Thoracoscopic left splanchnicectomy - role in pain control in unresectable pancreatic cancer. Initial experience.

BACKGROUND: The management of opiate-dependent intractable abdominal pain caused by unresectable pancreatic cancer remains challenging. The aim of this study was to evaluate the safety and efficacy of thoracoscopic unilateral left splanchnicectomy for pain control in a first series of 15 patients with unresectable pancreatic cancer. PATIENTS AND METHODS: Fifteen patients suffering from intractable pain due to unresectable pancreatic cancer (stage III and IV)underwent thoracoscopic unilateral left splanchnicectomy. To assess pain severity and the impact of this palliative procedure for pain relief, all patients completed Wong-Baker Faces Pain Rating Scale with a preoperative pain degree between 7 and 9. RESULTS: Surgical intervention duration varied from 30 minutes to 1 hour. Pleural drainage tube was removed 24 hours postoperatively.There were no complications nor deaths.Immediate pain relief (pain degree 0-2) was achieved in all patients after thoracoscopic unilateral splanchnicectomy, same level being registered at first check-up after one month. CONCLUSIONS: Thoracoscopic unilateral left splanchnicectomy decreases the pain substantially and significantly improves the quality of life in patients with unresectable pancreatic cancer.

Traumatic colon injuries -- factors that influence surgical management.

BACKGROUND: This study sought to evaluate current trends in surgical management of colon injuries in a level I urban trauma centre, in the light of our increasing confidence in primary repair. METHODS: Our retrospective study evaluates the results of 116 patients with colon injuries operated at Bucharest Clinical Emergency Hospital, in the light of some of the most commonly cited factors which could influence the surgeon decision-making process towards primary repair or colostomy. RESULTS: Blunt injuries were more common than penetrating injuries (65% vs. 31%). Significant other injuries occurred in 85 (73%) patients. Primary repair was performed in 95 patients (82%). Fecal diversion was used in 21 patients(18%). Multiple factors influence the decision-making process: shock, fecal contamination, associated injuries and higher scores on the Abdominal Trauma Index (ATI) and Colon Injury Scale (CIS). Colon related intra-abdominal complications occurred in 7% of patients in whom the colon injury was closed primarily and in 14% of patients in whom a stoma was created, ATI having a predictive role in their occurrence. The overall mortality rate was 19%. CONCLUSIONS: Primary repair of colon injuries, either by primary suture or resection and anastomosis, is a safe method in the management of the majority of colonic injuries. Colostomy is preferred for patients with ATI ≥ 30 and CIS ≥ 4. Surgical judgment remains the final arbiter in decision making.

Laparoscopic treatment of perforated duodenal ulcer -- a multicenter study.

AIM: The aim of this study is to evaluate the results of the laparoscopic treatment of perforated duodenal ulcer performed in 6 Romanian surgical centres with experience in the field of laparoscopic surgery. MATERIAL AND METHOD: Between 1996 and 2005, 186 patients with perforated duodenal ulcer were operated on in the centers participating in this retrospective study, all patients being ASA I-II. Thirty-nine patients (20.0%) presented mild peritonitis, 120 (64.5%) medium peritonitis and 27 (15.5%) severe (20.0%) simple suture was performed, in 110 (59.1%) suture with epiplonoplasty, for 1 (0.5%) only epiplonoplasty and 1 (0.5%) underwent excision of the perforation and suture. RESULTS: The operative time was between 30-120 minutes, with an average of 75 minutes. No death was noted. Average hospitalization time was 6 days, with periods varying between 3 and 18 days. Postoperative complications included: 5 patients (2,6%) presented infections of the abdominal walls, 1 patient (0.5%) duodenal fistula, 1 patient (0.5%) intra-abdominal abscess, 1 patient (0.5%) a superior digestive hemorrhage by "mirrored ulcer" and 1 patient (0.5%) duodenal stenosis 6 months after operation. The patients were administered 50% less analgesics, used 70% less dressings, 30% less antibiotics and had 60% less complications in comparison with those operated by the classical approach. CONCLUSION: The laparoscopic approach of perforated duodenal ulcer constitutes the first choice for patients without important co-morbidities, allowing a quick recovery and a significant reduction in the consumption of analgesics, antibiotics and dressing materials.

[Stapled vs. hand-sewn colorectal anastomosis in complicated colorectal cancer--a retrospective study]. / Anastomozele manuale versus anastomozele mecanice in cancerul colorectal complicat--studiu retrospectiv.

UNLABELLED: Emergens in colorectal pathology are in most cases by complications of cancer. The prognosis for colorectal cancer is poor when this pathology is addressed in emergency situations because, on one hand, of the organ specific structure, blood supply, septic content and, on the other hand, because of the special group of patients with this pathology: aged, immunosuppressed and with various comorbidities. The high rate of postoperative complications of these patients requires a specific management. The development and improvement of medical devices has brought to the surgeons new products among which mechanice devices for anastomoses. In this study we compared two groups of operated patients (with hand sutured and stapled anastomoses) who presented as emergences with complications of colorectal cancer. MATERIAL AND METHOD: Retrospective clinical study with a total of 72 patients who underwent a colorectal resection procedure in emergency in our clinic (Emergency Hospital Bucharest) over a period of 2 years (2007-2008). RESULTS: The 72 patients who required emergency surgery were randomly assigned to 2 categories according to the type of anastomosis: hand sutured (group 1, n = 34) and stapled (group 2, n = 38). Age, sex, comorbidities, and tumor staging were comparable in both groups. The emergency was represented by obstruction (56.94%), hemorrhage (8.33%) and perforation (34.72%). The mortality (10.5% vs. 8.8%) and orbidity rate (20.83% vs. 15.27%) was higher in the stapled anastomosis group. The average duration of the surgical procedure performed in emergency was also quantified and was 118 min. (group 2) vs. 236 min. (group 1) respectively. CONCLUSION: Comparison did not disclose any significant difference in the number of complications in these two groups. Anastomosis is safe in emergency colorectal surgery and the reduction of the operative time may also improve the outcome of these patients.

[Delayed rupture of the spleen in a multiply injured patient]. / Ruptura întârziata a splinei la un politraumatizat.

The authors present a case of delayed rupture of the spleen in a polytraumatised patient. This entity was defined as a late occurrence of signs and symptoms attributed to splenic injury not detected by diagnostic computed tomographic scanning during the initial examination. The mechanisms in which the delayed rupture of the spleen occurs are discussed and the conclusion is that the delayed rupture of the spleen represent a real clinical entity.

Clinical impact of cachexia on survival and outcome of cancer patients.

Approximately one half of all cancer patients experience a complex metabolic status involving progressive exhaustion of adipose and skeletal muscle tissue. This condition, known as cachexia, is responsible for more than 20% of the overall deaths in cancer patients. Although its main mechanisms remain unknown, several hypotheses have been proposed. One of the pathogenic mechanisms involves leptin and hypothalamic neuropeptide-containing pathways. Orexigenic and anorexigenic neuropeptides are down-regulated respectively upregulated as a result of cancer. Other pathogenic theories consider tumour derived factors, such as LMF (Lipid Mobilising Factor) and PIF (Proteolysis-inducing Factor), to be responsible for the weight losing pattern of cancer patients via activation of various catabolic pathways (e.g. ubiquitin-proteasome proteolytic-pathway, etc.). Despite the controversial discussion of cachexia-inducing mechanisms it is clear that proinflammatory cytokines, such as TNFalpha, IFNgamma, IL-1, IL-6 and IL-8, are linked to all pathways that induce cachexia. Although only limited treatment exists for patients with cancer cachexia, recent studies with eicosapaentanoic acid showed promising effects in reversing weight losing pattern of cachectic patients. Cytokine targeted monoclonal antibodies, cytokine traps and genetic therapies are also evaluated for future therapeutic strategies.