Introduction: Pancreatic cancer is the third leading cause of cancer death after lung and colorectal cancer and its diagnosis is often difficult to make in the early stages. Investigations such as echoendoscopy are an asset in the diagnostic arsenal of the medical-surgical team. Method: We propose for presentation a case of a patient who, at reevaluation one year after cholecystectomy, presents a cephalopancreatic tumor so he was proposed for duodenopancreatectomy following the decision of an interdisciplinary medical-surgical team. Results: A 69-year-old patient with a history of mediocoledocian stenosis for which biliary and pancreatic stents were fitted endoscopically, presents at the hospital with clinical signs suggestive of acute cholecystitis. Surgery is decided and an open cholecystectomy is performed for plastronated pyocholecystitis. Intraoperatively, it was observed an accentuated pericephalopancreatic inflammation, but it is not considered to be with a tumoral substrate. Subsequently, at approximately 1 year, CT scan is performed and suggests a cephalopancreatic tumor, so an echoendoscopy with biopsy was performed and the histopathological result was high-grade intraepithelial ductal pancreatic neoplasia. Following the multidisciplinary consultation within the tumor board, the patient is proposed for duodenopancreatectomy. Conclusion: Pancreatic neoplasm, although an extremely difficult pathology from the point of view of diagnosis and treatment, can and must be managed in multidisciplinary medical-surgical teams both in terms of medical expertise and investigations. Such therapeutic decisions are presented within specialized tumor boards, the oncological surgical treatment being an ample one.

Introduction: Pancreatic surgery is a complex surgery with still high morbidity and mortality and involves multidisciplinary team, specialized centers and standardization methods to reduce these rates. The National Register of Pancreatic Surgery is a useful tool in its standardization. Methods: The National Register of Pancreatic Surgery is the largest national database containing information on patients who have undergone total duodenopancreatectomy, cephalic duodenopancreatectomy or body-caudal pancreatectomy, for benign or malignant pathology, since October 1, 2016. Data are collected from over 7 centers and contain information about patient characteristics, pancreatic and associated pathology, surgical technique, complications and length of hospital stay. Results: For a young and growing team of HPB surgery, the National Pancreas Registry has been a useful tool in standardizing and developing this kind of surgery. Aspects like artery first approach, harvesting bilicultures, choosing the type of anastomosis according to the consistency of the pancreas have become standard, starting with January 2019, since our center participates in this register. Also, the offered landmarks helped us to transplant the experience in a new surgery center, along with the limitation of pancreatic surgery in St. John's Hospital Bucharest, due to the COVID-19 pandemic. Conclusions: The National Register of Pancreatic Surgery is a benchmark for the practice of this type of complex surgery and is an aid for its development in new centers at the beginning of the road.

Introduction: Although we live in the 21st century, hydatidosis is still a common disease Eastern Europe, especially in families with precarious economic and health status. Methods: We present a rare case of a voluminous hepatic hydatic cyst disseminated in both hepatic lobes with peritoneal hydatosis. After the anti-parasitic oral treatment, we performed a laparotomy with the excision of the cysts from segments 7-8, 4A and 4B, 5 and 2, partial omentectomy and cholecystectomy. The patient developed a large volume biliary fistula and although we performed an ERCP procedure with papilosfincterotomy and stenting with a significant decrease of the flow, the hospitalization period was still very long (8 weeks). Results: Patient never came for postoperative follow-up control and presented herself 5 months later, with a segment 7-8 hepatic abscess, that needed reoperation. Paradoxically, no biliary leak was developed after the second procedure, with smooth postoperative evolution. Conclusion: Managing such an advanced disease is challenging for the surgeon, not only technically, but also strategically, with a lot of costs for the hospital and treatments for all the postoperative complications. Difficult patients from rural areas are sometime difficult to manage, with fluctuant follow-up and an increase risc of complications.

Acute pathology of the cecal appendix - appendicitis, is a condition that does not take into account the pandemic period. The aim of this study is to retrospectively analyze the relationship of care for two groups of patients who underwent appendectomy in COVID-19 period and one year before, same period of time, in emergency hospital service. We performed a retrospective analysis on the patients admitted in our surgery center by comparing two groups for each period analysed: group A, for the period March-May 2019 and group B for the period March-May 2020 (corresponding to COVID-19 pandemic). We compared the groups analysing features that prove the change in age, incidence, grade (severity) of appendicitis, delay of surgery, length of surgery, postoperative complications and hospitalization time. CT scan was made for each patient. In the group B, PCR COVID-19 testing was made (all patients were negative for COVID-19). Our study consisted of 52 patients, group A-32 patients (61.53%) and group B-22 patients (38.47%). The Covid-19 pandemic influenced the incidence of appendicitis and we noted a delayed presentation which led to more complicated appendicitis than same period of the previous year. The impact also was noted on length of surgery, due to use of PPE (personal protective equipment) and also modified anatomy of the region related to inflammation. The severity of appendicitis was higher in the COVID-19 period when compared to 2019 similar period of time. Further research is required to draw more conclusions on this period.

The genetic syndrome known in literature as the Multiple Endocrine Neoplasia type 1 (MEN 1) is transmitted in a dominant manner. The primary discovery of more than two endocrine tumor formations representative for MEN 1 should guide the doctor to the suspicion and subsequent confirmation of the diagnosis. Statistics state a long association of the MEN 1 syndrome with the tumors discovered in the small intestine and the pancreas with the adenomas encountered in the parathyroid and pituitary glandular tissueWhile in postmenopausal women, the primary hyperparathyroidism is diagnosed mostly with abnormal levels of parathyroid hormone and serum calcium specifically. The most useful preoperative imaging tools are neck ultrasound scanning and technetium-99m sestamibi scintigraphy. Using bilateral neck exploration, subtotal, and parathyroidectomy are proposed. Our case consists of a 54 years old female, diagnosed with right inferior parathyroid adenoma. With three first degree relatives operated for neuroendocrine pancreatic tumors, her medical history includes distal corporeal-caudal pancreatectomy for a neuroendocrine tumor four years ago. Laboratory tests unveil increased calcium (12, 41 mg/dl) and glucose (150 mg/dl) levels. During hospitalization, the patient’s representative parameters for monitoring hyperparathyroidism maintained at high levels. Parathyroid ultrasound and the 99mTctetrofosmin/99mTc-pertechnetate parathyroid scintigraphy sustained the diagnosis. Consequently, the patient was proposed for a subtotal parathyroidectomy with a pathology examination. It is highly recommended the interdisciplinary cooperation for the monitoring and management of patients with suspicion of MEN 1. The annual assessment of serum calcium level, together with the parathyroid hormones, is proposed as a screening tool in early diagnosis.

Introduction: Ticagrelor is a very effective platelet aggregation inhibitor. Case report: A 72 years old man presented himself with intense right upper quadrant pain irradiated in the right shoulder. A CT scan was performed and a cyst in segments 6-7 was diagnosed, with 5mm free liquid around the liver. As the patient was stable and on Ticagrelor, we followed a conservative approach for the first 5 days. On the 6th day we performed an exploratory laparoscopy and a liver subcapsular hematoma of segment 6-7 was confirmed and evacuated via laparoscopy. Conclusion: Despite it's proven efficiency, Ticagrelor might have hemorrhagic side effects. We present the first case of liver spontaneous hematoma.

Background: We present the case of a 63 years old man who suffered a liver trauma seven years ago. Methods: He presents last year in our department with pelvic main due to giant pelvic hydatid cysts. Further abdominal Ct found a also a liver cyst in segment 8 with multiple adhesive between the cyst and the diaphragm. Results: A laparoscopic cyst fenestration (after inactivation) was performed and an open evacuation and partial excision of the pelvic cysts was performed. Conclusion: The peritoneal hydatidosis was most probably to a partial rupture many years ago of the liver hidatic cyst.

1.In autumn 2013 a new surgical oncology was created in Saint John Hospital Bucharest, with the main purpose to treat abdominal malignancies.

Background: In august 2013 a new department of Surgical Oncology with a focus on HBP surgery was founded inside our General Surgery Hospital. The division was established by a group of 2 enthusiastic young surgeons trained in western academic institutions. Methods: The first cases of anatomical liver resections were made by open approach and until 2016, only liver biopsies or atypical peripheral metastasectomies were performed by laparoscopy. In 2016 we performed 7 cases of anatomical laparoscopic liver resections which we case-matched with 7 cases performed by our mentors, in our "mother" department, the University Hospital in Antwerpen Belgium (UZA). Results: The procedures time was almost similar and postoperative evolution was also comparable as results in terms of complications and blood loss. A longer admission time was observed in all our cases compared to the belgian counterparts. Due to the presence of our surgeons in Belgium during some of the cases of laparoscopic liver resections and being part of the team at the beginining of the learning curve, our surgeons also faced near the belgian counterparts the shortcoming and tries of the period, making it more easy to apply it at home. Conclusion: Due to the presence of our romanian surgical team at the beginning of laparoscopic liver resections era in UZA, our surgeons learned how to start this new chapter in our home institution, managed to solve the intraoperative complications and postoperative events and strengthen a new department in our hospital.

Background: Liver tumors can sometimes be a difficult diagnostic. Without specific imagistic findings and with negative tumor markers Methods: We present the case of a 63years old man who presented with a liver tumor in segment 2 with no specific findings on MRI and negative tumor markers. Colonoscopy and upper GI endoscopy were negative for any lesions. A laparoscopic liver resection was performed - segment 2-3 resection with a smooth postoperative course. The pathology result was a neuroendocrine tumor metastases. Results: Two month after the operation the gastroscopy was repeated and a small tumor was endoscopically excised from the gastric antrum. The pathology result was a gastrointestinal non-secretant neuroendocrine tumor. Conclusion: Due to an increase in the expertise in laparoscopic liver resections, a minimally invasive hepatectomy was the first step in this case.

Matrix metalloproteinases (MMPs) are known ezymes involved in the modulation of extracellular matrix (ECM) and adipocyte and preadipocytes differentiation. Obesity implies a more or less rapid but generalized increase in adipose tissue (adipocyte and preadipocytes) and this proceses generate abnormal ECM metabolism. Aim: This study purpose was to determin if we can consider MMPs as a marker of effectiveness in bariatric surgery. Materials and methods: The experimental study used 20 obese wistar rats (10 in control group and 10 in Study group).The study group had gastric by-pass for obesity, and there were analised the pre and post operative MMP-2 and MMP-9. We compared the results in order to see if bariatric surgery modifies the MMPs status and if there is a correlation between the weight loss and the values of MMPs. Results: The MMP-2 and MMP-9 activities were detectable, but MMP-2 activity was significantly higher than MMP-9. MMP-9 was strongly correlated with body weight parameters before surgery, as well as after significant body weight reduction as a result of bariatric surgery. There is a strong correlation between a greater weight loss and the values of MMP-2. Conclusions: MMP-2 and MMP-9 are the two most important proteins of ECM involved in adipose tissue remodeling after bariatric surgery. Although we believe that more in-depth studies are required, MMPs may be considered a marker of the effectiveness of bariatric surgery and weight loss.

Introduction: The difficulty to set a histopathological diagnosis in patients with cholangiocarcinoma is a challenge Methods: We present 7 cases of cholangiocarcinoma for witch was performed an excisional biopsy of ganglion 5. For this patients the histopathological diagnosis was not able to be performed neither by endoscopic of ecoendoscopic maneuver. 5 cases were made by laparoscopic approach and 2 by open procedure. Results: All the results from the biopsies were inconclusive and indicated inflammation Conclusions: Although the mini series was not on a large number of cases, the examination of ganglion 5 was not edifying in establishing the histopathological results in patients with cholangiocarcinoma and present metastasis.

Aims: Caudate lobe resection is consider one of the most difficult liver resections. Doing it in the setting of an experienced departament is quite different from doing the operation for the first time in a general surgery departament. Methods: We compared two cases of caudate lobe resection - the first case was performed in the University Hospital of Antwerpen Belgium and one year later we tried to apply what we have learned by performing a similar case in Saint John Hospital Romania. Both cases had single colorectal metastases. Results: A segment one with a parcelar vena cava resection was succesfully performed. Patients were discharged in the first 10 postoperative days. The main difference was the operatory time (4 hours in Belgium and 8 in Romania). Conclusions: While organizatorical issues are a main concern in applying more complex surgery in your home departament after a fellowship, certain mindsets are also sometimes more difficult to change.

Aims: It has become evident that, in addition to the other dissimilarities, rectal cancer and colon cancer differ in their manner of management as well, starting from surgical techniques and going through specific use of radiation therapy and ending with the method for administration of chemotherapy. For rectal cancer in stages II and III, the current standard of treatment particularly involves pre-surgery chemo-radiation therapy, aiming at increase of the rate of survival. As revealed by studies, one of the means for that purpose is to increase sensitivity to radiation, in that respect identification of improved chemotherapeutic agents and delivery systems playing an essential role. Thus, targeted release systems have emerged, meant to decrease dosage frequency, lower drug level circulating variability, provide better uniformity of drug effect and diminish side effects. Several therapeutic schedules in rectal cancer chemotherapy use 5 fluorouracil (5-FU), whose targeted delivery most commonly is achieved by liposome. The current paper is involved with improvement of liposome formulations carrying 5-FU, for improved tolerability, possibility for reduction of adverse reactions and better quality of life. Methods: Two methods were used to prepare liposomes from various DPPC (dipalmitoyl-phosphatidyl-choline) and Chol (cholesterol) combinations, i.e. ethanol injection and reverse phase evaporation. The DPPC:Chol (55:45) was selected as best lipid composition (concerning drug loading efficiency, particle size and time stability), whereas preparation involved reverse phase evaporation complexation with 5-FU. 5-FU loading efficiency was spectrophotometrically determined at 265 nm. Results: Comparison of results yield by the two methods in terms of 5-FU encapsulation efficiency were 9% for reverse-phase evaporation and ca. 7% for ethanol injection. Respective vesicles were smaller than 130 nm and their preparation did not determine detectable drug degradation. Conclusions: DPPC:Chol (55:45) liposomes prepared by reverse phase evaporation were more suitable for 5-FU encapsulation than those obtained by ethanol injection.

Cystic lesions of the pancreas are relatively rare entities but have been increasingly diagnosed in recent years due to advanced imaging techniques. This category encompasses pancreatic pseudocyst as well as a wide range of pancreatic tumors with benign behavior, borderline or primary malignant. Serous cystadenoma of the pancreas represents the most common benign pancreatic tumor, with a very low but well recognized malignant potential. The clinical presentation varies according to its size; small tumors may be asymptomatic and discovered incidentally, while large tumors are more likely symptomatic. We report the case of a female patient presenting with non-specific left abdominal pain, who was diagnosed through a CT scan with a caudal pancreatic tumor. The patient underwent spleen-preserving distal pancreatectomy. The result of the histopathological examination revealed a serous cystadenoma.

Our paper presents the experience gained in nearly 12 years by the General Surgery Clinic of "Sfantul Ioan" Hospital, Bucharest in the field of laparoscopic hysterectomy. The period of time is quite long compared to the evolving of mini-invasive techniques and also unequal towards the experience of the surgeons who perform these procedure. The total number of hysterectomies was 1491 from which 251 by laparoscopic approach, the rest being made by the classic methods (most of them by laparotomy and some by vaginal approach). In the statistic we have included 15 myomectomies, 4 cases of radical hysterectomy with pelvic lymphadenectomy and 4 cases of complete hysterectomy after partial procedures made by laparotomy. The indications were represented mostly by uterine fibroma (82.07%), but also by uterine prolapse (13.14%), uterine bleeding, cervix severe dysplasia, uterine and cervix neoplasia (stage I) or associated to ovariectomy related to breast cancer. The paper analyses the results looking at the incidents and accidents (hemorrhagic, ureteral, urinary bladder or rectal lesions) and also postoperative complications (we had three reinterventions, two by laparoscopy and one by laparotomy). We also recorded one death not directly as a consequence of surgery, but as a diagnosis error. Regarding the surgical technique we initially chose the laparoscopic assisted vaginal hysterectomy. Afterwards by gaining experience we started treating the uterine pedicle and now we settled for the integral laparoscopic procedure. In our opinion laparoscopic hysterectomy represents all the advantages of mini-invasive approach. The technological development, but essentially the experience gained by surgeons are the key factors in accepting and promulgating the technique.

Our paper presents the experience gained in nearly 12 years by the General Surgery Clinic of "Sfantul Ioan" Hospital, Bucharest in the field of laparoscopic hysterectomy. The period of time is quite long compared to the evolving of mini-invasive techniques and also unequal towards the experience of the surgeons who perform these procedure. The total number of hysterectomies was 1491 from which 251 by laparoscopic approach, the rest being made by the classic methods (most of them by laparotomy and some by vaginal approach). In the statistic we have included 15 myomectomies, 4 cases of radical hysterectomy with pelvic lymphadenectomy and 4 cases of complete hysterectomy after partial procedures made by laparotomy. The indications were represented mostly by uterine fibroma (82.07%), but also by uterine prolapse (13.14%), uterine bleeding, cervix severe dysplasia, uterine and cervix neoplasia (stage I) or associated to ovariectomy related to breast cancer. The paper analyses the results looking at the incidents and accidents (hemorrhagic, ureteral, urinary bladder or rectal lesions) and also postoperative complications (we had three reinterventions, two by laparoscopy and one by laparotomy). We also recorded one death not directly as a consequence of surgery, but as a diagnosis error. Regarding the surgical technique we initially chose the laparoscopic assisted vaginal hysterectomy. Afterwards by gaining experience we started treating the uterine pedicle and now we settled for the integral laparoscopic procedure. In our opinion laparoscopic hysterectomy represents all the advantages of mini-invasive approach. The technological development, but essentially the experience gained by surgeons are the key factors in accepting and promulgating the technique.

Laparoscopy had significantly gained in the field of urologic surgery, almost all the surgical procedures in the retroperitoneal space being made, from the simple ones (renal cystectomy, varicocelectomy) to the ones requiring higher expertise (nephrectomy, adrenalectomy) by retro-peritoneoscopy and also transperitoneal. At the Surgery Department of "Sf. Ioan" Hospital, Bucharest, we approached initially the retroperitoneal pathology by lomboscopy, but afterwards we choose the transperitoneal approach because of the generous workspace and the clearer anatomical landmarks, regardless of the procedures (renal cystectomy, varicocelectomy, adrenalectomy, nephrectomy, pyelo-lithotomy, ureterolithotomy). In association with the Urology Department of "Sf. Ioan" Hospital we practiced two Hynes Andersen pyeloplasty for pyelo-ureteral junction stenosis by transperitoneal approach, using mini-laparoscopy tools. In one of the cases we also perform a basinetal lithotomy.