The role of intensive training courses in laparoscopic surgery on live tissue in the surgeon’s formation

Clinica 2 de Chirurgie, Clinica de Terapie Intensivă, UMF „Victor Babeş”, Timişoara, România, Al XII-lea Congres al Asociației Chirurgilor „Nicolae Anestiadi” din Republica Moldova cu participare internațională 23-25 septembrie 2015Obiectivul studiului a fost evaluarea eficacităţii instruirii intensive pe porci în chirurgia laparoscopică a chirurgilor în funcţie de experienţa acestora. Material şi metode: La Centrul de Chirurgie Laparoscopică şi Microchirurgie “Pius Brânzeu”, Timişoara, au fost organizate 29 de cursuri intensive şi 8 cursuri avansate. Şaizeci de chirurgi care au urmat cele 3 zile de cursuri intensive au fost repartizaţi în 3 grupuri (câte 20 de chirurgi): primul grup – fără experiență în chirurgia laparocopică; al 2-lea grup – cu mai puţin de 10 proceduri laparoscopice efectuate şi al 3-lea grup – mai mult de 10 proceduri laparoscopice efectuate. Un al 4-lea grup – fără experienţa în chirurgia laparoscopică au urmat 2 zile de pregatire pe “cutii de antrenament” şi simulator înainte de cursurile laparoscopice intensive. Rezultate: Primul grup a reuşit sa deprindă mai puţin de 30% din tehnicile prezentate, al doilea grup a avut un randament mai bun, însuşind 63% din tehnicile prezentate şi al treilea grup a avut un randament foarte bun, reuşind să însuşească 96% din tehnicile prezentate. Al patrulea grup a avut un randament mai bun faţa de primul grup, însuşind 49% din tehnici. Simulatorul nu a fost superior faţă de “cutiile de antrenamet”, dar a fost mai costisitor. Concluzii: Chirurgii fără experienţă anterioară în chirurgia laparoscopică au beneficiat puţin de pe urma acestor cursuri. Ei au nevoie să-și însuşească tehnicile de bază pe “cutii de antrenament” sau simulatoare înainte de pregătirea pe porci. Cel mai mare beneficiu a fost pentru chirurgii cu un bun început de experienţă în chirurgia laparoscopică.The aim of the study was the evaluation of efficiency of the training courses in laparoscopic surgery on pigs in dependence to the prior experience of the surgeons. Material and methods: At the Center of Laparoscopic Surgery and Microsurgery Pius Branzeu, Timisoara 29 intensive and 8 advanced courses were organized. Sixty surgeons which underwent 3 days intensive courses were classified into 3 groups (20 surgeons in each group): first group – surgeons without experience in laparoscopic surgery, second group – less than 10 laparoscopic procedures performed and the third group – surgeons with more than 10 laparoscopic procedures performed. The fourth additional group consisted of surgeons without experience in laparoscopic interventions, which had 2 days of preliminary training on „box trainers” and simulator. Results: The first group succeeded to assimilate less than 30% of presented techniques, the second – had a better performance, 63% of techniques were assimilated, and the third group presented a very good performance, it succeeded to learn 96% of presented techniques. The fourth group had better results in comparison to the first group, with performance of 49%. Simulator was not superior to „box trainers”, but much more expensive. Conclusions: Surgeons without prior experience in laparoscopic interventions obtained fewer benefits from these courses. They need to learn basic techniques on box trainers of simulators before the training on pigs. The most benefits had surgeons with good prior experience in laparoscopic surgery

Is natural orifice specimen extraction surgery really safe in radical surgery for colorectal cancer?

Scop: Chirurgia rectală robotică este în prezent o procedură nouă pentru cancerele rectale. Extracția eșantionului cu orificiu natural transanal (NOSE) este o tehnică nouă de îndepărtare a specimenului din cavitatea abdominală prin anus, în loc de o incizie suplimentară după o intervenție chirurgicală colorectală laparoscopică sau robotică. Siguranța NOSE rămâne controversată. Acest studiu și-a propus să investigheze siguranța precoce a NOSE transanal în tratamentul cancerului de colon sigmoid și rectal superior din următoarele aspecte: caracteristici clinice și patologice, indicatori inflamatori și imunitari și complicații postoperatorii. Prezentare de caz: O femeie de 61 de ani, diagnosticată anterior cu cancer rectal, cu antecedente de 6 luni de hematochezie și alternanta diaree-constipatie. Diagnosticul de cancer rectal a fost pus pe baza biopsiei colonoscopice care a confirmat un nodul circumferenţial neregulat de adenocarcinom bine diferenţiat la 10 cm de marginea anală. Rezecția anterioară joasă asistata robotic, urmata de extracția specimenului transanal a fost efectuată după obținerea consimțământului informat. Procedura a fost efectuată cu succes și pacienta a avut o evolutie postoperatorie fără complicații. Diagnosticul patologic postoperator a evidențiat un adenocarcinom moderat diferențiat de 4x4x0,6 cm3 și margine circumferențiala libera. Concluzii: Rezectia de rect robotica plus extractia transanala a specimenului pentru cancerul rectal poate fi efectuata în siguranță și poate fi o abordare eficientă în contrast cu abordarea deschisă sau laparoscopică.Background: Robotic rectal surgery is currently a novel procedure for rectal cancers. Transanal natural orifice specimen extraction (NOSE) is a novel technique to remove the specimen from the abdominal cavity through the anus instead of an additional incision following laparoscopic or robotic colorectal surgery. The safety of NOSE remains controversial. This study aimed to investigate the early safety of transanal NOSE in the treatment of sigmoid colon and upper rectal cancer from the follow aspects: clinical and pathological characteristics, inflammatory and immune indicators and postoperative complications. Case presentation: A 61-year-old women, previously diagnosed with rectal cancer with came 6 months history of hematochezia and altered bowel habit. A diagnosis of rectal cancer was made in view of colonoscopic biopsy which confirmed an irregular circumferential lump of well differentiated adenocarcinoma at 10 cm from the anal verge. Robotic low anterior resection (LAR) plus transanal natural orifice specimen extraction (NOSE) was performed after obtaining informed consent. The procedure was performed successfully and the patient convalesced nicely without any complications. The postoperative pathological diagnosis revealed a 4x4x0.6 cm3 moderately differentiated adenocarcinoma and circumferential clearance. Conclusions: Robotic LAR plus transanal NOSE for rectal cancer can be performed safely and may be an effective approach in contrast to open or laparoscopic approach

The role of the frozen section examination in the diagnosis of the thyroid nodules

Universitatea de Medicină și Farmacie Victor Babeș Timișoara, România, Al XIII-lea Congres al Asociației Chirurgilor „Nicolae Anestiadi” și al III-lea Congres al Societății de Endoscopie, Chirurgie miniminvazivă și Ultrasonografie ”V.M.Guțu” din Republica MoldovaIntroducere: Diagnosticul diferențial preoperator sau intraoperator între leziunile tiroidiene benigne și maligne este de o importanță majoră pentru decizia chirurgicală intraoperatorie. Acest studiu analizează corelația dintre rezultatul examenului extemporaneu și rezultatul examinării histopatologice la parafină în cazul nodulilor tiroidieni. Material si metode: Acesta a fost un studiu retrospectiv asupra a 330 de cazuri cu patologie tiroidiană, operate în cadrul Clinicii 2 de Chirurgie a Spitalului Clinic Județean de Urgență Timișoara din 2011 până în 2014, la care s-au efectuat atât examen extemporaneu intraoperator (EXT) cât și examen histopatologic la parafină în cadrul Departamentului de Anatomo-patologie al aceluiași spital. Rezultate: Din cele 330 de cazuri studiate, examenul EXT a stabilit diagnosticul în 244 (73,9%) cazuri și la 86 (26.1%) cazuri diagnosticul a fost incert, cu o sensibilitate de 93,33%, specificitate de 95,81%, în timp ce precizia a ajuns la 95,66%. Două sute douazeci și nouă (84,8%) au fost tumori benigne, iar 15 (27,3%) au fost tumori maligne. La examenul histopatologic, din 86 cazuri incerte 51 (59,3%) au fost benigne, 30 (34,8%) maligne și 5 (5,8%) au ramas neclare. Concluzii: Rezultatele noastre cu metoda EXT sunt echivalente cu cele disponibile în literatura de specialitate cu specificitate, sensibilitate si precizie foarte bune. În cazul în care investigațiile preoperatorii evidențiază noduli unilaterali, EXT a fost util pentru decizia intraoperatorie între lobectomie și tiroidectomie totală, evitând lobectomia inutilă sau reintervenția.Introduction: Preoperative or intraoperative differential diagnosis between benign and malignant thyroid lesions is of utmost importance for the surgical intraoperative decision. This study analyses the correlation between the frozen-section result and the result of the histopathologic paraffin examination in cases of thyroid nodules. Material and methods: This was a retrospective study upon 330 cases with thyroid pathology, operated on in the 2nd Surgical Clinic of the Clinical County Emergency Hospital of Timisoara from 2011 to 2014, that had both intraoperative frozen-section (FS) and postoperative paraffin histologic examination performed by the Pathology Department of the same hospital. Results: Of 330 cases studied, FS examination set the diagnosis in 244 (73.9%) cases and no diagnosis (uncertain) in 86 (26.1%), with a sensitivity of 93.33%, specificity of 95.81%, while accuracy reached 95.66%. Two hundred twenty-nine (84.8%) were benign tumors and 15(27.3%) were malignant tumors. At the histopathologic examination, from 86 uncertain cases 51 (59.3%) were benign, 30(34.8%) malignant and 5 (5.8%) remained unclear. Conclusions: Our results with FS method are equivalent to those available in the literature with very good specificity, sensitivity and accuracy. In cases in which the preoperative investigations show unilateral nodules, FS was still useful for the intraoperative decision between lobectomy and total thyroidectomy, avoiding inutile lobectomy or reoperation

Trends in pediatric epilepsy surgery in Europe between 2008 and 2015: Country‐, center‐, and age‐specific variation

OBJECTIVE: To profile European trends in pediatric epilepsy surgery (<16 years of age) between 2008 and 2015. METHODS: We collected information on volumes and types of surgery, pathology, and seizure outcome from 20 recognized epilepsy surgery reference centers in 10 European countries. RESULTS: We analyzed retrospective aggregate data on 1859 operations. The proportion of surgeries significantly increased over time (P < .0001). Engel class I outcome was achieved in 69.3% of children, with no significant improvement between 2008 and 2015. The proportion of histopathological findings consistent with glial scars significantly increased between the ages of 7 and 16 years (P for trend = .0033), whereas that of the remaining pathologies did not vary across ages. A significant increase in unilobar extratemporal surgeries (P for trend = .0047) and a significant decrease in unilobar temporal surgeries (P for trend = .0030) were observed between 2008 and 2015. Conversely, the proportion of multilobar surgeries and unrevealing magnetic resonance imaging cases remained unchanged. Invasive investigations significantly increased, especially stereo‐electroencephalography. We found different trends comparing centers starting their activity in the 1990s to those whose programs were developed in the past decade. Multivariate analysis revealed a significant variability of the proportion of the different pathologies and surgical approaches across countries, centers, and age groups between 2008 and 2015. SIGNIFICANCE: Between 2008 and 2015, we observed a significant increase in the volume of pediatric epilepsy surgeries, stability in the proportion of Engel class I outcomes, and a modest increment in complexity of the procedures

The phenotypic spectrum of WWOX -related disorders: 20 additional cases of WOREE syndrome and review of the literature

Purpose: Germline WWOX pathogenic variants have been associated with disorder of sex differentiation (DSD), spinocerebellar ataxia (SCA), and WWOX-related epileptic encephalopathy (WOREE syndrome). We review clinical and molecular data on WWOX-related disorders, further describing WOREE syndrome and phenotype/genotype correlations. Methods: We report clinical and molecular findings in 20 additional patients from 18 unrelated families with WOREE syndrome and biallelic pathogenic variants in the WWOX gene. Different molecular screening approaches were used (quantitative polymerase chain reaction/multiplex ligation-dependent probe amplification [qPCR/MLPA], array comparative genomic hybridization [array-CGH], Sanger sequencing, epilepsy gene panel, exome sequencing). Results: Two copy-number variations (CNVs) or two single-nucleotide variations (SNVs) were found respectively in four and nine families, with compound heterozygosity for one SNV and one CNV in five families. Eight novel missense pathogenic variants have been described. By aggregating our patients with all cases reported in the literature, 37 patients from 27 families with WOREE syndrome are known. This review suggests WOREE syndrome is a very severe epileptic encephalopathy characterized by absence of language development and acquisition of walking, early-onset drug-resistant seizures, ophthalmological involvement, and a high likelihood of premature death. The most severe clinical presentation seems to be associated with null genotypes. Conclusion: Germline pathogenic variants in WWOX are clearly associated with a severe early-onset epileptic encephalopathy. We report here the largest cohort of individuals with WOREE syndrome

Technical Design Report for the: PANDA Micro Vertex Detector

This document illustrates the technical layout and the expected performance of the Micro Vertex Detector (MVD) of the PANDA experiment. The MVD will detect charged particles as close as possible to the interaction zone. Design criteria and the optimisation process as well as the technical solutions chosen are discussed and the results of this process are subjected to extensive Monte Carlo physics studies. The route towards realisation of the detector is outlined.Comment: 189 pages, 225 figures, 41 table

Hungry Bone Syndrome after parathyroidectomy in dialysis patients with secondary Hyperparathyroidism

Universitatea de Medicină și Farmacie Victor Babeș Timișoara, România, Al XIII-lea Congres al Asociației Chirurgilor „Nicolae Anestiadi” și al III-lea Congres al Societății de Endoscopie, Chirurgie miniminvazivă și Ultrasonografie ”V.M.Guțu” din Republica MoldovaIntroducere: Hiperparatiroidismul secundar (HPTS) s-ar putea dezvolta la aproape toți pacientii cu boala renală cronică în stadiu final (BRSF). O opțiune pentru tratamentul acestor pacienți este paratiroidectomia (PTX). Scopul acestui studiu este identificarea factorilor de risc pentru Hungry Bone Syndrome (HBS) la o cohortă de pacienți cu BRSF care au suferit PTX. Material si metode: Este un studiu retrospectiv pe 80 pacienți BRSF, la care s-a practicat PTX pentru HPTS în Clinica 2 Chirurgie a Spitalului Clinic Județean de Urgență Timișoara, pe perioada Ianuarie 2013 și Decembrie 2017. Indicația pentru PTX a fost HPTS refractară la tratamentul medicamentos sau complicațiile HPTS. Rezultate: HBS a aparut la 36 de pacienți, care au fost dializați pe perioada cuprinsă între șase luni și 14 ani, mediană de 7,2 ani. Preoperator valoarile PTH-ului au fost comparabile între cele două grupuri HBS + 1831pg/ml vs HBS-1880pg/ml. Vârsta a fost HBS +: HBS-52,4: 54. PTX subtotală (două glande) a fost efectuată în 18 cazuri, PTX subtotală 3½ glande a fost efectuat în 25, în timp ce PTX total în 37. Timectomia s-a efectuat la 19 cazuri. Hipocalcemia a aparut după 19,9 ore postoperator. Postoperator valoarea PTH-ului a arătat diferențe foarte mici între 72pg/ml și 87,1pg/ml. Singurii factori de risc pentru HBS s-au dovedit: vârsta mai mică (p = 0,038), prezența osteoporozei avansate (p = 0,017) și post-operator PTH (p = 0,005). Concluzii: HBS este un efect advers obisnuit, dificil predictibil, varsta mai mica, prezenta osteoporozei inainte de operatie. Nivelurile PTH-ului post-operator par sã favorizeze aparitia acesteia.Introduction: Secondary hyperparathyroidism (SHPT) was found to be a common complication of chronic kidney disease (CKD). Nearly all patients with end-stage renal disease (ESRD) might ultimately develop SHPT. In these cases which don’t respond to medical therapy, one option of treatment is parathyroidectomy (PTX). Our study aims to identify the risk factors for HBS in a cohort of ESRD patients which underwent PTX. Material and methods: This was a retrospective study on 80 ESRD parathyroidectomised patients for SHPT in Timisoara County Emergency Hospital between January 2013 and December 2017. Indication for parathyroidectomy was SHPT refractory to medical treatment or complications of SHPT. Results: HBS occurred in 36 dialyzed patients (ranging from half to 14 years, median 7.2 years). Pre-operative levels of PTH were comparable between the two groups HBS+ 1831 vs HBS- 1880. Mean age was 52.4 for HBS+ vs 54 for HBS-. Subtotal PTX (two glands) was performed in 18 cases, subtotal PTX 3 ½ glands was performed in 25, whereas total PTX in 37. Timectomy was performed in 19 cases. Hypocalcemia occurred after 19.9 hours post-operatively. PTH postoperative determination showed very small differences 72 pg/ml vs 87.1 pg/ml. The only risk factors for HBS were found to be younger age (p=0.038), the presence of advanced osteoporosis (p=0.017) and post-operator PTH (p=0.005). Conclusions: HBS is a common adverse effect. Younger age, osteoporosis presence before surgery and post-operative levels of PTH seem to favor its appearance. The magnitude of surgery does not influence the occurrence of HBS