Acute appendicitis--open or minimally-invasive approach?

BACKGROUND: Although laparoscopy has become the standard approach in other procedures, this technique is not generally accepted for acute appendicitis. AIM: To evaluate the results after minimally invasive appendectomies. METHODS: All medical records of patients operated for acute appendicitis during the last year were retrospectively reviewed. We considered only patients with diagnosis of acute appendicitis confirmed by histopathology. We designed two groups: operated by open approach (OA) and operated by minimally-invasive approach (MIA). The two groups were compared for differenced in homogeneity and main end results: morbidity, mortality, hospital stay. RESULTS: The men/women ratio was 112/88 (1.27), with a mean age of 31.83 +/- 1.06 years. There were more women in the MIA and more men in the OA group, p = 0.001. The Alvarado score was significant lower in MIA group (5.69 +/- 0.24 versus 6.57 +/- 0.23, p = 0.009). Comorbidities were noted in 51% from the patients, most of them in MIA group: 58.8%; N = 60, p = 0.016. Mean operation time was similar in both groups: 36.96 +/- 1.48 in OA versus 37.03 +/- 1.39 minutes in MIA. The postoperative mortality rate was 0.5%. The postoperative morbidity rate was 12%. Even though the number of cases with postoperative complications were double in OA group (16 cases versus 8 cases in MIA group) it did not reach statistical significance, p = 0.073. Histopathological examinations revealed early acute appendicitis in 45.5% cases (N = 91), suppurative appendicitis in 46.5% (N = 93) and gangrenous appendicitis in 8% (N = 16); early acute appendicitis was more frequent in MIA group and suppurative appendicitis in OA group: p = 0.017. The hospital stay was similar in both groups: 4.34 +/- 0.39 in OA versus 3.58 +/- 0.25 days in MIA group; p = 0.103. CONCLUSIONS: MIA is a safe procedure and can be performed even in the patients with comorbidities. We didn't find any statistical significant difference from point of view of postoperative morbidity; however more postoperative complications were find in OA vs MIA group. The postoperative hospital stay was similar in both groups.

[Pancreaticoduodenectomy with or without pylorus preservation: a retrospective analysis of 137 patients]. / Duodenopancreatectomia cefalica cu sau fara prezervarea pilorului: analiza retrospectiva a 137 pacienti.

OBJECTIVE: We performed a retrospective study to assess the postoperative results, long-term survival and quality of life after pylorus preserving pancreaticoduodenectomy (PPPD) versus standard Whipple pancreaticoduodenectomy (WPD). METHODS: A retrospective study was performed in a nonselected series of 137 patients who were operated in the Surgical Clinics of "St. Spiridon" University Hospital Iasi, Romania, from January 1st, 1995 till December 31, 2005. Demographics, preoperative and intraoperative data, as well as postoperative morbidity, mortality and follow-up were analyzed. Quality of life, after to at least six months after discharge, was also studied. RESULTS: There were no significant differences noted in demographics data. Jaundice was more frequent in the PPPD group as for WPD patients (p=0.047). For the most patients the digestive reconstruction after resection were performed as in Child technique: the first anastomosis was pancreaticojejunostomy (end-to-end or end-to-side), the second anastomosis was hepaticojejunostomy (end-to-side) and the last anastomosis was gastrojejunostomy end-to-side (duodenojejunostomy in PPPD group). For 31 cases a pancreatico-gastrostomy were performed. We also noted 14 cases with pancreatico-gastrostomy and duodenojejunostomy end-to-end, and a Roux jejunal loop for 3 patients with previous gastrectomy and gastrojejunostomy (Reichel-Polya). The operating time was shorter in the PPPD group as in WPD (p < 10-3), but the mean blood loss was the same. Postoperative morbidity rate was 46.8% in PPPD group vs 39.2% in WPD (p > 0.05), but the reintervention rate was significant higher in PPPD group (30.6% vs 15%; p = 0.027). We also noted no significant differences of Delayed Gastric Emptying, postoperative mortality rate (14.5% in PPPD group vs 10.1% in WPD group) and mean survival time (42.42 months (24.94 - 59.89; 95% CI) in PPPD group vs 46.78 months (28.07 - 61.50; 95% CI) in WPD group; log rank test p = 0.643). Pathological exam diagnosed a malignancy in 109 cases (54 cases with pancreatic cancer); we noted chronic pancreatitis in 22 cases. Quality of life was also the same in the two groups. CONCLUSIONS: PPPD and WPD were associated with comparable results, but, there is a tendency of increase rate of postoperative morbidity and mortality for PPPD patients. We also noted that postoperative quality of life is the same for both procedures.

[Necrotizing fasciitis]. / Fasciita necrozanta.

The management of a right foot necrotizing fasciitis and severe sepsis in an old diabetic patient is presented. The early and aggressive surgery, adequate antibiotherapy and correction of organic disfunction (cardio-circulatory, renal, respiratory) eliminated the vital risk and resulted in a satisfactory morpho-functional recovery of the foot.

[Gastric stromal tumor. Case report]. / Tumora gastrica stromala. Prezentare de caz.

UNLABELLED: Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors of the gastro intestinal tract and express the c-kit proto-oncogene protein (CD-117). We report herein a case of a 58 years old male with upper abdominal pain and anaemia. Preoperative endoscopic and barium meal exams showed a submucosal tumor in the gastric fornix. Endoscopic biopsy revealed spindle-shaped cells with elongated nuclei specific of GIST. We performed a stapled resection of the gastric fornix associated with Hiss angle reconstruction. Postoperative histologic exam revealed the same spindle-shape cells characteristic of GIST with 2-5 mitosis/50HPF. Almost all of the cells showed immunoreactivity for c-kit, CD-34 and a Ki-67 labeling index of 30%. Postoperative course was non eventful and after 3 month the patient has no recurrence. CONCLUSIONS: GIST are rare gastric tumors and are usually associated with bleeding and abdominal pain. The preoperative diagnosis is usually established by endoscopy with biopsy or endoscopic ultrasonography fine needle aspiration and barium meal exam. Only immunoreactivity is able to differentiate GIST from other mesenchymal tumors. Surgical resection is a safe and effective treatment. The chemotherapy with tyrosine kinases competitive inhibitors (e.g. imatinib mesylate) is also recommended.