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Objectives. Up to 20% of patients with biliary lithiasis have bile duct stones, which are asymptomatic in 50% of cases. The aim of the study was to evaluate the role of choledoscopy in extracting stones from the main bile ducts. Materials and Methods. This is a retrospective study (January 2014 - December 2024) on 2309 patients who underwent a laparoscopic cholecystectomy. Laparoscopic choledoscopy was performed in 32 cases. Of the 32 patients with complete clearance, none had residual common bile duct stones (CBDS) at 1 year postoperatively. Results. The ideal approach in our study was the transcystic approach, with the shortest hospital stays (mean 3 days) transcholedochal approach; it was only feasible in 7 patients. All patients had transcystic drainage that was removed after 10 days (mean operative time 105 min). The transcholedochal approach was demanding from a technical point of view. Primary ductal closure was performed in 5 patients. Ductal closure with transcystic drain was in 9 patients. A total of 14 patients had a T-tube and a longer operative time (on average 170 min). Conversion to open surgery was performed in 4 cases, due to difficult dissection at the level of the hepatic porta. Conclusions. LCBDE for previously documented or discovered CBDS during LC is a safe and feasible procedure. The technique is technically demanding, and requires advanced laparoscopic skills. Patient selection is very important, but the transcystic approach for LCBDE when possible is optimal.

Myelolipomas are described as small tumors, with some authors referring to sizes less than 4 cm in diameter. However, when greater than 10 cm, myelolipomas are labeled as giant tumors and thus, have a definite indication for surgical resection. Myelolipomas represent a small percentage of adrenal tumors. Giant myelolipomas are usually discovered incidentally during imaging studies performed for other conditions. They are often slow-growing and may reach sizes that significantly distort the anatomy of the affected area. Despite their large size, they are usually benign and do not spread to other parts of the body. Adrenal myelolipoma is a benign tumor with a scarce number of detailed cases reported in literature. It is frequently discovered by chance, covering a variety of differential diagnoses. Imaging techniques and histopathological examinations are of great importance in the differential diagnosis of adrenal gland lesions, including retroperitoneal lipoma and liposarcoma, adrenal myelolipoma, adrenal lymphoma, adrenal adenoma, adrenocortical carcinoma, pheochromocytoma or metastasis. We performed a comprehensive review on PubMed of all cases of giant adrenal myelolipoma reported in literature with more than 10 cm in diameter, in order to estimate the incidence, diagnosis and treatment of giant myelolipoma. So far, only 15 cases of truly giant adrenal myelolipoma have been reported between 1981 and 2023.

Background. Colorectal cancer is a commonly diagnosed neoplasia in men and women worldwide. This study aims to rigorously map the arterial distribution of the colon in order to assess the implications of vascular patterns in surgical resection. Methods. Cadaveric dissections were performed to explore the arterial distribution (including collateral blood flow) of the colon. The study used standard dissection tools and photographic documentation to detail the vascular architecture supporting the large intestine. Results. The dissection revealed important arterial branches and anastomoses in the area of the superior and inferior mesenteric arteries, which are able to ensure continuous local blood supply especially in cases of arterial ischemia. An important arterial anastomosis was identified between the right branch of the middle colic artery and the ascending branch of the right colic artery, as well as the specific distribution of the marginal artery of Drummond and Haller-Riolan anastomotic arch. Conclusions. The blood supply of the colon derived from both mesenteric arteries includes redundant arterial anastomoses, but which are critical in specific situations such as the approach and results of surgical resection. Understanding these vascular patterns and collateral pathways, as well as careful intraoperative surgical exploration, are essential for oncologic surgeons to ensure successful colic resections with minimal complications and morbidity.

Diabetes mellitus is one of the most common comorbidities of patients undergoing surgery. Colorectal surgery is frequently associated with postoperative complications, and diabetic patients represent a population that presents a high risk of developing such complications. Understanding the interrelationships between neoplastic disease and diabetes, as well as the pathophysiological mechanisms underlying postoperative complications, are essential for effective therapeutic management. Genetic predispositions, alterations in the gut microbiota, inflammatory response, ischemic, thrombotic and infectious processes contribute significantly to the development of severe surgical complications, such as anastomotic fistulas. Postoperative ileus, characterized by gastrointestinal dysmotility, is common in diabetic patients due to neuropathic dysfunction and altered intestinal metabolism. In addition, diabetic patients are at increased risk of intestinal ischemia, requiring specific perioperative care. The strategies to avoid these complications assume an adequate surgical technique, a personalized anesthesia management, and last but not least, the best possible glycemic control. This article highlights the importance of a better understanding of the interaction between diabetes and postoperative complications, in order to obtain good results with an important impact on the patient's health and well-being.

Sentinel lymph node biopsy (SLNB) has become the gold standard for axillary lymph node staging, providing valuable prognostic information while minimizing complications compared to axillary lymph node dissection. However, there are ongoing debates and controversies surrounding SLNB in specific cases. Studies have explored the use of SLNB in neoadjuvant chemotherapy, emphasizing the need for customized therapy decisions. Factors such as age, tumor characteristics, and treatment response influence the selection of SLNB or axillary lymph node dissection. Additionally, the presence of extranodal extension, micrometastases, and isolated tumor cells has been evaluated to determine the need for lymphadenectomy. The importance of accurate oncological staging by thorough pathological evaluation has been highlighted, particularly with regards to invasion depth and lympho-vascular invasion. The significance of biological tumor status, such as hormone receptor and HER2 status, in axillary management decisions has been emphasized. Moreover, discussions have emerged regarding SLNB in the context of local recurrence, with differing perspectives on its utility. Future extensive studies are needed to refine protocols and incorporate these concepts related to SLNB into breast cancer management guidelines.

Diabetes mellitus is a complex and widespread metabolic disease, having extremely complex implications (biological, psychological, social) for patients. Understanding the pathophysiology of diabetes (majorly influenced by various factors such as genetic predisposition, age, lifestyle choices, etc.) is essential for the prevention of this condition and the establishment of effective treatment strategies. The latest and relevant literature data related to the epidemiology, pathophysiology, and treatment of diabetes are presented, after an exhaustive review of the articles published on this topic and indexed in the WOS, PubMed, Scopus and Google Scholar databases. Preventing or delaying the onset of diabetes can be achieved in some patients with type 2 diabetes. After onset, treatment of diabetes is complex, involving a comprehensive approach (pharmacological interventions, lifestyle changes, surgical interventions in selected cases, as well as psychological support), depending on the stage of the disease and possible associated complications. Finally, diabetes is often asymptomatic in the initial stages, so an early diagnosis remains the essential element for the best subsequent therapeutic control.

Objectives. The incidence of acute cholecystitis increases with age, when patients usually associate additional comorbidities. Such comorbidities and the late presentation to the doctor make the treatment more complex, associating higher rates of complications. The present study aims to evaluate the methods of diagnosis and treatment applied to a group of older patients with acute cholecystitis. Materials and Methods. 585 patients were enrolled in the study between 2019 and 2023. The inclusion criteria in the study were represented by the presence of the diagnosis of acute cholecystitis in patients over 65 years of age, while patients who presented complex locoregional pathologies (trauma, cancer, etc.) were excluded. Results. In about 91% of cases, acute cholecystitis was determined by gallstones. 61.19% of cases benefited from laparoscopic cholecystectomy, the rest of the patients requiring additional procedures or open surgery. Morbidity and mortality were not significantly influenced, but some of the patients required complex interventions and longer hospital stay. Conclusions. The clinical manifestations of acute cholecystitis can be diminished in some of the elderly patients (neurological disorders, diabetes, immunosenescence, etc.), being initially appreciated as mild forms. Later it is found (by imaging or intraoperatively) that these are much more severe forms, which often require a customized therapeutic approach.

Colorectal cancer is an important health problem with a significant impact on the individual and society. Malignancy (including colorectal cancer) is usually slightly symptomatic in its initial stages. This causes cancer to be discovered in some patients accidentally (either through screening tests in predisposed individuals or during routine investigations for other diseases), while in other patients the colorectal cancer is discovered in late stages, when the symptoms are much more intense due to complications. Unfortunately, such advanced cases of the disease have high rates of morbidity and mortality even with treatment. Current treatment methods are usually complex, interdisciplinary, causing significant suffering (physical, mental) to the individual, while the cost of treatment per patient seems to be extremely high. Until finding therapeutic methods that are effective and accessible to most patients with advanced colorectal cancer, several methods of prophylaxis and early diagnosis should be considered, to reduce as much as possible the devastating impact of this disease. The purpose of this review is to present literature data regarding the current methods of diagnosis and treatment of patients presenting to the doctor with colorectal cancer in advanced stages of complications.

Despite remarkable advances in medicine, limb amputations remain a therapeutic measure that saves the lives of many patients. Given the varied etiopathogenesis, such operations are performed both as an emergency and as an elective procedure. Such interventions address either only the distal segments of a limb, or even the entire limb, having a great psychological, functional and social impact on the patient. Due to these multiple implications, limb amputations must be performed by specialized teams, in order to achieve the best possible functional and aesthetic results to be compatible with the correction of the remaining deficit with a prosthesis. The main causes leading to amputations and the corresponding preventive measures are presented, as well as the general principles of amputations as a therapeutic solution of last resort. In conclusion, reducing the number of traffic/workplace accidents and effective treatment of chronic diseases affecting the vascular system can contribute to decreasing the need for amputations, a life-saving therapeutic solution, but with a devastating impact on the patient and society.

SARS-COV 2 recently caused a global pandemic, with the first case being reported in Romania in February 2020. Important restrictive measures were imposed, so that the addressability of patients to medical services decreased. Upper gastrointestinal bleeding had more severe forms of evolution at the time of presentation, which required additional methods of diagnosis and treatment. This is a retrospective study performed on 268 patients, which aims to evaluate the type and effectiveness of different treatment methods for upper gastrointestinal bleeding during the COVID 19 pandemic. Severity assessment was performed by measuring the Rockall score and additional methods of diagnosis. The association of COVID-19 with upper gastrointestinal bleeding can lead to much more severe outcomes for the patient, so treatment must be sustained and fast established. If the initial therapeutic methods fail, the other available therapeutic measures should be introduced progressively and without delay to achieve the best possible outcomes.

A rare entity of non-hiatal type transdiaphragmatic hernias, which must be clearly differentiated from paraoesophageal hernias, are the phrenic defects that bear the generic name of congenital hernias—Bochdalek hernia and Larey-Morgagni hernia, respectively. The etiological substrate is relatively simple: the presence of preformed anatomical openings, which either do or do not enable transit from the thoracic region to the abdominal region or, most often, vice versa, from the abdomen to the thorax, of various visceral elements (spleen, liver, stomach, colon, pancreas, etc.). Apart from the congenital origin, a somewhat rarer group is described, representing about 1–7% of the total: an acquired variant of the traumatic type, frequently through a contusive type mechanism, which produces diaphragmatic strains/ruptures. Apparently, the symptomatology is heterogeneous, being dependent on the location of the hernia, the dimensions of the defect, which abdominal viscera is involved through the hernial opening, its degree of migration, and whether there are volvulation/ischemia/obstruction phenomena. Often, its clinical appearance is modest, mainly incidental discoveries, the majority being digestive manifestations. Severe digestive complications such as strangulation, volvus, and perforation are rare and are accompanied by severe shock, suddenly appearing after several non-specific digestive prodromes. Diagnosis combines imaging evaluations (plain radiology, contrast, CT) with endoscopic ones. Surgical treatment is recommended regardless of the side on which the diaphragmatic defect is located or the secondary symptoms due to potential complications. The approach options are thoracic, abdominal or combined thoracoabdominal approach, and classic or minimally invasive. Most often, selection of the type of approach should be made taking into account two elements: the size of the defect, assessed by CT, and the presence of major complications. Any hiatal defect that is larger than 5 cm2 (the hiatal hernia surface (HSA)) has a formal recommendation of mesh reinforcement. The recurrence rate is not negligible, and statistical data show that the period of the first postoperative year is prime for recurrence, being directly proportional to the size of the defect. As a result, in patients who were required to use mesh, the recurrence rate is somewhere between 27 and 41% (!), while for cases with primary suture, i.e., with a modest diaphragmatic defect, this is approx. 4%.

Abstract Background Injury remains a major concern to public health in the European region. Previous iterations of the Global Burden of Disease (GBD) study showed wide variation in injury death and disability adjusted life year (DALY) rates across Europe, indicating injury inequality gaps between sub-regions and countries. The objectives of this study were to: 1) compare GBD 2019 estimates on injury mortality and DALYs across European sub-regions and countries by cause-of-injury category and sex; 2) examine changes in injury DALY rates over a 20 year-period by cause-of-injury category, sub-region and country; and 3) assess inequalities in injury mortality and DALY rates across the countries. Methods We performed a secondary database descriptive study using the GBD 2019 results on injuries in 44 European countries from 2000 to 2019. Inequality in DALY rates between these countries was assessed by calculating the DALY rate ratio between the highest-ranking country and lowest-ranking country in each year. Results In 2019, in Eastern Europe 80 [95% uncertainty interval (UI): 71 to 89] people per 100,000 died from injuries; twice as high compared to Central Europe (38 injury deaths per 100,000; 95% UI 34 to 42) and three times as high compared to Western Europe (27 injury deaths per 100,000; 95%UI 25 to 28). The injury DALY rates showed less pronounced differences between Eastern (5129 DALYs per 100,000; 95% UI: 4547 to 5864), Central (2940 DALYs per 100,000; 95% UI: 2452 to 3546) and Western Europe (1782 DALYs per 100,000; 95% UI: 1523 to 2115). Injury DALY rate was lowest in Italy (1489 DALYs per 100,000) and highest in Ukraine (5553 DALYs per 100,000). The difference in injury DALY rates by country was larger for males compared to females. The DALY rate ratio was highest in 2005, with DALY rate in the lowest-ranking country (Russian Federation) 6.0 times higher compared to the highest-ranking country (Malta). After 2005, the DALY rate ratio between the lowest- and the highest-ranking country gradually decreased to 3.7 in 2019. Conclusions Injury mortality and DALY rates were highest in Eastern Europe and lowest in Western Europe, although differences in injury DALY rates declined rapidly, particularly in the past decade. The injury DALY rate ratio of highest- and lowest-ranking country declined from 2005 onwards, indicating declining inequalities in injuries between European countries.

Giant pancreatic pseudocysts are considered those cysts whose dimensions exceed 10 cm and are sporadically reported in the literature. Although there are multiple treatment modalities, there are currently no treatment guidelines or consensus on the best therapeutic approach for giant pancreatic pseudocysts. We report the case of a 32-year-old male patient with a giant pancreatic pseudocyst after an episode of acute pancreatitis, which was treated by internal surgical drainage through cyst-jejunal anastomosis. This surgical procedure was followed by the formation of a retroperitoneal abscess which was resolved by ultrasoundguided drainage. The subsequent evolution of the patient was favorable, without other complications. Given their complex anatomical relations, the treatment of giant pseudocysts requires strategies adapted to the local conditions. The optimal choice of the operative time and of the therapeutic strategy is based on clinical considerations and the effectiveness of the method used can be assessed by a long-term follow-up.

Inflammatory bowel disease is a group of conditions of unknown etiology, represented by Crohn’s disease and ulcerative colitis and characterized by the presence of intestinal wall inflammation. From the first cases described to date, several studies have been performed to elucidate the cause of inflammatory bowel disease. Generally, the genetic factors predispose to their occurrence while epigenetic and environmental factors trigger them. Genetic factors are mutations of the genes involved in the response and recognition of immune cells to different pathogens. The most studied epigenetic and environmental factors are smoking (which predisposes to Crohn’s disease and can be protective for ulcerative colitis), lack of vitamin D, a diet rich in sugars and low in flavonoids and fibers. The diagnosis is usually established by endoscopy and biopsy. Recent technologies can perform live biopsies such as endocytoscopy or confocal laser endomicroscopy, with an accuracy of 100% compared to classical methods. Therapy involves several classes of drugs, preferably in association with diet and lifestyle changes. In case of complications or in non-responsive diseases, surgery must be considered, as documented for ulcerative colitis that can be cured by removing the entire colon. The purpose of this review is to present recent findings on pathology, as well as modern diagnosis and treatment methods for IBD.

Summary: Background: The COVID-19 pandemic highlighted gaps in health surveillance systems, disease prevention, and treatment globally. Among the many factors that might have led to these gaps is the issue of the financing of national health systems, especially in low-income and middle-income countries (LMICs), as well as a robust global system for pandemic preparedness. We aimed to provide a comparative assessment of global health spending at the onset of the pandemic; characterise the amount of development assistance for pandemic preparedness and response disbursed in the first 2 years of the COVID-19 pandemic; and examine expectations for future health spending and put into context the expected need for investment in pandemic preparedness. Methods: In this analysis of global health spending between 1990 and 2021, and prediction from 2021 to 2026, we estimated four sources of health spending: development assistance for health (DAH), government spending, out-of-pocket spending, and prepaid private spending across 204 countries and territories. We used the Organisation for Economic Co-operation and Development (OECD)'s Creditor Reporting System (CRS) and the WHO Global Health Expenditure Database (GHED) to estimate spending. We estimated development assistance for general health, COVID-19 response, and pandemic preparedness and response using a keyword search. Health spending estimates were combined with estimates of resources needed for pandemic prevention and preparedness to analyse future health spending patterns, relative to need. Findings: In 2019, at the onset of the COVID-19 pandemic, US$9·2 trillion (95% uncertainty interval [UI] 9·1–9·3) was spent on health worldwide. We found great disparities in the amount of resources devoted to health, with high-income countries spending $7·3 trillion (95% UI 7·2–7·4) in 2019; 293·7 times the $24·8 billion (95% UI 24·3–25·3) spent by low-income countries in 2019. That same year, $43·1 billion in development assistance was provided to maintain or improve health. The pandemic led to an unprecedented increase in development assistance targeted towards health; in 2020 and 2021, $1·8 billion in DAH contributions was provided towards pandemic preparedness in LMICs, and $37·8 billion was provided for the health-related COVID-19 response. Although the support for pandemic preparedness is 12·2% of the recommended target by the High-Level Independent Panel (HLIP), the support provided for the health-related COVID-19 response is 252·2% of the recommended target. Additionally, projected spending estimates suggest that between 2022 and 2026, governments in 17 (95% UI 11–21) of the 137 LMICs will observe an increase in national government health spending equivalent to an addition of 1% of GDP, as recommended by the HLIP. Interpretation: There was an unprecedented scale-up in DAH in 2020 and 2021. We have a unique opportunity at this time to sustain funding for crucial global health functions, including pandemic preparedness. However, historical patterns of underfunding of pandemic preparedness suggest that deliberate effort must be made to ensure funding is maintained. Funding: Bill & Melinda Gates Foundation.

Parathyroid carcinoma is an exceptionally uncommon endocrine neoplasm, accounting for less than 1% of parathyroid tumors and also a rare cause of primary hyperparathyroidism. Although this malignant lesion is usually slowly progressive, it is frequently associated with local recurrences and also with metastases involving the local lymph nodes or distant sites. We present a 59-year-old male patient who developed a parathyroid carcinoma metastasis involving the anterior mediastinal lymph nodes and thymus remnants, 3 years after the primary tumor was identified and treated by surgical excision followed by chemo and radiotherapy. The patient presented with severe, symptomatic hyperparathyroidism and a gamma scan revealed increased uptake hyperfixation in the paratracheal lymph nodes. A lymphadenectomy was performed and the gross examination of the specimen showed a pinkish – white, firm, poorly circumscribed mass. The microscopic examination revealed an epithelial proliferation with a predominantly nodular/solid growth pattern, composed of cells exhibiting moderate nuclear pleomorphism, prominent nucleoli and high mitotic activity, involving two lymph nodes and thymus remnants. Upon immunohistochemical analysis, the proliferation showed positive staining for GATA 3, as well as a high Ki 67 index, whereas TTF 1 and thyroglobulin were negative in the tumor cells. Thus, the diagnosis of metastatic parathyroid carcinoma was established. The aim of this paper is to gain further knowledge about the histopathological and immunohistochemical features, as well as about the clinical behavior of parathyroid malignant lesions, especially considering their rarity.

Mental health can be negatively affected during life to varying degrees, from minor indispositions created by daily debates, to major psycho-social traumas that have a significant and long-term impact. Physical injuries, especially those involving limb amputation, are probably the most traumatic and hard to accept events, as they cause severe biological, psychological and social damage to the individual. Losing a limb or part of a limb leads to significant physical disability, changes in physical appearance and self-esteem, difficulty returning to work and problems with social integration. Consequently, after an amputation operation, the patient's recovery must be approached with great care. Some of the patients adapt relatively easily to the new condition, while others successfully benefit from intensive recovery programs. Unfortunately, a small group of patients fail in post-operative recovery and some even believe that isolation/suicide could be a possible solution for their difficulties. The psychological response/behavior of patients to limb amputations is dependent on many factors, such as: personality, level of education, social status, the environment and culture from which it originates, the support from society in terms of their integration, age, gender, the affected limb and extent of amputation, accessibility to different methods of recovery/prosthetics, etc. This complexity of the factors involved in the post-operative recovery period of the amputee patient causes the rehabilitation programs to be extremely elaborate on the one hand, but also highly personalized according to the individual characteristics, on the other hand. In this review, aspects of the psychological rehabilitation of patients undergoing limb amputation are presented and updated. It seems that such measures should be approached interdisciplinary with the patient and initiated even before surgery, if possible, to achieve the best possible results.

Clinical problem solving evolves in parallel with advances in technology and discoveries in the medical field. However, it always reverts to basic cognitive processes involved in critical thinking, such as hypothetical–deductive reasoning, pattern recognition, and compilation models. When dealing with cases of acute abdominal pain, clinicians should employ all available tools that allow them to rapidly refine their analysis for a definitive diagnosis. Therefore, we propose a standardized method for the quick assessment of abdominopelvic computed tomography as a supplement to the traditional clinical reasoning process. This narrative review explores the cognitive basis of errors in reading imaging. It explains the practical use of attenuation values, contrast phases, and windowing for non-radiologists and details a multistep protocol for finding radiological cues during CT reading and interpretation. This systematic approach describes the salient features and technical tools needed to ascertain the causality between clinical patterns and abdominopelvic changes visible on CT scans from a surgeon’s perspective. It comprises 16 sections that should be read successively and that cover the entire abdominopelvic region. Each section details specific radiological signs and provides clear explanations for targeted searches, as well as anatomical and technical hints. Reliance on imaging in clinical problem solving does not make a decision dichotomous nor does it guarantee success in diagnostic endeavors. However, it contributes exact information for supporting the clinical assessments even in the most subtle and intricate conditions.

Epidermolysis bullosa (EB) is a rare, serious genetic disease, incurable through the current means. Apart from this initial definition, there was later some ease in the definition of the disease, including the manifestations of toxic epidermal necrolysis and Stevens Johnson syndrome in this entity. In medical practice, there are cases that do not overlap with the description in the literature, thus the treatment must be adapted and personalized to the particularities. We present the case of a female new-born, with "de novo" mutation for the early-onset antenatal epidermolysis and our personalized therapeutic management, based on collagen from bovine corneas by enzymatic process. The histological examination showed that the collagen membranes serve as a support for the epithelial cells that formed a surface monolayer after 48 hours. Therefore. this case report shows that collagen-based biomaterials could be used to accelerate the dermal-epidermal healing in various conditions of the child, such as Stevens Johnson syndrome, bullous epidermolysis and widespread burns.

Vaginal microbiome is submitted to permanent changes accordingly to age, menopausal status or association of different pathological conditions such as inflammation or mucosal atrophy. The presence of these modifications is usually associated with local development of infectious, inflammatory or atrophic vulvovaginitis. These represent the most commonly complaints which affect women at all ages. Therefore, attention was focused on creating a topic product which is able to control the local process and to alleviate the symptoms. The aim of the current paper is to analyze the physiology, physiopathology and therapeutic strategies in such cases with special focus on Cerviron, a product which seems to provide multiple therapeutic benefits in such cases.

We describe an uncommon clinical presentation of caudal duplication syndrome and features of caudal regression syndrome in a female infant with complex urogenital and colorectal duplication associated with lipomyleomeningocele and left lower limb hypoplasia. A staged surgical treatment plan was carried out to maintain fecal and urine continence, potential fertility, and cosmetic appearance.

Introduction: Recurrent laryngeal nerve damage during total thyroidectomy was, is, and probably will be in the near future the Achilles’ heel of total thyroidectomy. Material and method: To perform the research we used the PubMed database. The questions were conceived to respect the PICOS guidelines. The PRISMA checklist was used to filter the results. The search was structured following the words: „recurrent laryngeal nerve injury” AND „total thyroidectomy”. Results: A total of 60 papers were identified. We excluded 12 papers as they were duplicates. From the 48 papers left, another 4 could not be obtained. Another 3 papers from the 44 left were excluded due to the fact they were not written in English. One paper was excluded as the subject did not follow our research purpose. 40 papers were left for analysis and discussion. Conclusion: To prevent recurrent laryngeal nerve lesions, at the moment in the literature there is no consensus. Unintentional injury to the recurrent laryngeal nerve is predictable but not an avertible situation thus bilateral lesions still represent a dramatic situation across the world for the patients and the operating surgeon.

t has been widely demonstrated so far that lactobacilli represent probably the most important microorganisms which are developed at the level of the vaginal cavity and which are responsible for the maintenance of an adequate environment and pH at this level. Once the number of these microorganisms decrease the pH value increase leading to the apparition of a basic medium, which favors the development of certain microorganisms such as human papilloma virus. Meanwhile it is widely known that the presence of this virus is associated with an increased risk of developing premalignant and even malignant conditions. The aim of the current paper is to investigate the correlation between the vaginal pH, the risk of human papilloma virus infection and, in the meantime, to explore the possible benefits of local application of Cerviron, a topic, vaginal product which seems to significantly influence the risk of cervical lesions development.

Uterine fibroids represent the most commonly encountered uterine tumors in women worldwide which can develop at the level of any segment of the uterus and can pose different problems in regard to the most appropriate therapeutic strategy especially in young women which deserve fertility preservation. Meanwhile in certain cases they can impede the development of a normal pregnancy due to their location or can show significant enlargement in volume during pregnancy due to the increased blow flow at this level. In all cases in which they induce the apparition of symptoms or impede the apparition or development of a normal pregnancy they should be removed. In cases in which the fibroids are located at the level of the uterine cervix attention should be focused on providing a correct and efficient postoperative healing. The aim of this paper is to review the most important aspects related to uterine cervix fibroid symptoms, treatment and postoperative healing, particular attention being given to Cerviron, a topic agent which seems to provide an efficient healing at this level.

Vaginal atrophy represents a frequently encountered condition which is significantly correlated with decreased amounts of circulating estrogen levels. It is usually characterized by the presence of burning, itching, irritation and dyspareunia. In such cases attention was focused on identifying a topic product which might alleviate these symptoms and stop the deterioration process of the vaginal lining. One product which seems to have an effective role in order to stop this process and to offer a good local control of the disease should contain anti-inflammatory, healing and antiseptic principles. The aim of the current paper is to study the possible benefits of Cerviron a topic product with intravaginal administration which contains seven active principles in order to offer the above mentioned effects.

Bile duct lesions with leakage and stenosis can occur after open or laparoscopic cholecystectomy. Multiple factors are involved either related to the patient or external due to technical equipment or surgeon. Bismuth classification is generally accepted. The aim is to restore the bile duct and to prevent short-term and long-term complications such as biliary fistula, intra-abdominal abscess, biliary stricture, recurrent cholangitis, and secondary biliary cirrhosis. Endoscopic therapy with biliary sphincterotomy alone or with the additional placement of a biliary/nasobiliary stent drainage is recommended. Stenting should be avoided if complete strictures exist or a circumferential resection of the duct. Endotherapy can be considered a sensible option and should be the main-stay treatment in these patients but one must keep in mind it is costly and is usually practiced by experienced teams in tertiary centers. The purpose of our paper is to exemplify this complication which is inherently rare, to highlight the diagnostic and treatment tools with minimal long-term sequelae.

Although the standard treatment for ovarian carcinoma with peritoneal metastases is systemic chemotherapy alone or systemic chemotherapy with debulking surgery, a new technique gains more ground: a combination of hipertermic intraperitoneal chemotherapy (HIPEC) and optimal cytoreduction surgery. The proof is mounting regarding the benefits of HIPEC for patients with metastatic ovarian carcinoma but it still lacks a standard protocol of use. It has increased costs, and incomplete data regarding its safety. Due to these reasons, it is still considered an alternative treatment. Our study aimed to evaluate the published literature regarding this technique from the point of view of safety and efficacy when compared with the standard of care treatment.

Cytoreductive surgery and HIPEC have become de pillars of treatment in advanced, metastatic colorectal cancer. This state of evolution of the disease was considered terminal just a few years ago. It has been demonstrated that by combining these therapies in selected patients one can increase survival time. Once this has been obtained to some length modern studies have been focused on the quality of life, safety, and how this time interval can be increased. We have reviewed the most important prospective, randomized clinical trials regarding HIPEC and peritoneal carcinomatosis. The technique, complications, principles of action, and evolution through time of HIPEC have been addressed and covered. Special consideration had been given to the correlation between the carcinomatosis index and HIPEC. HIPEC with maximal cytoreduction can be considered a curative procedure only in strictly selected patients diagnosed with colorectal cancer and peritoneal carcinomatosis. Although it has been present in the medical field for almost 30 years, it is not wide-spread due to the high costs of implementation and the requirement of highly specialized surgical and medical teams. As technology evolves, the costs can be decreased and HIPEC should be largely available in oncological centers since the foundation of implementation is solid and the fact that clear benefits although small have been demonstrated. Taking into account all of the above, HIPEC should not be considered a standard treatment at present and should only be performed in experienced centers. The correct selection of patients is critical to the success of this procedure. Maximum cytoreduction should only be performed if the carcinomatosis index allows.

Oral manifestations are present both in Cushing's syndrome and in adrenal insufficiency. Possible oro-dental pathology in patients with Cushing's syndrome include jawbone loss, tooth loss, and periodontal diseases. Professional societies did not include Cushing's syndrome as being part of systemic diseases associated with loss of periodontal supporting tissues. The comorbidities of Cushing's syndrome such as obesity, osteoporosis, and diabetes are conditions that influence periodontal attachment apparatus. In patients with adrenal primary insufficiency, the most specific sign is the melanic pigmentation of the skin and mucosal surfaces due to increments of corticotropin and pro-opiomelanocortin peptide levels that occur as a result of decreased cortisol feedback. The oral mucosa develops black plaques that can also be present on the gums, palate, tongue, and lips. The pallor may occur in patients with adrenocortical insufficiency secondary to corticotropin deficiency. Patients with primary adrenal insufficiency need to increase their glucocorticoid doses during physical activity, intercurrent illnesses, surgery, and medical procedures. Current evidence indicates that routine, nonsurgical, or minor surgical procedures do not need supplemental glucocorticoids in diagnosed patients who are in a stable condition. However, for major oral surgery, glucocorticoid supplementation is necessary for the surgery day and for at least one postoperative day.

The use of alloplastic materials in different surgical urogynecological interventions has been subject to limitations during the past years by the international societies, because of late onset mesh-related complications. Xenograft-based biomaterials obtained from extracellular matrix offer a proper acellular foundation for tissue repair in urogynecology, with improved tissue-graft rejection. We have searched PubMed database to identify all publications regarding the use of extracellular matrix in gynecological reconstructive surgery. The use of these matrices in organ prolapse surgery has shown efficient integration and favorable outcomes. Biomaterials are used for vaginoplasties in patients with vaginal congenital agenesis, patients who underwent vaginal radical resection for cervical cancer or patients diagnosed with profound endometriosis, who had partial vaginal resection. Biomaterials may also have a future in vaginoplasties performed for aesthetic reasons. It is foreseen that in the future these biomaterials might be used in the treatment of certain fetal structural anomalies, like neural tube defects. Although nowadays the use of biological grafts is quite limited, due to the lack of prospective randomized trials to compare them with classical surgical techniques, with the emerging technologies, in the near future we foresee its significant role in urogynecology, plastic surgery repair and possibly fetal congenital malformation correction.

Many patients are not aware that natural products such as fruit juices or plant infusions can cause significant interactions with several drugs, some of which can be dangerous, especially when the medical treatment is for neurological or psychiatric disorders. Among the most predisposed for interacting with drugs are citric juices, particularly grapefruit and plant infusions, especially St John`s wort (Hypericum perforatum). Understanding the mechanism and the frequency of this type of interaction helps to avoid it. The goal of this research was to identify and summarize the most relevant reports on interactions between psychotropic drugs and natural beverages, in order to raise awareness among physicians that they should invest more time in educating patients how to administer drugs properly, thus reducing the likelihood of such unwanted events. For the purpose of this study, an electronic search of PubMed database was conducted until September 2019. We concluded that natural beverage consumption along side medical treatment is a widespread practice and the main mechanism generating interactions is related to the functioning of biotransformation enzymes.

Open fractures are orthopedic emergencies that require immediate surgical intervention in order to provide fracture stabilization and to prevent development of osteitis. We present the case of a 33-years-old patient presented in our clinic for a type IIIB neglected open fracture of the distal tibia. We used external fixation for fracture stabilization and a distal based fasciocutaneous sural flap for covering the wound. The purpose was to obtain union of the tibia and reducing the risk of infection. The results at 6 months are good, but the patient needs to be closely followed in time.

Summary: Background: Mental health is a public health issue for European young people, with great heterogeneity in resource allocation. Representative population-based studies are needed. The Global Burden of Disease (GBD) Study 2019 provides internationally comparable information on trends in the health status of populations and changes in the leading causes of disease burden over time. Methods: Prevalence, incidence, Years Lived with Disability (YLDs) and Years of Life Lost (YLLs) from mental disorders (MDs), substance use disorders (SUDs) and self-harm were estimated for young people aged 10-24 years in 31 European countries. Rates per 100,000 population, percentage changes in 1990-2019, 95% Uncertainty Intervals (UIs), and correlations with Sociodemographic Index (SDI), were estimated. Findings: In 2019, rates per 100,000 population were 16,983 (95% UI 12,823 – 21,630) for MDs, 3,891 (3,020 - 4,905) for SUDs, and 89·1 (63·8 - 123·1) for self-harm. In terms of disability, anxiety contributed to 647·3 (432–912·3) YLDs, while in terms of premature death, self-harm contributed to 319·6 (248·9–412·8) YLLs, per 100,000 population. Over the 30 years studied, YLDs increased in eating disorders (14·9%;9·4-20·1) and drug use disorders (16·9%;8·9-26·3), and decreased in idiopathic developmental intellectual disability (–29·1%;23·8-38·5). YLLs decreased in self-harm (–27·9%;38·3-18·7). Variations were found by sex, age-group and country. The burden of SUDs and self-harm was higher in countries with lower SDI, MDs were associated with SUDs. Interpretation: Mental health conditions represent an important burden among young people living in Europe. National policies should strengthen mental health, with a specific focus on young people. Funding: The Bill and Melinda Gates Foundation

Cases of digestive cancers diagnosed during pregnancy are rare. The increasing prevalence of pregnancy in women aged 30–39 years (and not exceptionally 40–49 years) could explain the frequent co-occurrence of cancers and pregnancy. The diagnosis of digestive cancers in pregnancy is difficult due to the overlap between neoplasm symptomatology and the clinical picture of pregnancy. A paraclinical evaluation may also be difficult depending on the trimester of the pregnancy. Diagnosis is also delayed by practitioners’ hesitation to use invasive investigations (imaging, endoscopy, etc.) due to fetal safety concerns. Therefore, digestive cancers are often diagnosed during pregnancy in advanced stages, where complications such as occlusions, perforations, and cachexia have already arisen. In this review, we highlight the epidemiology, clinical aspects, paraclinical evaluation, and particularities of the diagnosis and treatment of gastric cancer during pregnancy.

Background: Giant gallbladder is an uncommon condition that can result from a benign pathology and rarely presents with malignancy. Intracholecystic papillary–tubular neoplasm (ICPN) is a relatively new entity first described by V. Adsay in 2012 and included in the World Health Classification of Digestive System Tumours in 2019. Intracholecystic papillary-tubular neoplasm is a preinvasive lesion with an incidence of around 1% that may present as four histologic subtypes—biliary, gastric, intestinal, or oncocytic—of which the biliary subtype has the highest risk of associated invasive cancer. Although invasive carcinoma is present in about 50% of cases of ICPN, these patients have a significantly better prognosis than those with usual gallbladder cancer, suggesting that the entities may have distinct biological signatures. Case report: A 77-year-old female presented to the hospital with progressive swelling in the right hemiabdomen, a loss of appetite, and weight loss. MRI highlighted a giant abdominal tumor located in the right hypochondrium and right abdominal flank with liver invasion (segment V). Preoperatively, a gallbladder 25 × 17 cm in size was noted, and the patient underwent radical cholecystectomy. It was surprising to find such a giant malignant gallbladder tumor, diagnosed as invasive poorly cohesive carcinoma associated with ICPN. Discussion: A megacholecyst is a rare discovery. Although most often found in benign pathologies, giant gallbladder cancer can be considered. The neoplastic features and the loco-regional extension of the tumor must be evaluated by imaging scans. Few cases of giant benign gallbladder have been reported in the literature; however, this appeared to be the largest resectable gallbladder carcinoma reported to date according to the literature. Conclusion: The stage of gallbladder neoplasia is not correlated with the size of the gallbladder. Regardless of tumor size, the prognosis seems to be directly related to the stage, morphology, and resectability.

Introduction: Functional hypothalamic amenorrhea is a diagnostic challenge, especially in association with structural pituitary changes. We present the case of a patient with functional amenorrhea and pituitary microadenoma, evaluated in multiple medical centres. Case report: A 27-year-old female was referred to our clinic for secondary amenorrhea installed 18 months prior, insomnia, polydipsia (around 4-6 l water intake/day) and polyuria. Clinical examination revealed an underweight patient, with BMI (Body Mass Index) of 17.5 kg/m2, normal secondary sex characteristics, pallor of the skin and mucosa. The hormonal profi le revealed normal FSH (Follicle Stimulating Hormone) levels, low LH - Luteinizing Hormone (of 0.15 U/L, normal: 1.20-12.8 U/L), estradiol (of 11.2 pg/mL, normal: 49-291 pg/mL) and progesterone (of 1.13 ng/mL, normal: 5.16-18.56 ng/mL). No pathological changes were recorded at somatotropic, lactotropic, thyrotropic and corticotropic levels. The Diphereline stimulation test revealed functional integrity of the pituitary gland and ovaries. The progesterone with drawal test was negative. There were no pathological fi ndings on biochemical workup and the water deprivation test excluded diabetes insipidus. Morphological exploration of the hypothalamic-pituitary region by contrast-enhanced MRI (Magnetic Resonance Imaging) scan revealed a left pituitary microadenoma measuring 5 mm in diameter. Adequate diet and oral contraceptive treatment were recommended. Conclusion: Functional hypothalamic amenorrhea (FHA) is the most common cause of neuroendocrine amenorrhea. Identifying the context and causative factors is essential for making an appropriate therapeutic decision.

Introduction: Cushing’s disease (CD) is characterized by multiple complications, particularly due to the condition itself, but also as a result of curative treatment. Nowadays, transsphenoidal surgery is considered the first-line therapy. Persistent hypercortisolism requires the initiation of medical therapy in order to limit the consequences of the disease. A common complication of pasireotide treatment is type 2 diabetes mellitus. We present a case of persistent Cushing’s disease after transsphenoidal adenomectomy and pasireotide therapy, evaluated in several medical centers. Case presentation: A 27-year-old female was referred to our clinic for weight gain, hypertension, transient headache and recurrent depression. Clinical examination revealed plethoric moon face, purple striae, hirsutism with a Ferriman-Gallwey score of 14, acanthosis nigricans. The hormonal profile showed high ACTH (adrenocorticotropic hormone) levels (of 110.6 pg/mL, normal: 7.2-63.3 pg/mL), high urinary free cortisol (UFC) (of 846.5 μg/24h, normal: 50-190 μg/24h) and serum cortisol, accompanied by non-suppression of cortisol after the 1 mg DXM (Dexamethasone) suppression test (of 26.6 μg/dL, normal: 18 μg/dL) and adequate suppression after the overnight 8 mg DXM test. Pituitary MRI (Magnetic Resonance Imaging) revealed a microadenoma measuring 4.3/4.4/6.2 mm. Transsphenoidal adenomectomy was recommended. After surgery, the patient developed multiple pituitary hormone defi ciency, without signifi cant remission of hypercortisolism. Pasireotide therapy was initiated, followed by inadequate control of hypercortisolism and the onset of type 2 diabetes mellitus, requiring oral antidiabetic agents and insulin. Conclusion: In persistent Cushing’s disease, the challenge lies in identifying the optimal therapeutic methods in order to achieve a cure while, at the same time, limiting their side effects. Careful long-term follow-up by a multidisciplinary team is required.

Primary extragonadal germ-cell tumors (EGCTs) are a rare group of neoplasms, that can exist anywere along the midline of the body, without the evidence of a primary gonadal tumor. Their morphology varies widely and includes teratoma, seminoma, yolk sac tumor, embryonal carcinoma, choriocarcinoma, and mixed GCTs. The ethiopathogenesis of EGCT is poorly understood, existing multiple theories. Diagnosis is often difficult, but an accurate one should be made in order to apply a correct management.

Introduction. Precocious puberty is a common endocrine disorder in pediatric patients, leading to important changes in growth patterns. Case presentation. We present the case of a patient with precocious puberty and accelerated bone maturation, evaluated in several medical centers. A 9-year-and-11-month-old female patient was evaluated for premature thelarche, adrenarche and menarche starting at the age of 7. On clinical examination, height was 143 cm, 0.9 SD above the age and sex median, with 37.91% excess weight. She also presented with acne, cervical posterior acanthosis nigricans, hirsutism and Tanner puberty development stage B3/P4. The endocrine profile showed pubertal values for FSH (Follicle-Stimulating Hormone), LH (Luteinizing Hormone) and estradiol, before and after the Diphereline test, hyperprolactinemia (of 38.6 ng/mL, normal: 2-18.9 ng/mL) and high levels of 17-OH Progesterone (of 2.60 ng/mL, normal: 0.2-0.9 ng/mL). The Synactene® test excluded 21-hydroxylase deficiency. Knee X-rays showed a tendency for premature growth plate fusion and bone age advancement of 3.1 years. Gynecological examination and pelvic ultrasound showed normal ovarian morphology and volume, according to chronological age and a 17-mm endometrium. Hypothalamic-pituitary MRI (Magnetic Resonance Imaging) excluded the presence of a local lesion. Conclusions. In the absence of therapeutic intervention, accelerated skeletal development due to precocious puberty initially leads to high stature compared to the patient’s age group, followed by premature closure of the growth plates and low final height.

Introduction. Pineal tumors are an inhomogeneous group of lesions with pineal origin, characterized by various degrees of hypothalamic-pituitary dysfunction. Case presentation. We present the case of a patient with pineal germinoma and hypogonadotropic hypogonadism who was evaluated in several medical centers. A 31-year-old male patient with a history of primary hypothyroidism and pineal germinoma, for which he underwent surgery, radiation and chemotherapy, was admitted for frontal-temporal headache, nausea and moderate intensity asthenia. Clinical examination revealed normal weight, normal blood pressure, left eye strabismus, pale skin, diminished facial and body hair, bilateral gynecomastia. The endocrine profile showed adequate thyroid hormone replacement, low normal basal cortisol levels (5.88 µg/dL, normal 5-25 µg/dL), low IGF-1 (Insulin-like Growth Factor) (93.2 pg/mL, normal 115-307 pg/mL), low gonadotrophins, testosterone (0.57 ng/mL, normal 1.3-8.53 ng/mL) and estradiol (

Introduction. Mesh reinforcement is generally considered the standard of care in hernia repair. Infection is a common complication following hernia repair. Infection of the mesh is a complex problem. Knowledge of new treatment strategies is necessary for surgeons performing abdominal wall reconstruction. Case presentation. We present the case of a 68-year-old woman, who presented with a non-traumatic entero-atmospheric fistula at the site of the hernia repair, which had been done 2 years previously through the implantation of a dual mesh. The fistula has appeared one year previously. The treatment consisted in a complete removal of the infected mesh and segmentary enterectomy. The abdominal wall was repaired through a tissular procedure and the skin was left to close per secundam. The postoperative outcome was favorable. Conclusions. Following excision of infected mesh, multi-staged abdominal wall reconstruction can be considered. Biologic or biosynthetic mesh is recommended when repairing incisional hernias following excision of infected mesh and likely represent the patient’s best chance for a definitive hernia repair. Negative pressure wound therapy closure should be considered in higher-risk patients. Mesh infection is a complex complication that is commonly encountered by surgeons performing hernia repair. Prevention through patient optimization should be performed whenever appropriate. However, when patients develop a mesh infection, most of them will require a complete mesh excision and recurrent hernia repair.

Acute pancreatitis is an important current problem with a growing frequency and a potentially severe or even fatal evolution in some cases. In recent years, an increase in the incidence of acute pancreatitis has been observed in the population, which emphasizes the importance of establishing optimal therapeutic behavior. We performed a descriptive, retrospective clinical study, from January 2015 to November 2018, single-center, on a number of 57 patients with the diagnosis of acute pancreatitis. The presentation characteristics of patients with acute pancreatitis are largely consistent with the literature, with patient sex being the sure parameter that highlights a significant difference, with a greater number of women being diagnosed with acute pancreatitis.

Repairing an incisional ventral hernia represents a challenge for the surgeon. The high recurrence rates observed during hernia repair by tissue approximation leads to development of tension-free procedures by using prosthetic materials. Incisional or ventral hernia is a very common multifactorial pathology that requires surgical intervention to prevent complications, such as pain, discomfort, bowel obstruction or strangulation. To perform the wall repair it is of utmost importance to understand the pathogenesis of the hernia, the anatomy and physiology of the abdominal wall, and surgical techniques. Several repair methods are available, including open suture repair, open mesh repair, the component separation technique, and tissue expansion assisted closure. To perform the ventral hernia repair properly, a full understanding and correct selection of mesh and management of probable complications, such as seroma, bowel injury, enteric fi stulae, and recurrence, is essential. There are lots of scientific debates about an ideal material for mesh parietal repair. In latest years, the tendency is that the continuous decreasing territory of polyester mesh to be slowly replaced by the increasing territory of polypropylene mesh in open procedures for abdominal incisional hernia repair. The goals of incisional hernia repair are the prevention of visceral eventration, incorporation of the abdominal wall in the repair, provision of dynamic muscular support, and restoration of abdominal wall continuity in a tension-free manner. We present the case of a 55 years old woman who had a history of multiple surgical interventions. We performed an open surgical approach, tension free technique using an intraperitoneal dual-mesh.

Introduction: The prevalence of hypokalemia in psychiatric population is very high with eating disorders and laxative abuse being the main incriminated factors. Case presentation: We report a case of a 34-year-old woman with history of sleeve gastrectomy and breast implant, who presented for fatigue, severe myalgia, generalized hypotonia and palpitations. Laboratory exams revealed severe hypokalemia and rhabdomyolysis. The electrocardiography showed prolonged QT interval and ST segment depression with second-degree atrioventricular block. She received intravenous potassium supplementation with consecutive hydration. When potassium level was within safety limits, the patients received loop diuretics in order to decrease rhabdomyolysis and avoid kidney injury. The underlying cause was a pathological behavior, with frequent self-provoked episodes of nausea and vomiting after eating and chronic consumption of laxatives. She started psychotherapy. Conclusion: Psychiatric behaviour can lead to life-threatening conditions, therefore it should be discovered and managed promptly.

Psoriasis is a chronic inflammatory disease that affects the patients’ quality of life. In psoriatic patients, the quality of life is generally low due to multiple co-morbidities, treatments, stigma and misperceptions about this condition. Sexual dysfunction, in both women and men, is a comorbidity that may impact the quality of life of these patients, in addition to those listed above. Because the recognition of sexual dysfunction by the patient can be difficult and considered shameful, it is necessary for the family doctor to intervene to improve the sexual health of these patients.

The article is a review of the surgical therapies for iatrogenic bile duct lesions (IBDL). The history of the bile duct surgical procedures starts in 1882, when the first cholecystectomy is performed. There are several classifications of the IBDLs such as Bismuth, Wood et al., McMahon et al., Strasberg et al., Bergman et al., Bismuth and Majno, Stewart-Way, Hannover and Mattox. The choice of the proper surgical treatment of IBDLs depends of their type and the review describes the end-to-end repair, hepaticojejunostomy, hepaticojejunostomy without sutures, mucosal graft (Rodney Smith technique), hepaticoduodenostomy, Heineke-Mikulicz plastic repair of stricture, right and left duct hepaticojejunostomy, construction of hepatic duct bifurcation when bifurcation has been destroyed, intrahepatic cholangiojejunostomy, ligamentum teres (round ligament) approach to the left hepatic duct and Longmire procedure. Even the surgical treatment of IBDLs is in continuous development and research, their best prevention is the proper training of the biliary surgeons in the performance of safe cholecystectomies or any other abdominal surgeries, complex gastrotomies, pancreatic operations, endoscopic biliary tract investigations etc.

The link between vitiligo and depression is complex in many ways. Vitiligo predisposes to depression because it is a chronic, unpredictable, without curative treatment that affects the quality of life, especially because of skin damage. This meta-analysis emphasizes the importance of addressing depression in patients with vitiligo in medical practice as well as the predisposing factors of vitiligo that contribute to the further development of depression. There is a need for more studies on this issue.

Introduction. Scaphoid non-union associated with avascular proximal pole necrosis represent a really challenging problem for orthopedic surgeons and its treatment is still in debate. Case presentation. We present the case of a 33-year-old patient, with scaphoid non-union, who was treated according to Zeidenberg’s technique using a vascularized radial bone graft. The primary objectives of treatment were to obtain union of the scaphoid, to improve the functional recovery of the wrist and to allow professional reimplantation of the patient. We were able to obtain a functional graft and after 9 months the results were very good. Conclusions. Vascularized bone grafts represent the optimal method of treatment of scaphoid non-union associated to avascular proximal pole. It is mandatory to be associated to rigid osteosynthesis such as Herbert compression screw. The technique of Zeidenberg offers good results in these cases, but it should not be performed without magnifying lens and tourniquet uses.

Introduction. Struma ovarii represents a rare tumor, only 1% of the ovarian tumors, with an incidence of 0.3-0.7%. The positive diagnosis is obtained by microscopic examination; sometimes elevated serum levels of thyroid hormone, CA 125 and ultrasound aspects can suggest the preoperative diagnosis. Case presentation. We report the case of a 56-year-old woman with unilateral struma ovarii and no clinical or paraclinical evidence of the diagnosis to come. Transvaginal ultrasound revealed polyfibromatous uterus and apparently normal adnexa. Partial hysterectomy with bilateral salpingo-oophorectomy (considering the patients’ age) through laparotomy was performed under spinal anaesthesia. The histopathological result showed an endometrial polyp, multiple intrauterine leiomyomas, left ovary with thyroid follicles, which looked like normal thyroid tissue. The evolution of the patient was favorable, with no complications at the 6 months’ follow-up. Conclusions. In the literature, there are only a few cases of benign struma ovarium, and even less cases of malignant struma ovarium or bilateral presentation of the tumor. The particularity of the case consists in the diagnosis of struma ovarii only after surgery, in a patient without clinical or paraclinical evidence of this diagnosis.

Introduction. The continuous process of broadening the indications of laparoscopy has determined a reevaluation of its risks and benefits in extensive adhesiolysis. The objective of the study. The aim of the present study was to evaluate the efficacy and the associated risks of the laparoscopic adhesiolysis in the surgical management of the intestinal obstruction secondary to postoperative peritoneal adhesions. Material and methods. 17 patients with intestinal obstruction secondary to postoperative peritoneal adhesions admitted to the Surgical Department of the “Sf. Pantelimon” Emergency Hospital from Bucharest, Romania, between January 2014 and January 2018, were treated using laparoscopic surgery. The pneumoperitoneum was made using the open technique, far from the skin scars secondary to previous surgical interventions. After identifying the postoperative peritoneal adhesions as the cause of intestinal obstruction, the entire peritoneal cavity was rigorously inspected. Results. The laparoscopic exploration of the peritoneal cavity allowed for a clear identification of the cause and the level of the intestinal obstruction for all 17 patients included in the present study, 14 of them being treated by simple laparoscopic adhesiolysis, in 3 cases the conversion to laparotomy being necessary. The morbidity rate was low with no cases of death. The mean hospitalization stay was 5 days. Conclusions. The laparoscopic surgery represents an efficient therapeutic alternative to the classical methods for the treatment of the intestinal obstruction secondary to postoperative peritoneal adhesions, constituting a diagnostic and therapeutic tool that has the benefits of the minimally invasive techniques.