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Reflux disease continues to be one of the most common pathologies in the world. There is much discussion regarding the mechanism of developing and the variety of possible symptoms. In recent years, the use of new technologies, like high-resolution manometry and pH impedance, brought new insights into this disease. Also, there are emerging therapies that are covering the gap between the patients treated with proton-pump inhibitor (PPI) therapy and those who benefit the most from laparoscopic treatment (hiatal hernia, complications of gastroesophageal reflux disease (GERD). Also, most of them are less invasive than a laparoscopic fundoplication. We present a short review of the treatment options in patients who need more than lifestyle changes and PPI therapy.

Cutaneous metastases from endometrial cancer are rare and unusual. This is the case of a 72 years old female patient, diagnosed in 2018 with G3 endometrial serous carcinoma (ESC). At 18 months from the surgical intervention, the patient developed bilateral inguinal lymph nodes metastases and skin secondary lesions; histological and immunohistochemical tests were performed. Computed tomography scan did not indicate visceral secondary lesions, local or regional relapses. We present the treatment practiced, the case's evolution and we discuss about epidemiology, molecular biology, treatment options and management of advanced and local lesions. The appearance of skin metastases in theses cases is associated with poor prognosis and treatment options are limited to palliative chemotherapy and radiotherapy.

The emergency surgery for colorectal cancer is associated with high rates of morbidity and mortality due to factors related to the characteristics of the patients but also the therapeutic attitude. This study aims to identify the surgical interventions associated with the postoperative complications, with the main causes of morbidity, with the reinterventions and with the postoperative deaths. We included in this retrospective study 431 patients hospitalized and operated in an emergency for complicated colorectal malignant tumors in the Surgery II Clinic of the Clinical Emergency County Hospital "Sf. Ap. Andrei from Galati, in the period 2008-2017. The patients data were collected from observation sheets, operative protocols, pathological, imaging and laboratory bulletins, at the time of the emergency intervention, as well as from those of subsequent admissions in patients who benefited from serial interventions. The postoperative morbidity was 10.44%. The resections with anastomosis were associated with the presence of postoperative complications (p 0.01): pseudomembranous colitis, (p 0.01) and postoperative intestinal occlusion (p 0.01). The practice of lymph node dissection was associated with postoperative complications (p 0.01): pseudomembranous colitis (p 0.01) and intestinal occlusion (p 0.01). The reinterventions were associated with resections with anastomosis (p 0.01), lymph node dissection (p 0.01) or patients with open /semi-open abdomen (p 0.04). The postoperative mortality was 9.28%. It was associated with the practice of lymph node dissection (p 0.01), of the ileostomy (p 0.01), with the open /semi-open abdomen (p 0.04). Patients with colostomy had the lowest number of hospitalization days (p 0.01). The resections with anastomosis per primam and the lymph node dissection were associated with morbidity. The type of main surgery did not influence the postoperative mortality, this being associated with the concomitant surgery: the lymph node dissection, the ileostomy, and the abdomen closure type. The reinterventions were associated with resections with anastomosis per primam, with lymph node dissection and with the open /semi-open abdomen. The duration of hospitalization was significantly shorter in patients with a colostomy.

Introduction: Choosing the optimal treatment for patients with complicated colon cancer operated in an emergency remains a challenge. The study aims to identify the factors that influence the therapeutic decision in these patients. Patients and Methods: We included in this retrospective study 449 patients operated in emergency for complicated colon cancer, in the Clinical Emergency County Hospital "St. Ap. Andrei" Galati between 2008-2017. The patients data were collected from the observation sheets, the surgical, imaging and laboratory protocols. Results: The operations performed were: resections with a stoma in 37.63% of cases, resections with anastomosis in 36.97%, stomas in 16.26% and internal derivations in 9.13% of patients. Elderly age was correlated with stomas with or without tumour resection (p 0.05). Preoperative diagnosis of IDH was associated with resections with anastomosis, those with occlusion were associated with internal derivations and those with digestive perforations with resections with a stoma (p 0.05). The stomas were associated with the presence of intraoperatively detected complications (p 0.05). Conclusions: Complicated colon tumours operated on in an emergency require surgical treatment tailored to each patient. It is important to choose the type of treatment taking into account the patient's condition at admission, clinical-paraclinical data, tumour location, tumour complication and the presence of other complications detected intraoperatively.

Introduction: The GIST tumors are very rare entities ( 1% of all tumors). They originate in the Cajal interstitial cells, which are part of the autonomic nervous system of the intestine. Their most common location is the stomach, followed by the small intestine. The aim of this paper is to present a very rare case of perforated ileal GIST, associated with Meckel diverticulum. Case report: A 71 years old patient with comorbidities is admitted in emergency for symptoms and signs of acute surgical abdomen. The exploratory laparotomy reveals generalized acute peritonitis due to perforated ileal tumor and Meckel's diverticulum. A segmental enterectomy is performed, with favorable postoperative evolution. The histological examination of the resection piece shows the appearance of GIST, confirmed immunohistochemically. Conclusions: The GIST tumors of the small intestine are unusual tumors and the spontaneous perforation and life-threatening hemorrhage are a rarity. The main treatment for this form of GIST is the resection, with a favorable clinical outcome.

Background: Numerous procedures for reconstruction after total gastrectomy have been proposed in order to achieve the lowest postoperative morbidity. Roux-en-Y esojejunostomy is widely accepted as a standard reconstruction technique due to its simplicity and its satisfactory nutritional outcomes. The construction of a gastric pouch and the maintenance of the duodenal transit have been proposed to ameliorate the quality of life of patients with gastric cancer. The aim of this study is to assess the quality of life of patients with different types of reconstruction after total gastrectomy. Material and Method: A systematic literature search was performed in PubMed, Science Direct, Wiley Online, Springer Link, up to December 1, 2019. Only original articles published in English were included. Quality of life was measured using different instruments. Postoperative aspects of reflux oesophagitis, dumping syndrome, food intake and weight status were evaluated. Results: 15 studies were included in this research. Three techniques for restoring the digestive tract continuity were compared: Roux-en-Y eso-jejunostomy, jejunal interposition and gastric pouch construction. The statistical results of the included studies were evaluated in terms of quality of life or weight status. Conclusions: The length of the alimentary limb for prophylaxis of eso-jejunal reflux should be at least 50 cm, but not more than 60 cm for the prevention of malabsorption. The quality of life was significantly better in patients with gastric pouch. Maintaining the duodenal transit does not seem to bring any benefit in quality of life or weight status, even if this is a physiological way.

Introduction: Achalasia is the most common esophageal motility disorder. So far, the treatment, which can be medical, endoscopic or surgical, provides only symptomatic relief. However, this can grant a normal life to the patients. We focused our study on the value of pre- and intraoperative endoscopy and manometry for improving outcome of surgical treatment. Material and method This is a retrospective chart review of a cohort of patients diagnosed with achalasia at St Mary Clinical Hospital, Bucharest between 2013 and 2017. The objective of this study was the assessment of the immediate and long term efficacy of laparoscopic Heller myotomy associated with Dor anterior fundoplication, intraoperative endoscopy and intraoperative manometry, as well as the assessment of late post-operative complications. The diagnosis of achalasia was based on symptoms, barium esophagogram, upper endoscopy and esophageal manometry. The immediate efficacy was assessed by comparing Eckhart score, LES pressure and LES vector volume before and after surgery. Results: In total, 47 patients, had surgical treatment for achalasia between 2013 and 2017. For 7 patients who failed prior endoscopic or surgical, this was the second therapeutic intervention. 39 patients underwent laparoscopic surgery, 30 patients had associated intraoperative endoscopy and, 22 patients had associated intraoperative manometry. There was a significant improvement in mean Eckardt score (from 6,5 to 1,26, p 0,001), mean LES pressure (from 18,5 mmHg to 7 mmHg, p 0,001). Morbidity was 2,12 % and we have had 1 recurrence and 2 postoperative esophagitis. Conclusions: At present, laparoscopic Heller myotomy with an anterior Dor fundoplication, is a standard indication in achalasia, proving its efficiency and safety. Intraoperative use of endoscopy is recommended and intraoperative manometry may provide additional information on the effectiveness of myotomy. Surgical treatment of achalasia should be performed in specialized, experienced centers.

Scope neoadjuvant RCT influence on early and long term postoperative outcomes in patients with locally advanced esophagogastric junction adenocarcinomas. Materials and method Sixty two patients with locally advanced esophagogastric junction adenocarcinomas were treated at the Center of Excellence in Esophageal Surgery at St. Mary Hospital between 2010-2017. According to the Siewert classification, the group comprised of type I - 11 patients, type II - 18 patients and type III - 33 patients. Only 17 patients received preoperative RCT. The surgical treatment for the 62 resected patients was: abdominal extended gastrectomy - 40 patients, Ivor-Lewis - 13 patients, McKeown esophagogastrectomy (3 incisions) - 5 patients and transhiatal esophagectomy - 4 patients. Results: Postoperative morbidity was 46.77% and was mainly represented by fistulas in 17 patients and pulmonary complications such as pleurisy,pneumonia and ARDS in 12 patients. Fistula occurred in 15 cases: grade 1 - 2 patients, grade 2 - 10 patients, grade 3 - 5 patients. Postoperative mortality was 4.8% (p_value = 0.017980 Fisher's Exact Test). Downstaging was observed in 7 patients. I did not encounter statistically significant differences in long term survival. Conclusions: Neoadjuvant RCT had no impact on postoperative morbidity, but statistically influenced postoperative mortality.

Introduction: The Zenker Diverticulum is a rare pathology, the selection of patients for invasive treatments is questionable, as well as the applied therapeutic method. The aim of the study is to evaluate the main methods of classical and endoscopic surgical treatment in this pathology and to correlate pathophysiological aspects with clinical consequences. MATERIAL AND METHOD We included 36 patients with Zenker hypopharyngeal diverticulum treated in 2010/2017 in two university clinics: 7 patients by classical surgical approach at the General and Esophageal Surgery Clinic of St. Mary's Hospital Bucharest and 29 patients with endoscopic approach at Department of Diagnostic and Interventional Digestive Endoscopy of the Regional Institute of Hepatology and Gastroenterology Prof Dr Octavian Fodor, Cluj-Napoca. The age of the patients ranged from 42 to 84 years and in the 7th to 15th decade. Results: Cricopharyngeal myotomy was performed in all patients. Diverticullectomy was performed in 7 patients treated surgically. The average hospitalization duration was 4 days. Intra-procedural complications showed 3 patients treated endoscopically and consisted of laminar haemorrhage. Two patients were treated with endoscopic endoscopic hemostasis and hot pens and one patient had endoscopic hemostasis with clips. The post-procedural complications were: local pain, leukocytosis, melena, fever, cervical hematoma. These post-treatment events were seen in 6 patients. The posttreatment morbidity was 16.66%. Conclusions: In patients included in the batch, the endoscopic treatment efficiency was 80%. Peristent postinterventional symptomatology was mainly represented by dysphagia, post-procedural syndrome was associated with dysphagia persistence. Patients with persistent post-surgical symptoms were required to reintervention.

The purpose of this paper is to present the advantages and disadvantages of neoadjuvant RCT in multimodal therapyof ESC.Between 1998-2014 221 patients were treated with ESC, 85 of whom received neoadjuvant RCT. For these we have made imaging and pathologic assessment of response using RECIST and MANDARD criteria and statistical data were interpreted in terms of the factors that influence the response. Also, they were evaluated statistical correlations between RCT and resectability, postoperative morbidity, mortality and long-term survival.45 patients were imagistic responders and 34 underwent surgery, 40 non-responders of which 14 underwent surgery. Of the 48 surgical patients with preoperative RCT, histopathological evaluation showed that 32 were pathological responders and 16 non responders. There were performed statistical analyzes of correlations between RCT and resectability, stage, location of ESC, morbidity, mortality and survival.RCT increase resectability, improves survival and maximum duration of survival, more in responders than in nonresponders and does not affect postoperative complications and postoperative mortality, nor among the responders or nonresponders. Imaging evaluation result of the response to RCT overestimate responders.

Adenocarcinoma of the gastroesophageal junction is more common in the West. Preoperative chemotherapy or chemoradiotherapy is performed for locally advanced disease. Recent studies are suggesting higher rates of curative resection and reduced rates of local recurrence in patients with neoadjuvant combination of chemotherapy and radiation therapy. The role of targeted agents in neoadjuvant therapy is under investigation.

The 8th edition of TNM cancer staging is based on data from large patient cohorts, data collected from the Worldwide Collaboration Cancer Esophageal (WECC) group, or the International Association for Gastric Cancer (IGCA), including treated patients surgically per primate or after neoadjuvant treatment. This edition redefines the esophago-gastric junction tumors and recommends different TNMs staging: Siewert type I and II should be classified according to TNM recommendations for esophageal adenocarcinoma, while for Siewert type III the TNM classification for gastric cancer should be considered. Anatomical characteristics feature type T (tumor invasion), type N (regional lymph node invasion) and type M (distant metastasis). Non-anatomic characteristics include tumor differentiation (G) and tumor localization (L). Category descriptors are currently evaluated by endoscopy with biopsy, fine needle aspiration (EUS-FNA), thoraco-abdomino-pelvic computer tomography (CT) and positron emission tomography (CT-PET). The new TNM staging edition presents separate classifications applicable for therapeutic strategy: clinical staging cTNM (prior to any treatment), pathological staging pTNM (after surgery first) and neoadjuvant pathologic staging ypTNM (after neoadjuvant treatment followed by surgery). The refinement of each category and subcategory of T, N, M makes the 8th edition more accurate and adaptable to current practice, including for therapeutic strategy. The purpose of this study is to evaluate the clinical and therapeutical implications of the 8th edition of the TNM staging for esophago gastric junction adenocarcinoma.

Colonic cancer is the most common malignancy of the digestive tract, representing 13% of all malignancies. The aim of the study is to evaluate the current therapeutic strategy in patients with CC. Mortality from the disease is declining in many Western countries; this may be the result of screening for CC, resection of adenomas, early detection of tumoral lesions and the use of individualized therapeutic strategies. The multimodal treatment of the disease includes different sequences such as: surgery, chemotherapy, radiotherapy,immunotherapy. Current advances in the research of mechanisms of carcinogenesis in CC make it possible to use genetic information in order to establish the prognostic and predictive factors for selecting the patients for individualized therapy. The current methods of CC evaluation allow the planning of individualized therapeutic strategies, which would lead to optimal results.

Carcinosarcoma is a rare form of ovarian cancer with mixed origin, and its association with mature teratoma is extremely rare. We present the case of patient T. M. aged 67, admitted into our clinic on the 15/05/2016, F.O. 4877 for the increase of the abdominal volume. On admission, the patient was afebrile, conscious, cooperative, cardio-respiratory balanced, having the abdomen distended in volume, sharp dullness in the flanks, positive wave sign bioumoral within normal limits except: uric acid = 6.64 mg / dL, serum glucose = 113.7 mg / dl, serum total proteins = 8.65 g / dl, the albumin / globulin subunit, CRP 33.63 mg / l, sideremia 51 ug / dl, CA 125 = 588.4 IU. Abdominal ultrasound: high volume fluid and multiple perihepatic formations and multiple formations with cystic transformation in the abdomen and pelvis. CT exam describes multiple tissular masses localized intraperitoneal in the abdominal-pelvic region, sheath fluid effusion, infiltrative, with mass effect on the digestive lumens, without visible CT obstruction. Surgical treatment consisted in evacuation of the ascites fluid, excision of the tumoral lumps situated in the great omentum, omentectomy, excision of the lumps of the gastrocolic ligament, bilateral ovariectomy and hysterectomy. Postoperative simple evolution. Histopathology confirmed the diagnosis of bilateral ovarian carcinosarcoma associated with tridermic mature teratoma (presence of brain tissue areas associated with cartilage, transitional type epithelium, tubal type epithelium, endometrial stroma type and fatty tissue). IHC confirms the compatibility with the diagnosis of ovarian carcinosarcoma (mixed malignant Mullerian tumor). The patient followed adjuvant polichemotherapy. The association of teratoma with carcinosarcomatoase elements confers a poor prognosis case.

The management in severe acute pancreatitis evolved in the last two decades. Consulting the literature and the accumulated clinical experience manage to the release of this study based on the comparison of the treatment in PAS between two distinct periods: 1994-1999 (retrospective) and 2000-2007 (prospective). Among the 285 patients whit PAS admitted and treated in the two departments, 224 (78.6%) was submitted to the surgical intervention with various surgical indications. There is an obvious difference between the retrospective and prospective studies concerning the indication of surgery and mostly the timing for surgery. The lots were analyzed concerning the etiology, management of treatments and specific treatments, and the timing of the surgical intervention was analyzed based on the specific etiologic treatment and the period of time between the admission and the first surgical intervention, the mark being the 21 day according with the recommendations of the International Association of Pancreatology. There were analyzed: the period of time between the onset of the disease and the surgical intervention, the status of the patients at the surgical moment, the global mortality based on the timing of surgery, the evolution of the management of PAS along the period of the research, comparisons whit the literature. The registered data were statistically processed using the SPSS test version 17 for Windows.

Primary retroperitoneal tumors are relatively rare and the histological characters vary. We present the case of a retroperitoneal lipoma in a 51-year-old male patient, whose main complain was enlarging of the abdomen in the last 2 months. The CT of the abdomen and pelvis revealed a giant retroperitoneal tumor. The patient suffered a surgical intervention that revealed a giant retroperitoneal tumor, 40/35 cm, weighting 14 Kg. The pathology exam established the diagnosis: retroperitoneal lipoma with areas of necrosis and lipogranulomatosis. The postoperative evolution was simple.

The multidisciplinary approach in ESC emerged as a result of efforts to maximize the treatment outcome of this disease.Surgical approach as the only therapeutic option is not always followed by a good distance survival. A concomitant neoadjuvant radiochemotherapy in ESC may result in a favourable outcome for responding patients, reducing the size of the tumor and the degree of lymph node damage increasing resectability and the R0 resection rate, improving prognosis. For non-responding patients or if the disease continues to progress under RCT therapy, the surgical time is delayed, adverse effects of radiochemotherapy are added and postoperative morbidity and mortality are increased. The imaging methods for the assessment of response have only limited value and metabolic response; only FDG-PET manages to come close to pathological response. Determining the response degree is very important for the establishment of the surgical conduct: planned or necessity surgery, or non-surgical palliative therapy.

To analyze the correlation between the failure of medical treatment in patients with reflux esophagitis or Barrett esophagus and LES function, manometrically measured.This is a prospective study of 24 patients admitted in our clinic for reflux disease symptoms, who were investigated by endoscopy (combined with biopsy), esophageal manometry and 24 h pH monitoring. The including criteria for the patients was abnormal esophageal exposure to acid reflux, each patient having abnormal 24 h pH monitoring (pH4 in the esophagus more then 4.4% in 24 h). Each patient received medical treatment with clinic and endoscopic reevaluation after 3 months.From the 24 patients that were included: 4 patients having Barrett esophagus, 13 patients with esophagitis (3 patients associated complications such as ulcer or esophageal stenosis) and 7 patients without visible lesions on endoscopy. From the 24 patients, 11 patients presented an incompetent LES, characterized by the following values obtained by manometry: total lengthor = 2 cm, abdominal lengthor = 1 cm, mean pressure:6 mmHg. There were 2 patients from the 4 having Barrett esophagus that presented an incompetent LES, and also the 3 patients having esophagitis associated with complications. All patients were reevaluated clinically and endoscopically after 3 months of medical treatment with PPI 40 mg/day. From the 11 patients with incompetent LES, 5 patients had symptoms or modifications on endoscopy, whereas from 13 patients with a competent LES only one patient presented with symptoms of reflux disease.The presence of an incompetent LES may be a cause of a poor response to medical treatment and may also be an element for taking into consideration surgical treatment.