[The management of acute pancreatitis according to the modern guidelines]. / Managementul pancreatitei acute conform ghidurilor terapeutice actuale.

Severe acute pancreatitis is a critical illness as the organism that produces a significant mortality despite diagnostic and therapeutic acquisitions. While new mechanisms have been identified for production and were crystallized management principles, a number of controversies remain awaiting resolution in the near future. Aim is to establish, based on their experience and literature data, place the current means of diagnosis and treatment in close correlation with the pathophysiological events of acute pancreatitis.

[Interleukin 17--prognostic marker of severe acute pancreatitis]. / Interleukina 17--marker prognostic al pancreatitei acute severe.

OBJECTIVE: The evaluation of the interleukin 17 capacity as precociously predictive marker of the severe forms of acute pancreatitis. MATERIAL AND METHOD: This prospective and diagnosis study took place during 01.01.2006-31.03.2008 on a sample of 83 subjects hospitalized with acute pancreatitis. Among these, 48 have submitted forms mild disease and formed batch A. Subjects with severe acute pancreatitis formed batch B (n=16), to whom it was applied peritoneal lavage extended by laparoscopic method and batch C (n=19), who have used conventional methods of treatment. Were determined serum concentrations of interleukin 17 in the first and tenth days of admission for the subjects of A and C lots and in the first, third and tenth day at then subjects of B lot, they were dosage and levels peritoneal or lavage fluid in the third, sixth and tenth days of admission. At the same time were determined interleukin 6 levels. RESULTS: Interleukin 17 has proved a sensitivity of 97% and a specificity of 94% in early identification forms of severe acute pancreatitis, the correlation coefficient is 0.81. The correlation was good even in combination with organic disfunction (0.66) and the risk of death (0.54). The predictive capacity of sepsis has been reduced (0.44). The dynamics of this cytokines show a significant decrease in concentrations forms mild disease (batch A) and in severe forms treated with peritoneal extended lavage (lot B). In conversely, the subjects treated by conventional methods (lot C) the decrease was not significant between the first and tenth days of admission. A similar dynamic has been recorded after short peritoneal lavage, lasting three days. At large in, the concentrations of interleukin 17 have evolved in parallel with those of interleukin 6. CONCLUSIONS: Interleukin 17 is an important predictive marker of early forms of severe acute pancreatitis. Also, serum concentrations are correlated with the risk of organic disfunction development and the fatal evolution. The dynamics of this cytokine is depending on the therapeutic measures that attenuates the body's inflammatory response.

[Early and prolonged peritoneal lavage with laparoscopy in severe acute pancreatitis]. / Lavajul peritoneal precoce si prelungit prin abord laparoscopic în pancreatita acuta severa.

OBJECTIVE: The evaluation of precocious and prolonged lavage and drainage by laparoscopic approach in the treatment of severe acute pancreatitis. MATERIAL AND METHOD: This therapeutic prospective study was conducted during 01.01.2006-31.03.2008 on a sample consisting of 35 subjects with the severe acute pancreatitis has been divided into two lots. A lot is formed by 16 patients whom were applied the method mentioned ahead and in the B lot--19 patients, treated by conventional and known methods of treatment. The method proposed, completed about laparoscopic approach in a third day of admission, consists, after setting lesional balance, in lavage of peritoneal space and mounting two tubes drainage, one subhepatic space and the other in Douglas space. Post operator for 7 days performed peritoneal lavage discontinuous with physiological serum. For an accurate assessment may were determined serum and peritoneal concentrations of interleukin 6. RESULTS: The duration of organic disfunction was 8 days for A lot subjects and 17,7 days for B lot subjects. The complications occurred and the needs of surgical treatment was net disadvantage at the patients treated conventionally. The mortality at A lot was 12.5% (n=2) and at lot B 36.8% (n=7). The tardive mortality by sepsis was null at subjects with lavage and was 15,8% (n=3) at subjects without lavage. The precocious mortality was 12,5% (n=2) in the A lot and 21% (n=4) in the lot B. The average hospitalization was 25,8 days in subjects with peritoneal lavage and 35,8 days in those treated conservatively, the difference is statistically significant. The method has proved not generating of morbidity and supplementary mortality. Study of the variation of serum and peritoneal concentrations of interleukin 6 shows the modulator effect of the peritoneal lavage early and prolonged of the inflammatory response and offers an argument of the inefficiency of short peritoneal lavage. CONCLUSIONS: The data obtained indicate early and extended peritoneal lavage by laparoscopic method as a useful therapy in the management of severe acute pancreatitis.

[Hyperhomocysteinemia, risk factor in deep venous thrombosis: a case-control study]. / Hiperhomocisteinemia--factor de risc în trombozele venoase profunde. Un studiu de tip case-control.

UNLABELLED: Hyperhomocysteinemia, an established cardiovascular risk factor, has been recently associated with deep venous thrombosis. MATERIAL AND METHOD: A matched case-control study was designed to assess homocysteinemia as well as the acquired risk factors in deep venous thrombosis (DVT). We enrolled 227 subjects, 127 with DVT confirmed by Doppler ultrasonography and 100 controls. Homocysteinemia was measured using reverse-phase high pressure liquid chromatography. RESULTS: We found a significant association between hyperhomocysteinemia and DVT; the associated risk was weak (p = 0.025, OR: 1.7). Other risk factors significantly associated with DVT were: obesity (p = 0.04, OR for DVT: 2.9), varicose veins (p = 0.023, OR: 3.13), prolonged immobility (p = 0.015, OR: 3.1), history of DVT (p = 0.01, OR: 5.59). All these factors were found to be independent risk factors using multivariate logistic regression. CONCLUSION: hyperhomocysteinemia is an independent risk factor for DVT; the risk is not associated with the severity of hyperhomocysteinemia.

Mesenteric venous thrombosis: clinical and therapeutical approach.

Mesenteric venous thrombosis (MVT), an unusual location of deep venous thrombosis, occurs especially on a predisposing terrain. Recently, hyperhomocysteinemia has been shown to be associated with venous thrombosis, often recurrent and located in an uncommon site. Hyperhomocysteinemia is mainly due to genetic causes (mutations 677C>T and 1298A>C of methylenetetrahydrofolate reductase) and vitamins B deficiencies. MVT may present as acute, subacute or chronic form. The clinical supposition of mesenteric thrombosis is based on the discrepancy between the abdominal pain and the physical examination. The nonspecific character of the pain, mimicking peptic ulceration in some cases, and the possibility of an initial normal clinical examination may delay the diagnosis. The occurrence of the fever, rebound tenderness and guarding suggests progression to bowel infarction. MVT leads to peritonitis in 1/3 to 2/3 of cases. Laboratory blood tests are not helpful in confirming the diagnosis of venous thrombosis. Leukocytosis and metabolic acidosis are considered to be the most specific laboratory findings in patients with mesenteric ischemia. Abdominal computed tomography is the test of choice for the diagnosis. However, most of the cases are diagnosed during laparotomy or autopsy. Anticoagulant therapy administrated early increases the survival rate. Surgery is indicated in cases with bowel infarction or peritonitis.

Hyperhomocysteinemia: clinical and therapeutical involvement in venous thrombosis.

Hyperhomocysteinemia, considered "the cholesterol of nineties", is an established risk factor for cardiovascular diseases and premature atherosclerosis. Hyperhomocysteinemia is due to genetic and acquired factors (unhealthy lifestyle with poor diet in folate and vitamin B, elderly, renal impairment, thyroid diseases, malignancies). More recently, hyperhomocysteinemia was associated with venous thrombosis. Several studies found a correlation with a usual site of thrombosis (central retinal vein, mesenterical level, cerebral veins, Budd-Chiari syndrome). Other studies showed the association between hyperhomocysteinemia and recurrent venous thrombosis. This condition is of high interest because homocysteine may represent a potentially reversible cause of thrombophilia. Although methylenetetrahydrofolate reductase (MTHFR) C677T genotype and deficits of folic acid, vitamin B12 lead to hyperhomocysteinemia, in cases with a thrombotic event the correlations between homocysteine level and folic acid as well as between homocysteinemia and vitamin B12 were found to be weak and no significant correlation between homocysteinemia and MTHFR was identified. Recently, some authors reported an independent association between low levels of folic acid or vitamin B12 and venous thrombosis. Regarding the MTHFR genotype, the risk for venous thrombosis is increased only in patients with factor V Leiden. A recent meta-analysis of 24 retrospective and 3 prospective studies published in electronic literature showed that a 5 micromol/L higher homocysteine level was associated with a 27% (95% CI: 1-59) higher risk of venous thrombosis in prospective studies and a 60% (95% CI: 10-134) higher risk in retrospective studies. A meta-analysis of the short-term trials of therapy with folic acid showed a reduction of 25% of homocysteinemia and a further reduction of 7% when vitamin B12 was associated. This situation may be associated with a 10% to 20% decreased risk of venous thrombosis. Further trials are required to estimate if this is worthwhile from the clinical point of view. In medical practice the measurement of homocysteinemia may be indicated in unexplained idiopathic venous thrombosis, or recurrent episodes or venous thrombosis occurred at an early age or at an uncommon site.

[The place of surgery in the complex treatment of gastric cancer]. / Locul chirurgiei în tratamentul complex al cancerului gastric.

The fact that the first symptoms of gastric cancer occur when therapy, even surgical, is limited to palliative objectives, was the starting point of the present study. A clinical study was carried out in a group of 158 patients with gastric cancer admitted to the Surgical Clinic II of Cluj-Napoca in the past 10 years. The most frequent location of the gastric neoplasm was the antrum-pylorus, though there were also extended tumours that invaded the neighbouring organs. Secondary processes were evidenced in over 70% of the patients studied. This fact, together with the associated conditions, made us limit the gastric resection even for the cases in which we considered total extensive gastrectomy to be the best solution. The methods of restoration of the gastric passage were esophago-jejunostomy on the Y loop in the first place, followed by gastro-jejunostomosis with the other techniques of gastric reconstruction. Palliative procedures such as gastro-enteroanastomosis or nutritional gastro-jejunostomy were sometimes necessary. Good postoperative results were obtained in 69% of the patients, which emphasizes once again the importance of this study.

[The experimental heterotopic transplantation of an isolated segment of colon]. / Transplantarea heterotopica experimentala a segmentului izolat de colon.

The heterotopic transplantation of isolated colon segment was achieved in the cervical region, for to study the behaviour of the colon in this new situation. The study included 20 dogs from which there were taken segments of 10 cm length from, the left colon. Then was prepared the common carotid artery, superficial jugular vein and their branches. In 5 dogs the cervical esophagus was resected. Then was performed the transplant using micro-surgical techniques. In 15 dogs the colon was exteriorized at the skin and in 5 dogs the colon was placed between the ends of the esophagus. In 76% of cases the postoperative evolution was good. From the viable colon transplants were taken fragments for histologic examinations after 1, 2 respectively 4 weeks postoperative. The results obtained, recommend the colic transplant as a possible graft for repairing the cervical esophagus defects.

[Clinical, diagnostic and therapeutic problems in the postthrombotic syndrome. Our experience]. / Probleme clinice, diagnostice si terapeutice în sindromul posttrombotic. Experienta noastra.

An analysis is presented, of the experience acquired in the II-nd Surgical Clinic of Cluj-Napoca in connection with 150 cases of postthrombotic syndrome followed and treated over the last 5 years (1983-1987). Considerations are made concerning terminology, and evaluation of diagnostic and therapeutic means applied. The post-thrombotic syndrome develops in a variable interval after the thrombophlebitis (months and even years). A series of factors prevent of enhance the development of the syndrome (98% diagnostic errors and therapeutic failures). Phlebography is mandatory in cases where surgery is considered. Noninvasive explorations (Doppler, plethysmography) limit the use of phlebography. The most efficient treatment is prophylaxis (consisting in the prophylaxis and the correct treatment of thromboembolic disease). The usual treatment is mainly medical and conservative (59.4%). Surgery is carried out in cases where the superficial, the communicating and the deep venous systems are involved.

[Venous emergencies. Personal experience and viewpoint]. / Urgences veineuses. Expérience et attitude personnelles.

Based on a casuistic report of 226 cases, the authors propose a classification of venous emergencies, including acute deep thrombo-phlebites (with their anatomo-clinical and topographical varieties), the complications of varicose disease, venous traumatism and anorectal venous thrombosis. The authors touch on problems associated with clinical and paraclinical diagnosis, prophylaxis and active surgical therapy, respectively thrombectomy, ligation of the long saphenofemoral junction, the treatment of varico-phlebitis and urgent traumatic lesions, the thrombectomy and radical cure of haemorrhoids. The coupling of any of these affections presents a potential of great seriousness, sometimes a major vital risk which necessitates immediate therapeutic intervention. The classification of the idea of "venous emergency" in comparison with that of "arterial emergency", is outlined, and the authors mention that a surgical treatment in these affections is to be preferred.

Experimental preparation of deantigenized vascular heterografts and study of tolerance after transplantation.

A new technique in preparing a heterograft is presented. Deantigenized calf carotid arteries are obtained by papain digestion and formol tanning. The biochemical determinations show a pronounced reduction in total protein content after papain digestion. The formol tanning gives a good rigidity and elasticity in adapting to different blood volumes without aneurysmal dilatation. Eight dogs were grafted : two died after surgery, two were killed after 35 days and two others 60 days after transplantation, one died after 8 months and one is alive 30 months after transplantation. The good in vivo tolerability has been appreciated. There have been no haemodynamic troubles and no cell changes of rejection. An insignificant quantity of immunoglobulins G has been found in the sera of the animals with heterografts. These data draw attention on the possibility of the use, in clinical practice, of the deantigenized calf arteries.