Journal of Surgery

Background: Abdominal hyperalgic syndrome in unresectable pancreatic cancer worsens the quality of patients' life. The goal of this article is to evaluate the feasibility of performing the left splanchnicectomy using a two trocar thoracoscopic approach.

Material and Methods: One patient suffering from intractable pain due to unresectable pancreatic cancer (stage IV) with liver metastasis underwent thoracoscopic unilateral left splanchnicectomy. The procedure was performed using only two trocars, one of 10 mm for the optic and one 5 mm working trocar for Hook electrocautery, scissors and grasper. To assess pain severity and the impact of this palliative procedure for pain relief, the patient completed Wong-Baker Faces Pain Rating Scale with a preoperative pain degree of 9.

Results: Surgical procedure time was 30 minutes. Pleural drainage tube was removed 24 hours postoperatively. There were no complications. Immediate pain relief (pain degree 0 to 2) was achieved after thoracoscopic unilateral splanchnicectomy, same level beeing registered at first checkup after one month.

Conclusions: Thoracoscopic unilateral left splanchnicectomy using two trocars is feasible in selected cases, decreasing substantial the pain and significantly improving the quality of life in patients with unresectable pancreatic cancer.

Cushing Syndrome (CS) is a chronic condition due to sustained exposure to glucocorticoid excess. Most frequent clinical manifestations are obesity, “moon face”, muscle weakness, osteoporosis, menstrual irregularities, high blood pressure, diabetes. Sometimes the signs and symptoms are overt (subclinical Cushing Syndrome). The most frequent tests used are 24 hours urinary free cortisol, dexamethasone suppression tests, plasma ACTH levels as well as CT/ MRI to localize the adrenal tumor. The surgical treatment is adrenalectomy. This video present a left laparoscopic adrenalectomy for a CS secondary to a left adrenal adenoma. The patient is placed in a right lateral position. Operative steps are: mobilization of the left colon, mobilization of the spleen and tail of the pancreas by dividing the splenoparietal ligament, division of the splenorenal ligament, identification of the adrenal vessels, dissection of the adrenal gland (starting medial, continuing posterior and ending lateral on the surface of the kidney) and extraction of the specimen in an endobag. Postoperative follow-up was uneventful. CONCLUSION: In our opinion laparoscopic adrenalectomy is the gold standard procedure for adrenal CS.

Background: Abdominal hyperalgic syndrome in unresectable pancreatic cancer worsens the quality of patients' life. The goal of this article is to evaluate the feasibility of performing the left splanchnicectomy using a two trocar thoracoscopic approach.

Material and Methods: One patient suffering from intractable pain due to unresectable pancreatic cancer (stage IV) with liver metastasis underwent thoracoscopic unilateral left splanchnicectomy. The procedure was performed using only two trocars, one of 10 mm for the optic and one 5 mm working trocar for Hook electrocautery, scissors and grasper. To assess pain severity and the impact of this palliative procedure for pain relief, the patient completed Wong-Baker Faces Pain Rating Scale with a preoperative pain degree of 9.

Results: Surgical procedure time was 30 minutes. Pleural drainage tube was removed 24 hours postoperatively. There were no complications. Immediate pain relief (pain degree 0 to 2) was achieved after thoracoscopic unilateral splanchnicectomy, same level beeing registered at first checkup after one month.

Conclusions: Thoracoscopic unilateral left splanchnicectomy using two trocars is feasible in selected cases, decreasing substantial the pain and significantly improving the quality of life in patients with unresectable pancreatic cancer.

Entero-vesical fistulae (EVf) occurs rarely but it is a serious clinical condition often correlated with other pathologies. It accounts for 1 to 3000 hospital accesses/year. We present a patient with a sigmoid-vesical fistulae caused by the accidental ingestion of a wood skewer two years before. In literature about 6,09 % of accesses in the first aid area(FAa) are due to the ingestion of foreign bodies(FBs) but in 80-90% of them they are expelled with stools. In frequently FBs in the lower gastrointestinal tract can be the result of an orally ingested sharp object that becomes impacted. The management of this case was multidisciplinary, and the correction was a laparoscopic one time approach.

Airway obstruction and superior vena cava syndrome (SVC) secondary to huge retrosternal goiter are medical emergencies which need meticulous attention to prevent potentially life threatening events. We reported a case of huge retrosternal goiter which was neglected for years and later complicated by obstruction to airway and superior vena cava. Team effort which mainly involved endocrine surgeon, cardiothoracic surgeon and anaesthetist had successfully removed the gland without significa t morbidity. He was on tracheostomy due to tracheomalacia and was managed by ENT surgeon. He was discharged well after 2 weeks.

Aim: A tension haemothorax is an uncommon injury after penetrating chest trauma.

Introduction: Anterior thoracic penetrating injuries may result in life-threatening complications. One of these is massive tension haemothorax with pericardial tamponade as a result of stab wounds to the internal mammary artery.

Presentation of a Case: We present a case in which a 55 year old man sustained multiple thoracic stab wounds. He had emergency right antero-lateral thoracotomy and laparotomy. A massive haemothorax secondary to complete disruption of right internal mammary artery and a laceration to middle lobe of right lung was noticed.

Conclusion: Penetrating thoracic injury with isolated internal mammary injury is a very rare cause of massive haemothorax and associated with high mortality. Emergent thoracotomy can be life-saving for these patients.

Although there is a complete anatomical separation between urinary and digestive tract, in certain pathological conditions, the direct proximity between the bladder and the sigmoid colon allows the development of entero-vesical fistulas. Colic diverticulosis is the second leading cause of entero-vesical fistulas, after malignancy. Usually, the enterovesical fistula is unique, on a single bowel segment; rarely is multiple, involving different intestinal segments. We present the case of a 41 years old man, with a double fistula: sigmoido-vesical and recto-vesical, respectively. The diagnosis was challenging despite the clinical aspect included pneumaturia and fecaluria. A particular symptom was sexual dysfunction. CT scan and a pelvic MRI revealed the two fistula colo-vesical and recto-vesical. A recto-sigmoid resection with subperitoneal colo-rectal anastomosis and partial cystectomy were performed with uneventful postoperative recovery.

Conclusion: The multiple entero-vesical fistulas developed on a single intestinal segment are extremely rare, and, to our knowledge this is the only case reported in the literature. The management is challenging, and in our opinion the resection with anastomosis and partial cystectomy is the best choice.

Pheochromocytoma and paraganglioma are catecholamine secreting tumors. Malignancy is uncommon - approximately 10% for pheochromocytoma and 20% for paraganglyoma. Surgery, when possible, is the first line treatment. Prognosis is poor because of a frequent local recurrence and/or metastases and the lack of specific chemotherapeutic agents. We report the case of a 60 years old man who was hospitalized at the age of 48 for episodes of paroxystic hypertension with spells. The high levels of vanillylmandelic acid (VMA), more than 50 mg/24h at 3 determinations, confirmed the excess of catecholamine, but the CT scan failed to reveal the tumor. The iodine-131- meta-iodobenzylguanidine (I-MIBG) scintigraphy showed the presence of a 1.5 cm nodule in the left abdominal paraaortic region. The patient refused surgery and had a satisfactory evolution with antihypertensive therapy. 11 years later he was admitted in the Vascular Surgery Department for acute ischemia of inferior limbs; a voluminous para-aortic tumor was diagnosed and resected. The pathology confirmed paraganglioma and described some atypical cells without being able to discriminate between benign or malignant pattern. Anamnesis could not identify any other case in the family. After another year he was admitted in the Endocrine Department for the reappearance of the adrenergic syndrome, with VMA at 30.8 mg/24h. The thoracic and abdominal CT-scan showed abdominal and thoracic metastatic tumors. The patient was referred to a specialized center were octeotride scintigraphy confirmed local recurrence and metastatic tumors in the lungs. He was treated with Sunitinib with a good initial response and he died after 16 years from the initial diagnostic of paraganglioma.

Introduction: The term “damage control surgery” or “laparotomie écourtée” is not a new concept, but a recent paradigm in the surgery of abdominal trauma, when the ability to maintain homeostasis is impaired due to severe hemorrhage. It can be defined as a surgical method that prevents the trauma triad of death by hemorrhage control and the prevention of peritoneal contamination, while time is an essential factor. Damage control surgery is followed by vigorous resuscitation and definitive reconstruction. The concept of "damage - control” is less reflected in the literature related to surgical oncology.

Case Presentation: A 45-year-old patient, BMI 35, presented to the Emergency Services of the Regional Hospital with abundant hematemesis and shock. The patient had been previously diagnosed with adenocarcinoma of the gastroesophageal junction subsequent to CT scan and endoscopic evaluation and was under the way to complete surgical - oncological balance with scheduled neoadjuvant chemotherapy due to the size and extension of the tumor. Emergency gastroscopy revealed an accumulation of blood in the stomach with ongoing massive hemorrhage while emergency CT scan revealed left hemopneumothorax and hemoperitoneum. Due to the hemorrhagic shock caused by hemodynamic collapse, the patient was performed emergency damage control esophagogastrectomy in the same block with the esophageal hiatus and liver segment 2. Thus the greater curvature of the stomach was preserved, stapled, as well as the intrathoracic esophageal stump and jejunostomy for alimentation were performed. During evolution, several interventions were performed sequentially: hemostasis by packing for hemorrhage control in the hiatal area (day 0), depacking (day 3), left pleural drainage (day 5), left cervicostomy for salivary drainage (day 8), right transthoracic esophagogastric anastomoses by using the Ivor-Lewis technique (day 63) and esophagogastric stenting for the treatment of anastomotic fistula (day 71).

Results: Final evolution after three months of hospitalization, seven surgical interventions, more than 20 units of transfusion, is favorable. The jejunostomy tube was removed on day 95, after resuming in advance oral nutrition in parallel with enteral feeding, cervicotomy closed spontaneously. The esophageal stent was removed 6 months after placement. The pathological examination revealed a G3 poorly differentiated intestinal-type gastric adenocarcinoma (Lauren classification), which infiltrated the last 4 cm of the esophagus and 6 cm of the superior gastric pole towards the lesser curvature of the stomach (pT4N2M0). The patient underwent 6 cycles of adjuvant chemotherapy with DCF, 1 year and 6 months postoperatively becoming disease free and fully reintegrated from the social-professional point of view.

Conclusion: The presented case is a “damage control” type model approach in an imminent life-threatening situation, which successfully implements the principles of traumatology in case of a complex oncology situation and also a multidisciplinary model of approach and collaboration between multiple hospital units for saving a young cancer patient’s life.

Portal vein thrombosis is an unusual complication of acute pancreatitis. It occurs in some cases of severe acute pancreatitis particularly those associated with pancreatic necrosis. A review of relevant literature suggests a role of anticoagulants in such cases but further studies are needed to establish the advantage of such therapy conclusively. We present a case of acute necrotizing pancreatitis complicated by portal and splenic vein thrombosis managed with anticoagulants. This resulted in recovery without development of portal hypertension and its complications.

Introduction: Electrogalvanic stimulation (EGS) has been established as a safe and effective treatment for the management of levator ani syndrome (LAS). There is a paucity of recent literature regarding this treatment modality. The purpose of this study is to review recent experience with EGS in the treatment of levator ani syndrome at a single center.

Methods: A retrospective review of 22 patients treated with EGS for LAS from 07/04 to 08/08 was done. The EGS protocol begins with 30 minute sessions. Voltage is adjusted based on patient tolerance (range 100-330 volts) and is delivered at a frequency of 100 pulses per sec (pps). Length of treatment is gradually increased with increasing patient tolerance, from 30 to 60 min. Each session starts with minimal voltage and is slowly increased to maximum tolerance, held for 15-20 minutes, then intensity is gradually reduced from the peak of 100-330 volts to a minimum of 10-100 volts. Most patients were treated three times weekly for two weeks (average, six treatments per patients). The mean number of sessions was 7.5 (range 2-15). The average of duration of each session was 29 minutes for the initial visit and 46 minutes for the concluding visit. The intensity was 70% at initial visit, and 88% by the last treatment (330 volts=100%).

Results: Twenty two patients were treated (72% males). The mean age was 56 years. The mean duration of symptoms was 60 months (range 3-240). 41 percent of patients had additional anorectal pathology. Over 60% of patients were taking muscle relaxants and/or analgesics. In this cohort, 59% of patients had previous treatment, including biofeedback (32%), botox injection (14%) and epidural injection (14%). Patient assessment of results at the last treatment session: complete relief or significant improvement in 8 patients (36%); moderate improvement in 2 (9%); slight improvement in 7 (32%); and no improvement or worsening of pain in 5 patients (23%). The mean follow up was 11 months (range 0.4-38). There were no complications associated with the EGS. Both multiple linear regression and logistic regression showed the same results. The outcome of patients with levator ani syndrome treated with EGS is related to the number of treatment sessions and history of previous treatments (of any sort).

Conclusions: EGS is an effective treatment option in a selected group of patients with LAS. It offers significant to moderate improvement in 45% of patients with essentially no risk. Due to its safety profile and moderate efficacy, it should continue to be considered as a treatment operation for levator ani syndrome.

Background: Gastrointestinal stromal tumors (GIST) are the most common mesenchymal neoplasms of the digestive system. They originate from the interstitial cells of Cajal and are characterized by the over expression of KIT protein (Tyrosine Kinase), and they pose a diagnostic and therapeutic dilemma.

Objective: A challenge in diagnosis and treatment of GIST

Patients & Methods: This is a retrospective study of GIST cases that diagnosed and treated in our center during the past 5 years. These studies include clinical characteristics, imaging techniques, neoadjuvant therapy, surgical techniques, immunohistochemistry, and prognosis of such cases. Results: Sixteen patients were diagnosed as having GIST (12 males/4 females) with a mean age 62 years (31-83 years). Diagnosis was made preoperatively in 11 patients (69%) and intraoperatively with histopatholgical confirmation in five patients (31%). The site of the tumor was detected in the stomach in 6 cases (37.5%), one in duodenum (6.25%), five in small intestine (31.25%), one in mesentery (6.25%), two in colon (12.5%) and one rectal GIST (6.25%). The main presentation of the disease was anemia, GIT bleeding and abdominal mass. Fourteen patients considered resectable and they were operated upon (87.5%) and in two patients (12.5%) neadjuvant therapy was started with favorable response in one case and poor response in other one with advanced GIST. All patients received Imatinib as adjuvant therapy. Mean follow up period was 33 months (4-54 months).

Conclusion: GIST is a complex and challenging disease that requires a multidisciplinary approach in specililized center for better prognosis of such disease.

Background: The two most commonly employed options for esophageal reconstruction are the posterior mediastinal route and the substernal route. Therefore, the biggest disadvantage of the retrosternal approach is the potential risk for compression of the graft at the site of the thoracic inlet. The purpose of this study is to report our results by analysing the impact of the enlargement of the thoracic inlet by removing the left half of manubrium and internal third of clavicle on the cervical anastomotic leakage.

Methods: From 2005 to 2013, 82 left colonic interpositions for oesophageal caustic stricture were performed at our institution. There were 70 women and 12 men. Ten patients had a hypopharyngeal stricture that required also reconstructive surgery. Dilation was done in 56 patients.

Results: An esophagocolic anastomosis was performed in 72 patients. A gastroenteroanastomosis was performed before reconstruction in 10 patients. A pharyngoplasty was associated in 10 patients. The thoracic inlet was enlarged in 35 patients .The colonic graft was anastomosed to the posterior surface of the stomach in 69 patients. The mortality rate was 2.43 %. Graft necrosis occurred in two patients. Cervical leakage was occurred in 25 patients. Eight patients developed a cervical structure. Statistical analysis revealed that the non-enlargement of the thoracic inlet was a predictive factor of cervical leak (OR; 3.63, CI; 1.06 -12.40, P= 0.039 ) .therefore the enlargement is associate with lower rate of cervical leak. The functional results were good.

Conclusion: The non-enlargement of the thoracic inlet is a predisposing factor of cervical leak in substernal colonic interposition. Therefore the enlargement seems reduce the cervical leakage

Background: Paravertebral block (PVB) was shown to reduce postoperative pain and postoperative nausea and vomiting for breast surgery. However, there is no evidence showing that these benefits were solely provided by PVB and positively influence patient-perceived outcomes after breast cancer surgery.

Methods: One hundred breast cancer patients were randomized into three groups: general anesthesia (GA, n=34), GA with PVB (GA+ PVB, n=33), PVB with sedation (PVB, n=33). The quality of recovery (QoR) score was assessed preoperatively as baseline, 6 hours postoperatively, and on postoperative day (POD) 1. Analgesia effects, adverse events, and perioperative satisfactions were also assessed.

Results: The rate of QoR 6 hours reaching 18 in GA group (25.53%) seemed to be lower compared with GA+PVB (30.3%) or PVB (42.42%) but without statistical significance. Nevertheless, multivariate logistic regression analysis demonstrated that modality of PVB affected QoR 6 hours (p=0.04). Analgesic consumptions and pain scores were significantly higher and time to first request of analgesics shorter in GA group. The incidences of the GA-related undesired effects were significantly lower and satisfaction with emergence significantly better (P < 0.0001) in PVB group when compared with GA group. There was no difference between GA and GA+PVB in these outcomes.

Conclusions: Anesthesia modalities containing PVB provided better pain control. Anesthesia modalities avoiding GA, i.e. PVB alone, led to significantly lower incidences of GA-related adverse events, significantly better satisfaction with the process of emergence, and contribution to QoR 6hours reaching 18.

Most common manifestation of tumor metastasis after lungs and liver is the skeletal system with 60-80% of spine metastasis. In 30% of all cancer patients with metastatic spinal complaints are initial presentation of malignant primary disease while the primary paraplegia occurs in 5-10% of all spinal metastases. Thus a further operational metastases treatment is dependent on the entire metastasis status, the type and Tomita score as well as the risk of surgery considering general patient status. From 01.01.11 to 31.12.12 we included 16 patients with tumors. In 27% of the cases the first symptoms were paraplegia, but the primary tumor was determined in only one of these cases. 73% of patients underwent surgical treatment within the first 24 hours after admission. The hospital stay was 22 days. 56.3% of patients had incomplete paralysis at admission and 71% of these patients had postoperative improvement in neurological outcomes. All patients benefited as part of operational and rehabilitative treatment of a significant reduction in pain and 50% of patients were able to be discharged home. At the onset of paralytic symptoms we recommend immediate operation. In a multidisciplinary case conference the oncological treatment regimens should be defined also for the necessary paralysis treatment. Decision guidance is the height of paralysis, tumorgenesis, ASA classification and the pain symptoms of the patient. The treatment must adjusted and individualized according to the patient's general health, life expectancy, the primary tumor, the grading of metastasis and extent of neurological deficit.

Introduction: Plasma cell mastitis is a rare chronic inflammatory disease of the breast. Its cause and treatment have not yet been clearly identified. The aim of the study is to present the author's experience with various treatment methods applied on this disease.

Materials and Methods: We retrospectively analyzed the clinical findings, biological tests, imagistic results, therapeutic approach and the pathological response from 25 patients diagnosed with plasma cells mastitis between 2005 and 2013.

Results:  Only 7 cases underwent from the beginning to wide surgical excision of the inflammatory mass with favorable evolution. The rest of the patients, treated with antibiotherapy, corticotherapy or surgical drainage of the collections (when needed) presented early relapse that required surgical treatment: large excision to subcutaneous mastectomy.

Conclusion: Surgical treatment represented by wide excision going up to subcutaneous mastectomy is the most effective therapeutic method for this benign, but with high relapsing potential, disease. It also has the advantage of giving a more accurate positive and differential diagnosis, most important with breast carcinoma.

Introduction: Bilateral adnexectomy is a surgical procedure that is frequently associated with total hysterectomy performed for benign uterine conditions. Given the relatively wide range of indications for the aforementioned type of salpingo-ooforectomy which in it self is not devoid of potential risks the patients' and physicians' decision-making should take into account several parameters (most helpful to individualize treatment) such as published ratio of removal versus conservation of uterine adnexae, patients' age, pre/postmenopausal status at the time of surgery, relevant family and personal history including current use of hormonal replacement therapy.

Materials and Methods: This retrospective cohort study was conducted among 457 women aged 18 years or older who underwent abdominal total hysterectomies for benign uterine conditions between 2000 and 2011. The study patients were stratified by age for better characterization and according to recent publications.

Results: Uni- or bilateral oophorectomy was performed in 50% of the subgroup of hysterectomized women younger than 35 years old whereas in the other half of the same age category of patients the uterine adnexas were conserved. Among the study patients aged between 35 and 45 years in 50.5% of the cases the unilateral type of oophorectomy was undertaken while for the other 49.5% of women the bilateral adnexectomy was the rule. Finally, in all patients older than age 45 years the bilateral salpingo-oophorectomy was the procedure of choice. Moreover, out of the 55 study patients in which at least one ovary was preserved, 30.9% of cases underwent the removal of the remaining adnexa when affected de novo by malignant (n=3) or benign (n=14) pathology. Last but not least, in order to reduce both cancer risks and early menopause hazards, our analysis based on recent literature attempted to identify patient characteristics (relevant factors) associated with or without bilateral oophorectomy at the time of benign hysterectomy and to estimate modern trends in the performance of oophorectomy.

Conclusion: When considering options for treatment of benign conditions of the uterus both physicians and patients should ponder carefully the risk/benefit ratio of salpingo-oophorectomy according to each patient clinical profile.

Background: Routine resection of falciform ligament and ligamentum teres hepatis (FL-LTH) during cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS+HIPEC) has been advocated but may be associated with increased complications. We aimed to study the role of FL-LTH resection at the time of CRS+HIPEC.

Methods: Retrospective review of patients who underwent CRS+HIPEC from January, 2010 to April, 2013 was conducted. Non-parametric methods were used for analyses.

Results: CRS-HIPEC was performed in 71 patients (FL-LTH resection in 57, 80.2%). The sensitivity and specificity of visual examination were calculated as 97.4% and 75.0%, respectively. Visual examination falsely classified 1/33 cases as disease free (3.0% False-negative, pathology showed carcinomatosis) and 6/24 as diseased (25% False-positive, pathology showed fibroadipose tissue). False-positive resection was not associated with increased complications (0/6). The recurrence in porta-hepatis (of n=48 with CC0 cytoreduction) was lower in the resected group (3/41, 7.3%) vs. nonresected (2/7, 28.6%), and associated with a hazard-ratio of 0.17 (95% CI 0.02 – 1.20, p-value 0.07) at a median 11 (IQR 7.0 – 16.7) months follow-up.

Conclusions: Visual examination during CRS+HIPEC may miss disease at the falciform ligament. A policy of routine resection is not associated with increased complications and should be considered.

Background: Compartment syndrome (CS) remains an elusive diagnosis with limited awareness despite progress of glorious investigative, diagnostic and imaging modalities. This review aims to reiterate the surgical fraternity to the fragility one faces with the concept of CS.

Methods: A retrospective desk review of published literature has been undertaken through the review of PubMed, Cochrane Library, Medline, EMBASE and Web of Science databases to portray the spectrum of presentation with involvement of rare sites in CS that have the capacity to stupefy the surgical fraternity.

Results: 18 articles and book chapters were reviewed from the search chain of over 200 articles. Through literature review it is appreciated that the sites of involvement with CS are varied and can encompass regions that are once thought unlikely. There is great degree of variance in the incidence of this syndrome. Though the implications are grave, the diagnosis of the syndrome is complex given the presentation spectrum.

Conclusion: Despite its immemorial descriptions and characterization as a surgical emergency, compartment syndrome remains an elusive diagnosis given its lack of awareness and wide presentation profile.

Colon cancer is a major public health problem. The treatment of colon cancer is primarily surgical using open and minimally invasive techniques. Minimally invasive surgery approaches for colon cancer include single-port laparoscopy, natural orifice transluminal endoscopic surgery, and robotic-assisted laparoscopic surgery. The techniques are based on the same principles: complete mesocolic excision, high vascular ligation, and extended lymphadenectomy. Laparoscopic surgery is characterized by short hospital stay, reduced postoperative pain, and less need for painkillers. Laparoscopic resections are less expensive than open surgery, but with similar quality of life outcomes. Robotic surgery is an alternative to open and laparoscopic techniques. This type of surgery results in a lower conversion rate and a shorter learning curve than laparoscopic surgery. When comparing the clinical outcomes of laparoscopic surgery versus open surgery no difference in disease free survival and overall survival were found. This article shows the role of minimally invasive surgery in colon cancer, the clinical outcomes of laparoscopic and open colon being similar.

Gallstone disease is the most common gastrointestinal disorder. The best epidemiological screening method to accurately determine the prevalence of gallstone disease is ultrasonography. Gallstone disease is considered a surgical disease since only cholecystectomy is capable of definitively curing the disease. Cholecystectomy is a limited indicator for the prevalence of gallbladder stones, as the perceived threshold for surgery and patient access to care differ markedly. Most patients with gallstones are asymptomatic and the risk of developing symptoms or complications related to gallstones is approximately 1-4% per year. The common complications of gallstones include biliary colic, acute cholecystitis, common bile duct stones, and gallstone pancreatitis. Although this disease has a low mortality rate, its economic and health impact is significant due to its high morbidity. Many risk factors for gallstone formation are not modifiable such as ethnic background, increasing age, female gender and family history or genetics. Conversely, the modifiable risks for gallstones are obesity, rapid weight loss and a sedentary lifestyle. The recognized risk factors of gallbladder stones for females cannot be extrapolated to men, and this demonstrates the polymorphic character of the etiopathogeny of cholelithiasis and requires further specification. Therefore, there is need for more knowledge of the epidemiological characteristics of gallstone disease in order to better identify therapeutic strategies.

The anatomy of the thoracic lymphatic system is very complex and not completely known yet. Thoracic malignancies, especially lung and esophageal cancers, are rapidly increasing as incidence. A good knowledge of the thoracic lymphatic system is very important in staging, diagnosis and treatment of these malignancies. The complete lymphadenectomy has a crucial role in both to achieve a correct postoperative stage and a complete resection of pathologic tissue. The article is a glimpse on the lymphatic anatomy of the thorax, as it should be known by surgeons involved in thoracic oncology.