Massive intraoperative bleeding after laparoscopic assisted abdominoperineal resection: a case report and systematic review of the literature.

INTRODUCTION: The laparoscopic-assisted abdominoperineal resection (LAPR) has been proved to be associated with a shorter postoperative recovery, with equivalent oncological results and similar survival when compared with conventional open surgery, for patients with low rectal cancer. METHOD: Case report of a massive intraoperative bleeding during LAPR and systematic review of the English language literature, using PubMed Medline, ISI Thopmson, OVID and EMBASE databases. RESULTS: 58 years old patient admitted in emergency setting or rectal bleeding. Rectal examination revealed a protruding,frail tumor, located 2 cm from the anal verge. Total colono scopy revealed an infiltrative, protruding tumor, situated at 2 cm from the anal verge, with a 5 cm cranial extension,without any additional colonic lesions. Computed Tomography showed a 4,5 cm circumferential rectal wall thickening, without any enlarged mesorectal or abdominal lymph nodes. The patient was transported to operating room for a LAPR. During final hemostasis, at the level of perineal surgical wound, an acute massive bleeding occurred from the presacral vessels with severe blood loss. This bleeding couldnot be managed laparo scopicaly and conversion to laparotomywas decided, with pelvic packing. At 48 hours after the initial surgical approach, the tamponing packs were removed, without signs of active bleeding. There were applied haemostatic agents and the perineal wound was sutured, without further rbleeding during in-hospital stay. CONCLUSIONS: A rapid and effective control of the presacral bleeding is mandatory to prevent a fatal outcome. Pelvic packing remains a life-saving procedure and the treatment of choice in severe cases.

High Grade Penetrating Pancreatic Trauma - Case Report and Review of the Literature.

INTRODUCTION: The pancreatic injuries have fortunately a low frequency, but when present associate multiple intraabdominal lesions, and carry a significant morbidity and mortality. The aim of this study is to underline the significant morbidity associated with high grade pancreatic injuries. CASE REPORT: Female patient, 36 years old, with penetrating abdominal trauma due to domestic violence was referred to our center from a regional county hospital, after multiple laparotomies, hemodynamically unstable, with multiple organ failure. Abdominal clinical exam revealed evisceration, with massive pancreatic leakage at the level of the median laparotomy and through the stabbing wounds from the right flank. Emergency Computed Tomography showed multiple intraabdominal collections, with laceration of the liver, right kidney and pancreatic head. Abdominal exploration was decided. After a thorough abdominal debridement was revealed a deep laceration of the pancreatic head, with active extravasation of pancreatic secretion, correlating with a grade IV injury. Peritoneal lavage and large drainage of the lesser and greater peritoneal cavity was performed. The postoperative recovery was uneventful, with progressive decrease in pancreatic fistula output and discharge after 35 days. CONCLUSIONS: High grade pancreatic traumas associate a significant morbidity. Efficient drainage of the pancreatic head injuries and patients management in high volume centers for pancreatic surgery maximize the survival rate.

Traumatic Tricuspid Valve Rupture after Blunt Chest Trauma - A Case Report and Review of the Literature.

INTRODUCTION: Despite the high frequency of thoracic injuries secondary to traffic related accidents, the blunt cardiac valve rupture is extremely rare. METHOD: Case report and review of the literature using PubMed/MEDLINE and EMBASE databases. RESULT: A 38 year old female patient, victim of car accident was admitted. On primary survey the patient was conscious, cooperative and hemodynamic and respiratory stable. On secondary survey was found a bilateral open leg fracture and a seat belt sign. Whole body Computed Tomography revealed minimal haemorrhagic contusion of the cortex, left hemopneumothorax and right pneumothorax, bilateral rib fractures, liver contusion, left femoral neck fracture and fracture to the lumbar spinal column. After bilateral pleurostomy, the patient becomes hemodynamically unstable, but with no signs of external bleeding. The transthoracic echocardiography revealed an acute severe tricuspid regurgitation with hepatic veins reflux. After orthopaedic surgeries, the tricuspid valve rupture was managed by replacing the valve with a bioprostheses. The hospital stay was 122 days. CONCLUSION: Only a high index of suspicion may reveal blunt cardiac lesions as a cause for hemodynamic instability in acute setting.

Epidemiology of diverticular disease -- systematic review of the literature.

INTRODUCTION: Associated with the Western diet and life style,diverticular disease is affecting more and more developing countries worldwide. Recent studies show an increase in incidence of the disease at young age, that raises the risk of complications, along with major consequences for the patient but also for the healthcare system. METHOD: Systematic review of the literature with US National Library of Medicine and National Institutes of Health International PubMed Medline, using abstracts and articles available in PubMed Medline, Cochrane databases searching for ("Diverticulosis, Colonic epidemiology" [MeSH] OR"Diverticulosis, Colonic etiology" [MeSH] OR "Diverticulosis,Colonic genetics" [MeSH] OR "Diverticulosis, Colonic history" [MeSH]). RESULTS: Even from the rise of diverticular disease as a public healthcare problem, at the end of the previous century, it was associated with a diet rich in refined sugars, lacking vegetable fibres. The higher incidence in countries like U.S.A., Canada, United Kingdom and the northern states compared with its rare occurrence in the sub-Saharan African continent, strengthen the anterior assumptions. In regions like Asia, the disease pattern is characterized by are latively low incidence of colonic diverticular disease, with distribution of diverticula mainly on the right colon. The different incidence by sex and age show the possible existence of hormonal protective factors. Studies from countries with a rich ethnic diversity, bring into question the probable genetic predisposition to diverticular disease, fact backed-up by the few studies on twins and 1st degree relatives available in the literature. DISCUSSION: The rising incidence of colonic diverticular disease in Romania makes our country adhere the epidemiologic model existing in countries with a close socio-economic status.Although with a lower incidence than countries that have adopted a Western diet, Romania is likely to encounter a public health problem, if certain measures to identify and minimise the population exposure to risk factors are not taken.

Trauma registry -- a necessity of modern clinical practice.

INTRODUCTION: Traumas represent the cause of 10 % of deaths in the entire world. The successful development of trauma systems, including the use of trauma registries, played a significant part in lowering the mortality and the disabilities due to injuries resulted from trauma. METHOD: Review of the literature using computerized database of National Library of Medicine and the International Institutes of Health MEDLINE using PubMed interface. There were selected the articles that address the issue of trauma registry from the different world trauma systems. RESULTS: Trauma registries have developed once they were introduced in centers and trauma systems in the United States of America in 1970. First trauma database processed on computers was created in 1969 in Cook County Hospital in Chicago. This database became the prototype of trauma registry in Illinois which started gathering information from 50 designated hospitals across the entire state in 1971.Countries with limited resources were able to start useful trauma registers. Continuous financing and dedicated personnel inside the team are two essential factors in the success of a trauma registry. NISS (New Injury Severity Score) higher than 15 is a widely used inclusion criteria in the trauma register. Exclusion is represented by patients admitted at over 24 hours after the accident, those declared dead before hospital arrival or with no signs of life on arrival in hospital. In addition, it is recommended that asphyxia,drowning and burns to be excluded. CONCLUSION: The improvements regarding the treatment of multi-traumatized people in developing countries depend on establishing and performance of trauma systems, where trauma registry represents a part of these systems infrastructure.

A polarographic study of some complexes of Tl(I) with polyoxa macrocyclic ligands.

The log beta(1) values at 25 degrees for the reaction in aqueous solution of Tl(I) with 15-crown-5, benzo-15-crown-5, 18-crown-6 and dicyclohexyl-18-crown-6 (isomer cis-syn-cis) have been determined by d.c. and a.c. polarographic measurements.

The relationship between the urinary level of some amino acids and the occurrence of metabolic diseases associated with psychic disorders.

Assays of the branched chain amino acids, of those with basic character, of phenylalanine and glutamic acid were performed in the 24 hrs urines of 50 patients with psychic disorders, ranging in age from 0 to 20 years, and in 30 normal controls. Similar investigations were carried out in the patients' parents. Abnormal levels of urinary amino acids in some of the adults suggested the existence of mutant genes in one or both parents of one or two descendents with mental handicap. The levels of urinary amino acids correlated with the severity of the predominant psychic manifestations, which were more severe in the cases with a wide deviation from normal of aminoaciduria.

Serial study of the urinary metabolites in newborn children.

Study on 24-hour, 30- and 60-day urine collected from 1500 newborn infants pointed out in some cases an abnormal excretion of some of the 40 urinary metabolites investigated. The analysis of urinary metabolites allows to detect a relation between abnormal excretion of urine metabolites and various types of "inborn errors of metabolism".

The relationship between aminoaciduria and plasma hemoglobin levels.

Investigations in newborns, children and young adults have revealed an inverse proportion between aminoaciduria and plasma hemoglobin (Hb) levels. Values above normal were recorded for alanine, leucine, valine, phenylalanine and glutamic acid, correlating proportionally with their increased blood levels, and preceding or being concomitant with the decrease of plasma Hb, both during the first 20 months of life and in young adults. The return to near normal values of aminoaciduria occurred generally only after an early treatment with minerals, vitamins and trace elements (Supradyn), activators of the enzymes involved in the amino acid metabolism. After treatment, the Hb levels also became almost normal. An early re-equilibration of the amino acid metabolism can prevent the risk of developing, at the adult age, certain anemias and other diseases (rachitism, mental handicap, urinary infections, conjunctivitis, stomatitis, a.o.). The correlation factor was r = 0.964 and the differences between the data recorded in patients and in controls were statistically significant (p < 0.01).

Predictive value of glucose and proteic sulphur levels in the hair for an early detection of the preclinical stage of IDDM.

Assays of glucose and proteic sulphur levels in the hair of patients with recently detected IDDM provided information on the preclinical stage of insulin secretion disorders, which was estimated at 6 +/- 2 months. Such investigations in subjects at high risk of developing an IDDM might reveal the period preceding the disease onset, thus enabling to start an early therapy.

Evaluation of the metabolic balance in type 1 (insulin-dependent) diabetics, by assay of the hair biochemical components.

A new method of long-term retrospective evaluation of the metabolic balance in type 1 diabetic was based on the variations of the hair biochemical components. Glucose, proteic sulfur and amino acid assays were performed in two consecutive hair segments, proximal and distal, of 1.5 cm each. The differences between the glucose and the sulfur values in the two segments correlated with the HbA1 levels (r = +0.971 and r = +0.957, respectively), being statistically significant in both situations (p less than 0.001). The hair components assay permits to follow up the diabetics' metabolic balance on longer time periods than by determination of the HbA1 values.

The hair levels of unsaturated fatty acids (oleic, linoleic, and linolenic) indicators of the lipid metabolic balance.

The lipid metabolism was evaluated using a new method for assay of the hair contents in unsaturated fatty acids. Determinations in various hair segments and in the blood serum were performed before and after a hypolipemic diet and drug therapy in hypercholesterolemic patients in comparison with a control group. The correlation factors between the levels of the oleic, linoleic and linolenic acids in the serum and those in the hair were +0.967, +0.987 and +0.992, respectively. The method provides information on the therapy influence on the lipid metabolism variations within several weeks or months.

Early cystinuria, a risk factor for metabolic urolithiasis.

The levels of urinary amino acids (cystine, amino acids with basic character, branched chain amino acids and phenylalanine) were determined in the 24 hr urines of 5,500 newborns and in 20 subjects ranging in age from 2.5 to 20 years, with a suspicion of metabolic diseases. Seven newborns have shown a biochemical pattern of cystinuria. The urinary cystine levels in the first days of life appeared to correlate with an increased risk of developing, at the adult age, metabolic mono- or bilateral urolithiasis.

Cholesterol and lipid levels in the hair: indicators of the lipid metabolism balance.

A new method of long term, retrospective evaluation of the lipid metabolism balance, by cholesterol and lipid assays in the human hair, is described. The correlation index between the blood and the hair cholesterol and lipid concentrations was + 0.980 and + 0.9925, respectively. The effects of hypolipemic diet and drug therapy on the cholesterol and lipid values were studied comparatively in the blood and in successive hair segments. The results demonstrate that the new method permits an evaluation of the therapy effectiveness and of the lipid metabolism variations during several weeks or months.