Risk of hepatitis B virus reactivation in hepatitis B virus + hepatitis C virus-co-infected patients with compensated liver cirrhosis treated with ombitasvir, paritaprevir/r + dasabuvir + ribavirin.

Hepatitis B virus may reactivate in patients with chronic hepatitis C treated with direct-acting antivirals. The aim of this study was to investigate the risk of hepatitis B virus (HBV) reactivation in HBV + hepatitis C virus (HCV)-co-infected patients with compensated liver cirrhosis treated with paritaprevir/ombitasvir/ritonavir, dasabuvir with ribavirin. We reviewed prospectively gathered data from a national cohort of 2070 hepatitis C virus patients with compensated liver cirrhosis who received reimbursed paritaprevir/ombitasvir/r, dasabuvir with ribavirin for 12 weeks from the Romanian National Health Agency during 2015-2016. Twenty-five patients in this cohort were HBs antigen positive (1.2%); 15 untreated with nucleotide analogues agreed to enter the study. These patients were followed up: ALT monthly, serology for HBV and DNA viral load at baseline, EOT and SVR at 12 weeks. Hepatitis B virus (HBV)-co-infected patients were all genotype 1b and 52% females, with a median age of 60 years (51 ÷ 74); 76% were pretreated with peginterferon + ribavirin; 72% were with severe necroinflammatory activity on FibroMax assessment; 40% presented comorbidities; and all were HBe antigen negative. Hepatitis C virus (HCV) SVR response rate was 100%. Hepatitis B virus (HBV)-DNA viral load was undetectable in 7/15 (47%) before therapy, and for the other 8 patients, it varied between below 20 and 867 IU/mL. Five patients (33%) presented virological reactivation (>2 log increase in HBV-DNA levels) during therapy. One patient presented with hepatitis associated with HBV reactivation, and two started anti-HBV therapy with entecavir. Hepatitis B virus (HBV) virological reactivation was present in 33% in our patients. Generally, HBV-DNA elevations were mild (<20 000 IU/mL); however, we report one case of hepatitis associated with HBV reactivation.

Adalimumab and Infliximab in Crohn's disease - real life data from a national retrospective cohort study.

AIM: to compare the efficacy and safety of Adalimumab(ADA) and Infliximab(IFX), in a large Romanian population and to identify predictors of response. Methods We performed a national retrospective cohort study including 265 patients (136 ADA, 129 IFX) between 2008-2014. Binary logistic regression was performed with the statistical program Minitab. RESULTS: Patients were half women, with a median age of 36, a median disease duration of 2.5 years, 80% received Azathioprine. Mean therapy duration was 20 months in ADA group and 36 months in IFX group. Complete response to Adalimumab respectively Infliximab was recorded in 77%vs.65%, secondary loss of response in 18%vs.28%, statistically comparable. We failed to identify predictors of response. In 79.2%of patients with secondary loss of response to ADA, the dose was escalated, 12.5% were switched to Infliximab. In 70%of patients that lost response to IFX, the dose was increased, 30% were switched to Adalimumab. CONCLUSIONS: Adalimumab and Infliximab have similar efficacy, with a complete response rate of~70%. In case of secondary loss of response to IFX, the best solution is to switch to ADA, with 83% response rate, while in case of secondary loss of response to ADA, increasing the dose leads to 84 % response rate.

Open vs robotic radical gastrectomy for locally advanced gastric cancer.

BACKGROUND: This study aims to evaluate the immediate outcomes of robotic and open gastrectomy for patients with locally advanced gastric adenocarcinomas. METHODS: A retrospective analysis was performed on patients undergoing curative intent gastrectomies between 2004 and 2013 in our department. Operative and postoperative outcomes as well as long-term survival data were analysed. RESULTS: Two groups of patients were analysed: the robotic group (n = 18) and the open surgery group (n = 29). Operating time in the robotic group (320.833 ± 85.186 min) was significantly longer (p = 0.0004) as compared with the open group (243.366 ± 57.973 min). The number of retrieved lymph nodes was not statistically different between the two groups (p = 0.108) and neither was the rate of postoperative complications (p = 0.294). CONCLUSIONS: Robotic gastrectomy is a safe procedure, with satisfactory short- and long-term outcomes in locally advanced gastric cancer. Studies on a larger number of patients are necessary in order to confirm whether an immediate benefit in survival exists due to robotic surgery. Copyright © 2015 John Wiley & Sons, Ltd.

Fecal Microbiota Transplantation in Recurrent NAP1/B1/027 Clostridium Difficile Infection (CDI) Resistant to Vancomycin and Metronidazole in a Patient with Ulcerative Colitis (UC): A Case Report.

Most of the studies showed that IBD patients inflammatory bowel diseases (IBD) with CDI have more of the whole range of short- and long-term worst outcomes than those without CDI. Initial infection with the BI/NAP1/027 epidemic clone was found to be a significant risk factor for relapse. However, current literature is suggesting increasingly that for patients with infections that fail to resolve with traditional antibiotic regimens, FMAT's average cure rate of >90%. We report a case of a 40-year-old man, diagnosed with ulcerative colitis (UC) in 2012 who presented in our clinic for 20 watery stools per day with mucus and blood, hypogastric pain, pyrexia and chills. Rectosigmoidoscopy and histopathological examination diagnosed a ctive lesions of ulcerative colitis with Clostridium difficile toxins A/B enzyme immunoassays (EIA) testing initially negative. The patient was non-responder at day 10 of intravenous (iv) corticotherapy and received induction therapy with Infliximab 5 mg/kg. EIA testing for Clostridium difficile was repeated at day 12 of hospitalization with positive results for toxins A/B, and associated oral therapy with Vancomycin and Metronidazole was initiated without clinical response in day 7, reasons for what intravenously therapy with Tigecycline was started with good response. Patient was discharged after 10 days of Tigecycline, but came back twice for two relapses of Clostridium difficile colitis treated successfully with Tigecycline, reasons for what fecal transplantation was performed in Matei Bals Institute, which induced remission of both CDI and UC.

Endoscopic therapy with curative intent for neoplastic epithelial lesions: indications rewiew and the role of "water-jet" technology.

Neoplastic lesions of the gastrointestinal tract have a large prevalence worldwide and in Romania. Their therapy is tailored to their TNM stage, which can be estimated using non invasive or minimally invasive imaging studies. Precursor lesions and superficial carcinomas are amenable to endoscopic therapy, providing that their endoscopic and/or endoscopic ultrasound aspect suggest a maximal extension to the submucosal layer. Polypectomy, endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are ablative techniques used for their curative intent treatment. Large superficial carcinomas are to be removed by ESD as "en bloc" resection is essential to post procedure histological appraisal of the curative oncology nature of their resection. ESD complications rates and duration are nowadays reduced with the aid of "water-jet" technology, by combining submucosal fluid jet injection and electro-resection in a single knife.

Robotic surgery of locally advanced gastric cancer -- an initial experience.

BACKGROUND: The treatment of gastric cancer is currently based on open gastric resection and regional lymph node dissection. Although the minimally invasive approach is currently being adopted for ever more complex procedures in order to improve post-operative outcomes, the laparoscopic radical D2 gastrectomy has not yet gained a wide acceptance, it being considered one of the most difficult operations in general surgery. Robotic surgery is better than the conventional laparoscopic approach, in that it avoids some of its limitations. Wristed instruments with seven degrees of freedom, the tremor filtering system, the ability to scale motion, and tridimensional vision improve the surgeons' dexterity when a fine manipulation of tissues in a narrow, fixed operating field or handsewn sutures are required. This study will attempt to evaluate the feasibility of robotic total and subtotal gastrectomy for locally advanced gastric cancer. METHODS: Two patients with locally advanced gastric adenocarcinoma underwent robot-assisted gastrectomy with D2 lymph node dissection, with no open or laparoscopic conversion. RESULTS: The post-operative evolution was uneventful and they were both discharged without complications. The number of lymph nodes retrieved was comparable to open surgery. Currently, after a follow-up period of 23 and 26 months respectively, both patients are disease-free. CONCLUSIONS: Robotic surgery can be a simpler way of expanding the indications of minimally invasive surgery so as to include the advanced gastric cancer. However, controlled prospective studies are needed in order to evaluate the role of robotics in the management of gastric cancer.

The evaluation of interstitial Cajal cells distribution in non-tumoral colon disorders.

Interstitial cells of Cajal (ICC) are pacemakers that generate electric waves recorded from the gut and are important for intestinal motility. The aim of the study was to evaluate the distribution of interstitial cells of Cajal in colon specimens from patients with idiopathic chronic pseudo-obstruction and other non-tumoral colon disorders as compared with samples from normal colon. The distribution pattern of ICC in the normal and pathological human colon was evaluated by immunohistochemistry using antibodies for CD117, CD34, and S-100. In two cases with intestinal chronic idiopathic pseudo-obstruction we found a diffuse or focal reducing number of Cajal cells, the loss of immunoreactivity for CD117 being correlated with loss of immunoreactivity for CD34 marker. Our study revealed that the number of interstitial cells of Cajal also decrease in colonic diverticular disease and Crohn disease (p<0.05), whereas the number of enteric neurones appears to be normal. These findings might explain some of the large bowel motor abnormalities known to occur in these disorders. Interstitial Cajal cells may play an important role in pathogenesis and staining for CD117 on transmural intestinal surgical biopsies could allow a more extensive diagnosis in evaluation of chronic intestinal pseudo-obstruction.

Multicystic mesothelioma--a rare case of ascites: case report.

We present the case of a 37-year-old male, admitted to our clinic with abdominal tenderness, right supraclavicular tumour, and ascites. The presence of ascites was incidentally reported 6 years before, but no other evaluation was done at that moment or during this period. Abdominal ultrasound and CT scan revealed moderate ascites, perivascular adenopathies, and multiple abdominal cystic lesions, while thoracic CT scan revealed the same lesions in mediastinum. Laboratory data were within normal limits, including the tumoral markers, and the tests for hydatid cysts. A biopsy from the right supraclavicular nodule was performed, and based on usual and immunohistochemical stains (calretinin, mesotheline, CK 5/6, CK 7, CK18 diffusely positive in mesothelial cells, and CEA -M, bcl-2 and vimentin negative), suggested the diagnosis of mesothelioma. Based on these results, the diagnosis of "multicystic mesothelioma" was made. The patient was referred for surgery.

[D2 lymph node dissection in gastric cancer surgery: long term results--analysis of an experience with 227 patients]. / Limfadenectomia D2 în chirurgia cancerului gastric. Rezultate pe termen lung dupa analiza unei experiente de 227 de cazuri.

AIM: The main objective of the study was to evaluate the postoperative mortality and 5 year survival in gastric cancer patients undergoing a minimum of D2 lymphadenectomy. MATERIALS AND METHODS: A retrospective study was conducted on 1170 patients operated for gastric adenocarcinoma in the Department of General Surgery and Liver Transplantation of Fundeni Clinical Institute, between 1997 and April 2005. Only 443 patients underwent a curative resection, from which 216 patients had D1 resection and in 227 cases a D2 or D3/D4 lymphadenectomy was performed. Information about survival was available for 189 patients of those who had a D1 resection and for 210 of those who underwent a D2 or D3/D4 lymphadenectomy. RESULTS: Postoperative mortality was 6.5% in the group of curative resection, with 9.2% for D1 and 3.9% for D2/D3 D4. Five year survival according to Kaplan Meier curves was 32 % in the D1 group vs. 51,8% in D2/D3-D4 (p <0.0001). Significant differences were noted in the median survival-- D2/D3-D4 group 63 months vs. 28 months in D1 group. CONCLUSIONS: Our data support the gastric resection with a minimum of D2 lymphadenectomy in the radical surgery of gastric cancer. However, an accurate interpretation of the statistical interpretation between the different groups of patients is difficult, mainly because of the retrospective character of the study.

Esophageal tumor with an unusual histological appearance: a case report.

An unusual esophageal tumor in a 58-year-old man complaining of dysphagia and weight loss is herein described. Esophageal radioscopy and endoscopy visualized a huge polypoid tumor which was occluding the esophagus. After esophageal resection, the histological examination revealed miscellaneous benign cells (squamous, columnar fat cells, cartilaginous cells, and glandular structures) and two different malignant areas (spindler sarcomatous cells and squamous cells). There was no malignant invasion in the stalk, in the adjacent esophageal wall, or in the periesophageal tissue, and there were no malignant adenopathies. The postoperative course was favorable for one year, until the patient developed pain in the right superior back. A sarcomatous relapse was diagnosed by fine-needle biopsy under CT guidance, and the patient subsequently received radiation therapy.

[2 cases of total duodenopancreatectomy with resection of the portal vein in cancer of the pancreas]. / Consideratii asupra a doua cazuri de duodenopancreatectomie totala cu rezectie de vena porta pentru cancer de pancreas.

Two cases of pancreatic cancer with portal vein invasion are presented. In both cases a total duodenopancreatectomy was performed due to the extension of tumour. The portal vein invasion was diagnosed intraoperatively; it was a circular invasion in one case and a lateral invasion in the second case. A segmental resection of the portal vein (2 cm in length) with end-to-end anastomosis was performed in the first case, while a lateral excision with venorrhaphy was sufficient in the second case. The first patient died after six months while the second patient is still alive, without recurrence, at seven months postoperatively.