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Laparoscopic cholecystectomy has become the "gold standard" for cholelithiasis. In laparoscopic technique, the incidence and the severity of injuries of the extrahepatic bile ducts are significantly higher (0-2,7%) than in open surgery (0,2-0,5%). The authors present a series of 18 patients with such lesions, operated between 1996 and 2005 in the surgical departments of 2 Clinical Hospitals: "Dr.I.Cantacuzino" and Coltea, from Bucharest. The injuries were: 2--of type A, 10--of type D and 6--of type E, according to Soper-Strasberg classification. There are analysed the causes and the circumstances in which these injuries have occurred, the clinical signs and imagistic findings and, most of all, their treatment. In complete transections of the common bile duct, a hepatico-jejuno-anastomosis using a Roux en Y-loop appears to be the best solution. It is emphasized the fact that an accurate diagnosis and surgical technique are essential for a favourable evolution. That's why these operations must be accomplished by experimented surgeons, from highly specialized departments.

The lesions of the pancreas represent a very interesting chapter of its pathology. Although they seem very much alike, the different anatomo- pathological forms have well defined individual features, which impose the therapeutical attitude. The authors have analyzed a group of 62 patients, admitted in our clinic between 1974 and 2003. Most of them had pancreatic pseudocysts (54-86%); 6 (10%) had cystadenomas; 1 (2%)--cystadenocarcinoma and 1 (2%)--solid and papillary cystic tumour. The diagnostic methods are largely presented and compared to the literature; it is emphasized the importance of imaging procedures and of the histo-pathological examination. The different therapeutical procedures, their advantages and limits are also analyzed--the necessity of a conservative attitude, with the total or partial preservation of the pancreas, is almost unanimously recognized.

We present the pathogenic and the therapeutic features of the extensive necrotizing perineal infections in diabetic patients, based on the clinical experience of our surgical department (45 cases in 10 years) and on the data in the medical literature. We analyzed the case of a 45 years male with an unbalanced type I diabetes mellitus, which has been admitted for an extensive necrotizing infection of the lower abdominal wall (hypogastrium and both right and left lower quadrant), with crepitation on this area. The origin of this necrotizing infection was an upward extension of an insufficiently drained right ischiorectal abscess. The therapeutic management consisted in 6 consecutive surgical procedures (drainage, necrectomy, large fasciectomy), which permitted a favourable evolution and the healing of the patient. We used this demonstrative case for emphasizing the clinical, paraclinical and therapeutical peculiarities of the extensive perineal infections in diabetic patients.

The authors present the case of a 28 years old female with a mature, three-layers sacrococcygeal teratoma, which has been operated using an abdominoperineal approach. Teratomas are quite frequent in pediatric surgery; their incidence gradually decreases in adult population. Lately, significant progresses in the diagnosis and treatment of fetus and new born teratomas have been achieved; a review of the literature (2000-2004) is added. In adults, the diagnosis of teratomas is rather difficult. The symptoms are due to their size, to the compression of pelvic viscera or to their complications (infections, bowel obstruction, fistulas, malignancy). The treatment of teratomas is mainly surgical. The approach depends on the peculiarities of each case (size, invasion of the nearby viscera).

Late intestinal perforation is the most rare and the most serious complication following the repair of abdominal parietal defects with alloplastic material. The authors have gathered in 7 years 6 cases of perforations which occurred between 1 and 10 years after using nonabsorbable synthetic mesh prostheses made of polyester (4 cases) and polypropylene (2 cases) as parietal substitution materials. The perforations were discovered either by the appearance of complete enteric fistulas after exploration of circumscribed parietal suppurations (3 cases) or during surgery of suppurations without external fistulas. All cases involved perforations of the small intestine and in only one case there was also a perforation of the transverse colon. In 4 cases, where eventration relapse co-existed, the polyester prostheses were found partially or totally detached from the abdominal wall. The treatment of enteric perforation consisted of 5 segmental enterectomies (one of those a double one) followed by anastomoses and one enteroraphy. The colic perforation was excised and sutured. The mesh was totally removed in 5 cases and partially removed in 1 case (around the perforation). The postoperative evolution was simple in only 3 cases. In the other 3 cases anastomotic fistulas occurred and one of them (with reduced leakage) was treated by nonoperative management. It did not close spontaneously even after 12 months. The other 2 cases required multiple reinterventions (enterectomies, ileostomies, ileocoloanastomosis). One of these patients has been lost away after 200 days of hospitalization and multiple reinterventions. In all cases, the closure of the abdominal wall was simplificad by cutaneous suture only whereas consecutive relapsed eventrations remain to be treated by subsequent reinterventions.

Insulinomas represent the most common cause of organic hypoglycemia. They are rare tumors: a review of the world literature reported a total number of 2000-3000 cases. The clinical diagnosis is based on the Whipple triad, which consists of: a) symptoms of hypoglycemia, b) blood glucose level: 40-50 mg/dl during the crisis, c) relief of symptoms after oral or intravenous administration of glucose. The most ticklish problem is the settlement of the accurate location of the tumor. Nowadays, there are many diagnostic methods; one of the best appears to be intra-operative ultrasonography. The authors analyse a series of 16 patients, operated between 1985 and 2002 in "I. Juvara" Surgical Clinic and present their opinions concerning tactic and technical aspects of different surgical procedures, with their advantages and limits. The results of the surgical treatment are detailed. There are also mentioned new imagery techniques and laparoscopic procedures, from recent medical issues.

Difficulties of diagnosis and of an adequate treatment of psoas muscle abscesses are increased by the evolution of the suppurative process in diabetic patients. We review 3 cases of poses muscle abscesses, characterized by a long-term evolution until revealing the initial source of the abscess and by particular clinical features, due to the exteriorization of suppuration far away from its source (retrosacral, hip, thigh). Computerized tomography is essential for diagnosis and for an accurate therapeutical approach, consisting in incision and drainage of primary abscess in psoas muscle and of its expansions as well in the same time, with an adequate antibiotherapy.

The large variety of the lesions in diabetic gangrene which require different therapeutical decisions explains our attempt to determine an useful way for the approach of the surgical treatment. Our aim was to avoid both an underestimation of the lesion, which may lead to an insufficient procedure, followed by reinterventions, as well as an overestimation--generating avoidable amputations. We have elaborated a scale of indices of therapeutical prognosis (ITP), using a computer programme, with the main risk factors. The result was a scale between 1 and 10; the value is proportional to the severity of each lesion. We have also analyzed the fiability of ITP on a prospective study including 72 patients with diabetic gangrene. The result was 93%, which has encouraged us to consider ITP useful in establishing a therapeutical attitude.

As "CSS" the authors name the left segment (1/3) of the transverse colon with the splenic angle and fixed segment of the left colon. The author's conclusion of a retrospective analysis upon 34 neoplasms situated in this colonic area is the fact that there are enough arguments to treat them as a unitary group. From the anatomic point of view these arguments are the common vessels and lymphatics reports, and from the clinical point of view these neoplasms have in common the symptomatology (generally the diagnostic is established later on) and a great tendency of a loco-regional invasion which generate severe complications. The surgical treatment with oncologic radical intervention is the same for any primary neoplasm localization (within the there segments of "CSS"). Multi-visceral resections are frequently necessary too.

Authors report a case of clostridial myonecrosis postcholecystectomy. The causes of the occurrence of this severe, frequently lethal complication are reviewed, as well as the difficulties of an early diagnosis, the only factor able to save the patient. The curative treatment of the detected infection requires the initiation of a series of local and general measures and a permanent cooperation between the surgeon, the specialist in resuscitation and the infectionist.

The authors present the case of a male patient aged 51 years who, on the background of a chronic intoxication with lead, developed an acute, pseudo-obstructive dilatation of the colon. The diagnosis was established during surgery, and the therapeutic solution consisted in cecostomy with a favourable result. A synopsis is also presented, of the literature concerning this rarely encountered syndrome.

The authors consider the internal biliary derivations as a choice procedure for the resolution of various pathological conditions of the biliary pathways and of the pancreas. They are based on the experience accumulated in the course of a total of 416 derivations performed in the last 10 years. The confrontation with particular problems raised by 40 re-interventions for failure of internal biliary derivations has determined an analysis of causes, clinical manifestations and possibilities to solve the disturbances. Categories are discussed, in which these patients can be classified and clinical observations are presented, in connection with the etiopathogeny of the non-functioning of the derivations. Possibilities are also presented for the resolution of the problems in each particular case. Two technical possibilities are presented for the correction of non-functioning biliary-digestive anastomoses, by performing bilio-biliary anastomoses.

In spite of the contemporary progresses in the field of surgical therapies, of the use of antibiotics, and of resuscitation techniques, resection of the colon with closure of the distal end and terminal colostomy, as suggested by Hartmann at the start of the century, has still some indications. Moreover, beside the original indications, this type of intervention can also be aplied in the case of some other benign lesions, and extension of the colon resection may involve other areas beside the recto-sigmoid zone. The specific indications of the intervention are the severe, very extensive and usually complicated lesions of the colon, frequently associated with a general biologic deterioration, conditions that make highly improbably the success of other surgical procedures. In a group of 28 patients (4,6 percent of the total number of cases in which interventions on the colon have been performed), of which 15 neoplasies and 13 benign lesions, the following resections have been carried out: 19 sigmoid resections, one resection of the transverse colon, 3 rectosigmoid resections, one left hemi-colectomy, 2 sub-total colectomies, 2 interventions for dehiscence of anastomoses. Considering the critical condition of the patients the high post-operative mortality appears to be easy to explain, as well as the non-lethal septic post-operative complications. In 7 patients (25 percent of the survivors) secondary restoration of the transit was carried out (4 benign lesions, and 3 cases of neoplasy). Reconversion raises some tactical and technical problems concerning the time of the intervention, the route, the attitude in front of colostomy, the mobilization of the segments and the type of anastomoses.

In 39 cases of re-interventions carried out after vagotomy (of which 31 were patients hospitalized in the Clinic and represent 8,6% of the total 358 vagotomies performed), the experience, the viewpoints and the recommendations of the authors are presented. Early re-interventions were necessayr because of complications which are common to abdominal surgery and only in a much lower degree to accidents that can be attributed to vagotomy or the associated intervention. Late re-interventions (26 cases) were necessary in 20 cases for ulcer recidives (13 for vagotomies performed in the Clinic and 7 for vagotomies performed in other units) while late-re-interventions for dumping syndrome, cholelythiasis, etc. represented only isolated cases in these statistics.

The authors make an analysis of factors which led to a late diagnosis, and to the choice of various surgical procedures used in the treatment of neoplasms of the main biliary pathway. The classical picture of "nodose jaundice" was encountered in only 24% of the cases, and this explains the wrong interpretation of the jaundice etiology in the early stages. A series of diagnostic difficulties are stressed, especially during the surgical intervention, related to some macroscopic forms of the neoplasm, the localization in ares which are difficulty accessible, and the bioptic sampling which is only rarely possible. The advanced stage of the lesions explains the fact that therapeutic attempts were limited in 52% of all patients to laparotomy performed for exploratory purposes, while exeresis of the neoplastic formation was possible in only 3% of the cases. Palliative interventions were used in 45% of the cases. Trans-tumoral intubation was used for draining purposes in the internal derivations. This was applied in 9 cases since it is simple and easy to perform, providing results which are similar to those obtained with other types of derivations. When no such possibilities existed external draining of the bile was achieved, a minimal procedure which assured the solution for the jaundice problem.

A 23-year retroactive analysis of a heterogeneous series of observations with unfavourable tardy results after antiulcer surgeries showed that the most failures requiring a second surgery appear after large resections with gastrojejunal or gastroduodenal anastomosis and after vagotomies associated with gastric drainage. The most favourable tardy results followed the vagotomy associated with limited gastric resection (hemigastrectomy). This kind of intervention prevents the appearance of the ulcerous relapses and lowers significantly the incidence of the other type of post-surgical iatrogenic complications. The optimal protection against the ulcerous relapse given by vagotomy associated with hemigastrectomy permits a tactical adaptation of the intervention to the lesional and physiopathological characteristics of each case.

The authors attempt an approach of a controversial problem of contemporary surgery and stress the following significant aspects:--the frequency of multiple colon cancers is of 3%, approximately 25% of the cases being associated with benign proliferative lesions:--the intra-operatory diagnosis of multiple colon cancers is difficult (3 out of 12 cases); intrasurgical exploration may give rise to problems in connection with the insufficiency of the exploration, or the inaccessibility of unique tumors, thus existing the risk of leaving in place a developing tumor, that can be discovered at a new intervention (one case); the operability of multiple colon cancers is similar to that of the unique malignant lesions, depending on the extension, the variety and the focal distribution of the neoplastic lesions.

Based on the experience acquired in 20 cases the authors discuss the use of the mannitol solution in the surgery of the colon. The colic voiding was evaluated in 19 cases as very good, a fact that stresses the efficiency of this method of mechanical preparation of the colon. The method is very well tolerated by the patients, and the secondary biological modifications are not significant. Contraindications are limited to the very aged (above 75 years), in patients with cardiac disease, or in those with hepatic and renal diseases, as well as in those with occluding forms of neoplasies.

Based on 17 observations the authors review the major etiopathogenic, evolutive, clinical and therapeutic aspects of pancreatic fistulae. In 14 cases the cure was achieved by medical treatment while surgery was resorted to in only three cases. The medical measures are discussed, as well as the indications for surgical treatment.

The present paper reports on the first autochtonous case of amoebic hepatic abscess in Romania in a patient in which the epidemiologic survey showed that there had been no possible import infection. The amoebic abscess was located in the superoexternal area of the right hepatic lobe. Subsequently a major complication developed: a tendency to pleuropulmonary invasion with the formation of fluid in the right pleural cavity. The diagnosis, suggested by the aspect of the abscess cavity, was established by the presence of the parasite in the flaky pleural exudate obtained by puncture, by cultures in Loeffler medium and by serum immunofluorescence. The abscess was evacuated surgically and a specific treatment with Chloroquine and Metronidazol combined with antibiotics and a symptomatic medication was prescribed. The patient recovered and was discharged 51 days after surgery.

The authors present the case of a female patient aged 19 years with chorionepithelioma, multiple pulmonary metastases, and an unique intestinal metastasis, complicated by severe digestive haemorrhage and haemoperitoneum. Surgery was carried out in risky conditions and consisted in segmental enterectomy and subtotal hysterectomy, and bilateral adnexectomy. The postoperative evolution was unsatisfactory, and the patient died following continued digestive bleeding, probably due to coagulation disturbances induced by prolonged loss of blood. Although the disease is encountered and treated in ob-gyn departments, the general surgeon can be confronted by such complications of this affection which may take on extremely severe aspects, and where surgery, provided that is performed sufficiently early, can save the patient's life.