Risk factors for complications after duodenopancreatectomy. Initial results after implementing a standardized perioperative protocol.

INTRODUCTION: During 1993-2008 period, in the Surgical Clinic III were conducted several retrospective studies, in order to identify risk factors for complications after cephalic duodenopancreatectomy(DP). As a result of these studies, a preoperative protocol was developed for preparation of patients proposed for DPC, as well as a number of intraoperative technical changes in order to improve postoperative morbidity and mortality. Implementation of the protocol was gradually and inomogenic done in our service. METHODS: The study is prospective, conducted in 2009-2012, ina group of 180 patients and aims to evaluate immediate results after DPC for periampular malignancy, looking to analyze the effects of implementation of the protocol mentioned above.We analyzed the rates of complications (pancreatic fistula,blunt pancreatitis, bleeding from the pancreatic blunt, delayed gastric emptiness), and the factors that might influence their occurrence. RESULTS AND CONCLUSIONS: of the 180 patients, 10 (5.5%) developed pancreatic fistula and 24 (13.3%) had delayed gastric emptiness. Among the factors that have been significant associated with these complications we mention: the pancreatico-jejunalanastomosis and gastro-jejunal transmesocolic assembly. With the implementation of the protocol, the risk factors previously identified in retrospective studies performed in our service(elevated transaminases, experienced surgical team, etc.) have lost significance, but they have not disappeared entirely, due to fact that the conduit proposed was not entirely followed. We believe that the homogeneous application of a perioperative guide, together with a standardized surgical technique, will lead to improve immediate results after DP.

Modern therapeutic approach of acute severe forms of pancratitis. A review of the literature and experience of Surgical Department No III Cluj.

UNLABELLED: The title of "the great abdominal drama" attributed to acute pancreatitis is fully justified by the impressive clinical presentation, the deep consumptive character of physio-pathological processes taking place, the severity of the complications and the complexity of the treatment. MATERIALS AND METHODS: The aim of our study was to analyze the results on a number of 81 consecutive patients hospitalized in the Surgical Clinic III Cluj during 28 months, all diagnosed with severe forms of acute pancreatitis. There were two groups of patients, non-surgical (43 cases) and surgical cases (38 cases), respectively. The diagnosis and forms of the disease took into account the clinical picture, serum amylase, CPR and Balthazar procalcitonine,together with the classification of the lesions on CT scan. RESULTS: All patients were admitted to the intensive care unit and received supportive treatment such as antibiotics, pancreatic exocrine secretion inhibitors and proton pump inhibitors. The surgical act in the 38 cases was indicated by septic intra-abdominal pressure or high functionality threatening vital viscera. Intraoperatively the abscesses were drained, the necrotic areas were removed and cholecystectomy was performed in patients with biliary etiology. Statistically, we obtained significant differences in the incidence of complications between the group of patients operated and those not operated (p = 0.000048), but not in what concerns the length of hospitalization (p = 0.99999) and the number of deaths (p = 0.2102). The overall mortality was 14.41%, comparable to that found in the literature. In none of the patients CT guided drainage of collections was performed prior to surgery, which was a major drawback of the treatment. CONCLUSIONS: Our results support the importance of an early diagnosis and medical treatment, the delayed surgery being required in high intra-abdominal pressure or SEPS.

[Evaluation of prognostic factors for colon cancer]. / Evaluarea factorilor de prognostic în cancerul de colon.

INTRODUCTION: Colon cancer represents a major health problem in the world. The outcome of newly diagnosed cases predominantly relies on stage as defined by the UICC-TNM and American Joint Committee on Cancer classifications. AIMS: The aim of this retrospective study was to identify the additional prognostic factors for patients with colon cancer. PATIENTS AND METHODS: We retrospectively analyzed the incidence and significance of 8 clinical and pathological factors in 225 patients treated over a 2-year period in Surgery Clinic No. III, Cluj-Napoca. In order to avoid selection bias, all cases with a prior diagnostic of colon cancer and intervention for recurrence or metastasis, as well as cases lacking more than 20% of necessary datawere excluded. The candidate variables were analyzed using the Cox Proportional Hazards Model in order to select those who influence the outcome. RESULTS: The overall 5-year survival rate was 42%. Patients treated with resection of the primary tumor had a survival rate of 50%, ranging from 82% in patients with stage I malignancy to 11% in the presence of metastatic disease. 21% of all patients underwent emergency operation for obstruction or perforation but this did not significantly influence survival (p = 0.1). TheTNM stage of the tumor (HR = 1.2-8.4), grade of tumor differentiation (HR = 2.1) and perineural invasion (HR = 1.8) were independent negative prognostic factors. Venous invasion and status of resection margins were found to influence the outcome on univariate analysis, but were discarded when integrated in the multivariate model. The number of lymph nodes analyzed (p = 0.9) and the tumor location (p = 0.3) did not significantly affect the outcome of patients. CONCLUSION: These results suggest that the prognosis of newly diagnosed cases of colon cancer is influenced by the TNM stage, the degree of tumor differentiation and the presence of perineural invasion.

[Jejunal ischemic ulcer with perforation: a case report]. / Ulcer jejunal de tip ischemic, perforat. Prezentare de caz.

Ulcerative ischemic lesions of the small bowel represents a rare abdominal pathology. We present the case of a 68-year-old male who was admitted to our hospital for abdominal pain, nausea and vomiting. Ultrasound examination followed by upper endoscopy raised up the suspicion of a jejunal ulcerative perforated lesion. Surgery confirmed the diagnosis, revealing the jejunal ulcer, perforated and blocked by the adjacent enteral loops. Ischemic etiology of the ulceration was indicated by the mesenteric thrombus. The anatomopathologic finding together with the clinical and imagistic examinations lead us to the diagnosis of thromboangiitis obliterans, cause of the mesenteric ischemia; the future problems regarding this case are the long term follow up, in order to be able to recognise the visceral ischemic recurency that might occur.

[Duodenal adenoma--a rare cause of upper gastrointestinal hemorrhage]. / Adenomul duodenal--cauza rara de hemoragie digestiva superioara.

The tumors of the small bowel are rare entities, whose incidence comprises ca. 1-5% of the total amount of tumors in the digestive tract. Most of the cases involve the ileum and duodenum is least involved. The most frequently encountered duodenal tumors are the Brunner's Gland Adenomas. We can encounter unique or multiple lesions, sessile or pedunculated which develop proximal to duodenal papilla and are usually less than 1 cm in diameter although 12 cm lesions have been reported. In most of the cases they remain asymptomatic and constitute incidental discoveries. Sometimes they can present complications such as obstruction, hemorrhage and malignant transformation. Diagnosis is difficult due to the lack of symptoms and is delayed by an average of 6 months from symptoms onset. Barium contrast studies and superior digestive endoscopy is performed in most of the cases to reveal the diagnosis, but other methods, such as CT or ultrasound can be useful. A case of duodenal adenoma is described; the patient was admitted suffering digestive hemorrhage, which resulted in melena, secondary anemia, and ulcerous dyspeptic syndrome.