic metastases or duodenal stenosis was present in nine cases (6 with nodes metastases). The practiced surgery was: Whipple operations (in one--the majority--or two steps)--35 cases (65%); palliative surgery for biliary drainage 16 (30%) cases; others 3 (6%) cases. The postoperative staging of pT parameter (in situ or ex situ dimensional determined) reveled: pT1-12 patients; pT2--9 patients; pT3--14 patients; pT4--19 patients. Histopathological examinations confirmed the diagnostic of periampullary adenocarcinoma (32 patients) or carcinoma (3 patients) for the 35 patients with resectional operations. The determination of the tissular origin of the periampullary tumor was initially possible only in 11 (31%) operative specimens. A secondary study with many repeated sections in the wax included blocks specified the histogenesis of the tumors to other 10 patients, therefore for a total of 21 cases. We think that this histogenetically diagnosis aspect is important only for some predictive appreciations regarding the outcome of the operated patients and not for the elected therapeutically surgical method. RESULTS: The globally perioperative mortality was 8 (15%) patients. Three from this deceased were a consequence of palliative surgery applied to patients with advanced stages of neoplasic disease. The medium outcome for patients submitted to Whipple operation--in course of evaluation--is between 32 and 41 months to the patients which we can followed. For the patients with palliative operations the same distant survival is between 12 and 24 months.
Adenocarcinoma↗
[Pancreaticoduodenectomy--the rutin surgery?].
Pancreaticoduodenectomy with or without pylorus preserving remains the only possibility for cure for the patients with malignant tumors of duodenum, periampullary and cefalopancreatic region, and distal biliary tumors; Pancreaticoduodenectomy is proceeded also for benign tumors of the head of the pancreas (chronic pancreatitis, cysts) but today the standard became preserving duodenum pancreatectomy with good functional results comparing with standard Whipple resection. The last decade had shown a dramatically decrease of the postoperative death for this kind of operations, centers with high volume have been reported a postoperative mortality rate between 1-3%. Our study is a retrospective analysis witch compare the postoperative mortality between 1 January 1990-1 October 2002. The results have shown a decrease of the postoperative mortality from 30.4% (1990-1995) to 9.8% (1995-1999) and 3.6% in the last three years (2000-2002). Also the surgeon volume of operation is closely linked with the postoperative mortality, at the first operations the postoperative mortality rate is 20-33% and after 20 pancreaticoduodenectomy the rate decrease dramatically to 2.6-5.5%. We conclude that pancreatodudenectomy today is routine operation which mortality have decreased at 5% and should be performed in high volume hospitals by surgeons with sufficient experience to minimize the postoperative death.
Carcinoma↗
[Central hepatectomy].
Central hepatectomy (CH) is a major liver resection that removes Couinaud's segments IV, V and VIII, indicated for centrally located lesions and designed to preserve functional parenchyma and prevent liver failure. During an 8-year period between January 1995-November 2002, 507 liver resections were performed in Fundeni Center of General Surgery and Liver Transplantation (Bucharest). There were three CH performed for colorectal metastases (1 case) and inflammatory pseudotumor (2 cases). The mean duration of the procedure and the mean blood loss were, respectively, 231 minutes and 915 ml. The patients had a good post-operative course, with only minor complications.
Adolescent↗
[Neoadjuvant radiochemotherapy in the treatment of esophageal squamous carcinoma:Preliminary results in a series of 15 patients].
The purpose of this study is to analyze the experience of the Center of General Surgery and Liver Transplantation from Fundeni Clinical Institute (Bucharest) regarding the results of neoadjuvant radiochemotherapy in the squamous carcinoma of the esophagus. During 01.01.2001-09.07.2003, 15 patients with squamous carcinoma of the esophagus were treated using neoadjuvant radiochemotherapy (RCT); 13 patients (86%) underwent esophageal resection (in 2 patients resection was not possible due to the mediastinal invasion). Complete histological response (the lack of malignant tissue on the esophagectomy specimens) was noted in 5 cases. The morbidity and mortality rates were 48%, respectively 6%. RCT increases the resectability in esophageal cancer and decreases the postoperative morbidity and mortality.
Adult↗
[The value of resection in pancreatic cancer: the analysis of an experience of 180 patients in 10 years].
Pancreatic cancer (PC) represents one of the most severe malignant diseases, with an extremely high mortality rate (80% in the first year following diagnosis). The only potentially curative treatment is resection. This report evaluates the last 10-year experience in surgical resection for pancreatic cancer in the Center of General Surgery and Liver Transplantation from the Fundeni Clinical Institute (Bucharest--Romania), between 01.01.1995-01.05.2004. From a total of 832 patients with pancreatic cancer who were surgically treated, 180 underwent various resections (a resecability rate of 21.6%). There were 120 resections for cancer of the pancreatic head: 61 Whipple procedures, 10 pilorus preserving pancreaticoduodenectomies, 10 pancreaticoduodenectomies associated with complex resection, 17 pancreaticoduodenectomies with resection of the portal vein, 15 pancreaticoduodenectomies with extensive lymphodissection, 2 subtotal pancreatectomies and 5 total pancreatectomies; 60 standard splenopancreatectomies were performed for cancer of the pancreatic tail. The overall morbidity was 34%--61 patients (38 with cancer of the pancreatic head and 23 with pancreatic cancer of the tail), with the prevalent complication represented by pancreatic fistula. The mortality rate was 6.6%--12 patients (9 with cancer of the pancreatic head and 3 with cancer of the tail); there was a continuous decreasing trend from 9.1% between 1994-1999 to 1.6% between 2002-2004. In our Center an increasing preoccupation for pancreatic surgery, along with an improved surgical experience, resulted in a constant raise in the number of patients resected for pancreatic cancer, with a low morbidity and mortality rate.
Adult↗
[Orthotopic liver transplantation in adult patients with cadaveric grafts. Experience of the Fundeni Center of General Surgery and Liver Transplantation].
We analyze the experience of the Center of General Surgery and Liver Transplantation from the Fundeni Clinical Institute (Bucharest, Romania) regarding orthotopic liver transplantation (OLT) in adult recipients, with whole liver grafts from cadaveric donors, between April 2000 (when the first successful LT was performed in Romania) and December 2004. This series includes 37 OLTs in adult recipients (16 women and 21 men, aged between 29-57 years--average 46 years). Other two LT with whole liver cadaveric grafts and two reduced-size LT were performed in children; also, in the same period, due to the acute organ shortage, other methods of LT were performed in 28 patients (21 living donor LT, 6 split LT and one "do mino" LT), that were not included in the present series. The indications for OLT were HBV cirrhosis--10, HBV+HDV cirrhosis--4, HCV cirrhosis--11, HBV+HCV cirrhosis--2, biliary cirrhosis--5, Wilson disease--2, alcoholic cirrhosis--1, non-alcoholic liver disease--1, autoimmune cirrhosis--1. With three exceptions, in which the classical transplantation technique was used, the liver was grafted following the technique described by Belghiti. Local postoperative complications occurred in 15 patients (41%) and general complications in 17 (46%); late complications were registered in 18 patients (49%) and recurrence of the initial disease in 6 patients (16%). Intrao- and postoperative mortality was 8% (3/37). There were two patients (5%) who died because of immunosuppressive drug neurotoxicity at more than 30 days following LT. Four patients (11%) died lately because of PTLD, liver venoocclusive disease, recurrent autoimmune hepatitis and liver venoocclusive disease, myocardial infarction, respectively. Thirty-four patients survived the postoperative period (92%); according to Kaplan-Meier analysis, actuarial patient-survival rate at month 31 was 75%.
Adult↗
[Therapy of malignant liver tumors using microwave and radiofrequency ablation].
The aim of our study was to evaluate the efficiency for thermo-ablation with microwave and radiofrequency on patients with malignant liver tumors. From January 2002 to January 2005, in our Center of General Surgery and Liver Transplantation in 53 patients 70 sessions of thermoablation were carried out. The mean age was 58 years (25-79 years). Sex ratio men: women was 1.8 (34:19). The diagnosis was hepatocarcinoma in 38 patients (72%), liver metastases from colorectal cancer in 9 (17%) and from non-colorectal cancer (6-11%). The most tumors were single (36-68%). The mean diameter was 39.5 mm (9-94 mm). Percutaneous approach was used in 14 interventions (20%), laparoscopic in 2 (3%) and open approach in 54 cases (77%). We performed 54 sessions of microwave ablation in 42 patients and 8 sessions of radiofrequency ablation in 5 patients. Both methods were applied in 6 patients during 8 sessions. Tumor ablation was done together with liver resection in 10 patients (19%) and resections of other organs in other 8 patients (15%). Morbidity was 12%. The encountered complications were ascites, right pleural effusion and liver abscesses. There was no death. Total and partial necrosis was observed in 27, respectively 20 patients. Local recurrence occurred in one patient but distal liver recurrences were diagnosed in 13 patients. After thermoablation for partial necrosis, local or distal recurrences patients received arterial chemoembolization (5), systemic chemotherapy (23), liver resection (1) and transplantation (1). The mean survival at 1 year and 3 years was 77% and respectively 38%. Microwave or radiofrequency ablation is a simple treatment method, with proved efficiency and minimal risks whose main indication is unresectable tumor.
Adult↗
[Current treatment of hepatocellular carcinoma. Analysis of a series of 123 cases over a 5-year period].
We analyze a 123-cases experience over a 5-year period in the treatment of hepatocellular carcinoma (HCC). Liver resection, transplantation and hyperthermic ablation of the tumor were used according to the indication and patient selection. Systemic chemotherapy followed resection in 18 cases and hyperthermic ablation in 5 cases. Chemo-embolisation was performed in patients to be transplanted and in other two patients with tumor destruction. A number of 86 liver resections were performed in 84 patients (2 re- resections in 1 patient, subsequently transplanted) - 43 on normal liver and 41 on cirrhotic liver. Postoperative mortality was 4.7% in non-cirrhotic and 4.9% in cirrhotic patients. Survival in non-cirrhotic patients was 77% at 1 year, 65% at 2 years, and constant - 45% at 3 and 4 years, whereas in cirrhotic patients it was 60%, 56%, 56% and 36% (Kaplan-Meyer actuarial survival rates). Nine patients underwent liver transplantation (4 OLTs, 3 living donor LT, 1 split LT and 1 "domino" LT); postoperative mortality was 11% (1 patient). At present five patients are alive and well. One patient died by peritoneal carcinomatosis at 10 months; another patient died at 6 months by severe cholestatic recurrent C virus hepatitis and one patient was discharged with permanent severe neurologic disturbances. In 31 patients hyperthermic ablation of the tumor was used with zero mortality. Actuarial survival rates were 75% at one year and 67% at 2 years. In conclusion, in non-cirrhotic patients with HCC resection is the treatment of choice. In cirrhotic patients limited resections should be preferred and liver transplantation is the best solution in selected cases; local ablative methods may be used for some unresectable tumors. The role of adjuvant chemotherapy has to be determined in future comparative studies.
Actuarial Analysis↗
[Central pancreatectomy--indications, technique, outcomes].
Central pancreatectomy is a conservative resectional procedure indicated for benign and low malignant tumors located in the neck and/or body of the pancreas. We report our experience on 5 patients and some considerations about this surgical technique from medical literature.
Adolescent↗
[Surgical treatment of liver metastases from colorectal cancer].
We analyze our experience over a 10-year period in the surgical treatment of liver metastases from colorectal cancer. Between 01.01.1995 and 08.31.2005 189 liver resections were performed in 171 patients with liver metastases from colorectal cancer (16 re-resections - 2 in the same patient and a "two-stage" liver resection in 2 patients). In our series there were 83 patients with synchronous liver metastases (69 simultaneous resections, 12 delayed resections and 2 "two-stage" liver resection were performed) and 88 metachronous liver metastases. Almost all types of liver resections have been performed. The morbidity and mortality rates were 17.4% and 4.7%, respectively. Median survival was 28.5 months and actuarial survival at 1-, 3- and 5-year was 78.7%, 40.4% and 32.7%, respectively. Between January 2002 and August 2005 hyperthermic ablation of colorectal cancer liver metastases has been performed in 6 patients; in other 5 patients with multiple bilobar liver metastases liver resection was associated with radiofrequency ablation and one patient underwent only radiofrequency ablation for recurrent liver metastasis. In conclusion, although the treatment of colorectal cancer liver metastases is multimodal (resection, ablation, chemotherapy and radiation therapy), liver resection is the only potential curative treatment. The quality and volume of remnant liver parenchyma is the only limitation of liver resection. The morbidity, mortality and survival rates after simultaneous liver and colorectal resection are similar with those achieved by delayed resection. Postoperative outcome of patients with major hepatic resection is correlated with the surgical team experience. The long-term survival was increased using the new multimodal treatment schemes.
Adult↗