Gastroduodenal Surgery in Cirrhotic Patients - Case Series and Literature Review.

Specific risk factors for gastroduodenal surgery in cirrhotic patients have been identified, which dictates for a more personalized management. The retrospective study was conducted between 2012-2019 on twelve patients (7 cases of duodenal ulcer, 2 cases of gastric ulcer and 3 patients with gastric cancer). We took into account a number of possible factors involved in the unfavorable evolution of patients, based on data published in the literature so far. In order to follow the involvement of each factor we compared two groups of patients, one with unfavorable evolutions, exitus and another with favorable evolutions. Emergency surgery, the presence of ascites at the time of intervention, a higher than 30 MELD score, alcoholic cirrhosis, liver encephalopathy and liver failure are common factors that are found in a high percentage (between 75% and 100%) in patients who have had an unfavorable evolution, exitus. The same risk factors are found in much lower percentages in patients who have evolved favorably postoperatively, most between 12.5% and 25%. We analyzed preoperative aspects, surgical approach, complications and risk factors for these patients, compared them with the results of our study and identified future therapeutic possibilities. For CHILD B or C patients, the indication for surgery should be discussed in advance with a multidisciplinary team. Endoscopic submucosal dissection or discontinuation of D2 dissection should be considered in these patients.

The Role of Matrix Metalloproteinase-9 (MMP-9) as a Prognostic Factor in Epithelial and Lymphatic Neoplasia.

Matrix metalloproteinase 9 is a zinc-dependent extracellular matrix remodeling endopeptidase directly involved in the local invasion mechanisms and in metastasis. The current review aims to evaluate the expression of MMP-9 and its prognostic value in the most common epithelial and lymphatic neoplasia of the pelvic-abdominal region. We included 19 studies published between January 1st, 1995 and July 31st 2015, involving a total of 1523 patients. The analysis indicate that MMP-9 is valid marker of poor survival in epithelial and lymphatic neoplasia.

Hysterectomy for benign uterine pathology: comparison between robotic assisted laparoscopy, classic laparoscopy and laparotomy.

OBJECTIVE: Hysterectomy is one of the most important surgeries in gynecology and requires a lot of care and skill. In this study we attempt to make a comparison between laparoscopic hysterectomy, robotic assisted hysterectomy and abdominal hysterectomy for treatment of uterine pathology. MATERIALS AND METHODS: We conducted a study comparing 29 patients who were treated by robotic assisted laparoscopic hysterectomy in Cisanello Hospital, Pisa, Italy, 30 patients who were treated by laparoscopy in General Surgery Clinic, Craiova and 30 patients who were treated by abdominal hysterectomy in General Surgery Clinic, Craiova. RESULTS: Comparing the surgeries, it was noticed that the operative time of a robotic assisted interventions is the largest, 183.9 minutes. Even if the duration was greater, the time needed to perform vaginal suture was lower, 17.75 minutes to 22.79 minutes by classic laparoscopic approach. In terms of blood loss we concluded that intraoperative blood loss was lowest during a robotic surgery, 199.3 ml versus 285 ml in the laparoscopic group and 417 ml in the laparotomic group. CONCLUSIONS: Robotic assisted laparoscopic hysterectomy is a feasible method that can be used very successfully to treat patients diagnosed with benign uterine pathology.

The assessment of primitive or metastatic malignant pulmonary tumors in children.

BACKGROUND: The purpose of our study is to assess primitive and secondary malignant pulmonary tumors in children. The presence of lung tumors in newborns and infants is a point of interest to specialists in pediatric surgery, thoracic surgery and genetics due to the high death rate. The 5-years survival rate communicated by EUROCARE-study is less than 10% for primitive tumors and less than 15% in lung metastases. MATERIALS AND METHOD: We performed a retrospective study which analysed 11 children with pulmonary primary ormetastatic tumors admitted in the Pediatric Surgery Department "Prof. Dr. Al. Pesamosca" of the Emergency Clinical Hospital for Children "Maria Sklodowska Curie",Bucharest. The analysed and operated patients underwent surgery by Prof. Dr. Al. Pesamosca and the authors during the period of 1985-2011. In our series there where 4 primitive lung tumors and 7 secondary ones: 8 underwent surgery and 2 died before being operated on. The incidence of primitive pulmonary lung malignancies is higher for females, 3 to1, and secondary ones are more frequent in males, 6 to 1. RESULTS: Patients with primitive pulmonary malignancies were late diagnosed. Their age ranged between 1 to 6 years;3 were operated on, out of which 2 died, and 1 operated still survives. The 7 patients with secondary pulmonary malignancies were late diagnosed, too, probably as a consequence of a late diagnosis of the origin tumor. CONCLUSIONS: Even if all malignancies require an early diagnosis and treatment, this aim regarding malignant lung tumors is still a desideratum animating all practitioners. Primitive tumors are diagnosed presenting the main clinical manifestation abroncho pulmonary infection. Secondary lung malignancies are usually asymptomatic and are diagnosed when monitoring a patient for a malignancy with another origin. Chemotherapy,radiotherapy and surgery of malignant primitive tumors or metastatic ones in children remain unsatisfactory because of the late diagnosis and the limited methods of treatment. Nowadays genetics identified the responsible oncogenes for pulmonary blastic explosion and better results could be obtained by genetic surgery.

Herbert capsuloplasty and Burnei tenomyoplasty for the correction of genu flexum in cerebral palsy, arthrogryposis and posttraumatic.

INTRODUCTION: Studies of gait dynamics revealed the complex motions that the knee must undergo in sync with the hip and ankle, in both the swing and support phase of walking. If these motions are restricted, usually as a consequence of cerebral palsy or arthrogryposis, normal gait is hindered; the patient may be able to walk for very short distances or, eventually, not at all. Children with knee extension limited by 10 - 30 degrees,especially those with cerebral palsy, exhibit a stance compatible with walking. Walking is difficult and the gait pattern, "crouch gait", is considered typical for this degree of limitation. AIM: This paper is meant as an update regarding the usefulness of Herbert knee capsuloplasty, conceived in 1938 and introduced in Romania in 1956 by Clement Baciu, and Burneidistal medial hamstring tenomyoplasty, invented in 1993. MATERIALS AND METHODS: Herbert knee capsuloplasty, although initially intended for ailments other than spasticity or arthrogryposis,became known, in time, as a useful operation for spastic genu flexum with a 15 to 30 degree limitation of extension. Severing the posterior cruciate ligament (PCL) in children less than 10 years old often results in genu recurva tumor joint instability. In order to avoid these complications, PCL transection has been phased out and our clinic started to use, preferentially for spastic genu flexum rather than arthrogryposis,the Burnei tenomyoplasty. When applied in the same operative session, the two techniques complement each other and act in synergy. RESULTS: Herbert capsuloplasty can achieve only partial correction of genu flexum ranging between 30 and 60 degrees of extension deficit. Full extension is opposed by the PCL,contracture of the hamstrings and vascular retraction. Burnei tenomyoplasty used by itself is useful for genu flexum with less than 30 degrees of extension deficit. For children with 30 to 60 degrees of knee extension deficit, combining the Herbertand Burnei procedures achieves the best results. CONCLUSIONS: The simultaneous application of Herbert capsuloplasty and Burnei tenomyoplasty allows for the correction of stiff genu flexum and enables the patient to resume walking,with or without support. This course of treatment also avoids the progression of genu flexum beyond 60 degrees, which would require an osteotomy. This combined procedure avoids the cartilage lesions which may develop when patients with 30- 60 degree genu flexum undergo Herbert capsuloplasty alone.Not in the least, the risk of postoperative knee dislocation is significantly reduced.

Theoretical characterization of laser- and sympathetically-cooled ions in surface-electrode ion traps.

Using molecular dynamics simulations we characterize theoretically Coulomb clusters of laser- and sympathetically-cooled ions in a five-wire surface-electrode ion trap. We show that the asymmetry of the trapping potential leads to significantly different cluster structures and ion energy distributions in comparison to conventionally used linear Paul traps and to an asymmetric segregation of the ions in bi-component Coulomb clusters. We explore the impact of our results on the implementation of sympathetic cooling of molecular ions in surface-electrode traps and discuss possible challenges for the realization of such experiments.

Target structure induced suppression of the ionization cross section for very low energy antiproton-hydrogen collisions.

Low energy antiprotons have been used previously to give benchmark data for theories of atomic collisions. Here we present measurements of the cross section for single, nondissociative ionization of molecular hydrogen for impact of antiprotons with kinetic energies in the range 2-11 keV, i.e., in the velocity interval of 0.3-0.65 a.u. We find a cross section which is proportional to the projectile velocity, which is quite unlike the behavior of corresponding atomic cross sections, and which has never previously been observed experimentally.

[A study of the incidence and the specific risk factors for surgical site nosocomial infections]. / Studiu asupra incidentei reale a infectiilor nosocomiale de sediu chirurgical si a factorilor de risc specific.

UNLABELLED: The aim of our study is to estimate the incidence of surgical site nosocomial infections in a general surgery department and also to present the importance of the risk factors associated with these infections using the latest diagnostic protocols. MATERIAL AND METHOD: a retrospective analysis of 3038 surgical procedures performed between 2000-2002. We identified all the patients with surgical site nosocomial infection (SSI) mentioned in the observation sheet using NNISS/HELICS protocols to appreciate the risk for surgical site nosocomial infections. The results were compared to those published in the literature. RESULTS: we selected 198 cases (6,55%) with surgical site nosocomial infections of 3024 surgical patients (we excluded 14 cases): 41.4% of them were superficial infections, 49% profound infections, 7.1% organ-space infections and 2.5% with mixed nosocomial infections. We analysed the incidence depending on the risk factors and the type of surgical procedure, the agents involved in the development of the postoperative nosocomial infections, the germs concerned and their antibiotics resistance. CONCLUSIONS: the rates of different NNISS values after surgical procedures with nosocomial infections are analysed relative to the rates published by HELICS study for Romania and other European countries and it shows larger rates than the european average, maybe because our country has not started yet the HELICS protocol for SSI.

[Correlation of adenomatous polyps and early colorectal cancer. Diagnostic and therapeutic implications]. / Relatia polip adenomatos--cancer colorectal precoce. Implicatii diagnostice si terapeutice.

AIM: To detect the patients with colorectal adenomatous polyps or those with adenocarcinoma areas with a view to prevent and to treat the malignant disease. MATERIAL AND METHOD: A prospective study including 309 patients hospitalized between 2000-2005 diagnosed with isolated adenomatous polyps after repeated colonoscopies. The research method was selective screening with identification of risk factors regarding the evolution of colorectal polyps in early cancer, using colonoscopy and histopathological examination. RESULTS: We identified 464 single or multiple isolated polyps of which 399 were adenomas, 59 hyperplastic polyps and 6 other types of lesions. Histologically we recorded 41 (13.27%) polyps with a low grade of dysplasia, 56 (18.12%) with severe dysplasia and 30 (9.7%) intramucosal adenocarcinoma with submucosal invasion. TREATMENT: Colonoscopic polypectomy was used for benign polyps and in situ carcinoma. In case of adenocarcinoma is probable the invasion of submucosal lymphatics being shown a colorectal resection as appropriate. We performed 279 colonoscopic polypectomies and 30 conventional resections. CONCLUSIONS: High grade of dysplasia, the number of polyps, ulceration, bleeding, intraepithelial areas of neoplastic transformation are predictive factors for early colorectal cancer. Depth of submucosal invasion of malignant transformed polyps are important pathological factors to predict lymphatic metastasis and to select the therapeutic procedure.

Ileal iterative spontaneous perforation from foreign body granuloma: problems of histopathologic diagnosis.

Spontaneous ileal perforation is a very rare cause of peritonitis. It occurs, in most of the cases, as a complication of Crohn's disease or intestinal tuberculosis. We present the case of a 23-year-old female patient with multiple surgical interventions during the last year, for iterative ileal spontaneous perforation with generalized peritonitis of which cause was initially assigned to intestinal tuberculosis. Actual episode of generalized peritonitis was determined once again by an ileal perforation of 5 mm at 70 cm from the ileo-cecal valve situated on a suture scar. Distally, a bowel stricture and a non-complicated Meckel's diverticulum were also noted. We performed an enterectomy including all three aforementioned lesions with end-to-end anastomosis. The histopathologic report revealed granulomatous giant-cellular inflammation in the margins of the perforation. The tuberculous etiology was questioned because of the negativity of the PCR-test and multiple recidives of perforation under specific anti-tuberculous medical therapy. The discovery of some rests of non-resorbable suturing material in a granuloma on an ancient enterorraphy scar in the resected specimen, finally established the cause. The granulomatous giant-cellular inflammation of foreign body is a rare cause of ileal perforation. The histopathologic differential diagnosis is difficult needing correlation with clinical data. Usage of resorbable suture material avoids that risk.

Balthazar Score and Neutrophil-Lymphocytes Ratio in Acute Pancreatitis.

Acute pancreatitis is a pathological entity that poses numerous diagnostic and treatment problems. Severe form is a real challenge for a physician because it has multiple obscure causes, as well as a complex pathophysiology. Thus, the diagnosis is difficult and the choice of the right time for surgical treatment is controversial, the treatment being more frequently nonspecific, supportive for the various affected systems and organs. On a group of 337 patients, laboratory and imaging investigations were performed to diagnose and determine the severity score of acute pancreatitis and the correlation level between the neutrophil-lymphocytes ratio values and the Balthazar score, as a valid assessment method for local and systemic inflammatory changes. The distribution's study of acute pancreatitis by gender according to etiology confirms the predominance of the acute ethanolic pancreatitis in male, but also the higher proportion (54%) of male pancreatitis (181 man vs. 156 women) with gender ratio male/female 1.16/1. The neutrophil-lymphocytes ratio mean value varied according with the Balthazar severity score, that got higher as acute pancreatitis got more advanced and with a certain cut-off value can be considered a simple indicator to determine the severity of acute pancreatitis.

[Theoretical considerations and comments on the physiopathology in renovascular hypertension]. / Consideratii teoretice si comentarii privind fiziopatologia hipertensiunii arteriale de origine renovasculara.

The researches performed during the last four decades did not elucidate completely the pathogenic mechanism of the renovascular hypertension. The present knowledge considers that the origins of renovascular hypertension are the imbalance between the renal hypotensive system located in the medullar renal site (antihypertensive and hypotensive substances) and the renal hypertensive system (renin-angiotensin-aldosterone) located cortically. As an additional mechanism in producing hypertension is involved the disorder of hydro electrolytic metabolism, as a result of decreased excretory function, inducing an increase of plasmatic natrium level, of volemia and interstitial liquid.

Colorectal Cancer Biomarkers - A New Trend in Early Diagnosis.

Colorectal cancer (CRC) is one of the most widespread malignancy, posing as a great challenge due to its high incidence and mortality in both genders. Yet, it also stands as one of the most preventable diseases because of its known malignant transformation mostly from tubular adenomas or serrated polyps, therefore offering a strong incentive to the screening programs that are being developed for this disease. Current diagnosis of CRC has surely evolved along with the evolutionary step in gastrointestinal technology of flexible endoscopy. These innovations have promoted colonoscopy as a primary choice for screening programs of colonic lesions, proving to be of great benefit for patient's well-being. In this review, we present the current status of CRC screening methods from the non-invasive options to the long developed colonoscopic and imaging techniques. We search through PubMed and Medline databases and chose relevant articles on CRC with focus on blood based biomarkers and stool based tests. Additional relevant publications were also according to the reference lists of firstly identified articles.

Correlations between CD34 Immunolabelled Blood Vessels and CD34 mRNA Expression in Colorectal Cancer.

PURPOSE: This study aims to determine the correlation between microvessel density of CD34 immunolabelled blood vessels and CD34 mRNA gene expression in colorectal cancer tissue. MATERIAL/METHODS: Standard immunohistochemistry and gene expression was perform on samples collected from 76 patients with colorectal cancer in order to determinate the number of CD34 immunolabelled blood vessels and the relative quantity of CD34 mRNA. RESULTS: For the study group, the mean CD34 immunolabelled microvascular density (MVD) was of 307/mm2, and the mean CD34 gene expression value for colon cancer was 2.303. The low p value (<0.001) of the Spearman correlation test showed a significant direct correlation between CD34 MVD and CD34 gene expression for the entire study group. CONCLUSIONS: CD34 gene`s expression can be looked at as a prognostic factor in colorectal cancer.

[Septic complications in acute appendicitis. Problems of diagnosis and treatment]. / Complicatiile septice perioperatorii în apendicita acuta. Probleme de diagnostic si tratament.

AIM: diagnostic improvement in complicated acute appendicitis (AA) by implementing the new sepsis concepts and modern imaging procedures; optimization of treatment with decreasing postoperation morbidity and mortality and improving the cost-efficiency indicator. 1495 cases of AA admitted between 2000 and 2004 have been assessed retrospectively and among them 306 (20.46%) had complications. On admission 80.43% patients were diagnosed with AA, 17.50% with acute abdominal syndrome and 2.07% with chronic appendicitis. On discharge there were 1158 (77.45%) cases of inflammatory AA and 306 (20.46%) cases of complicated AA (perforation, gangrene, peritonitis, plastron abscess). TREATMENT: 98.26% of patients under-went operation and 1.73% did not. SURGICAL PROCEDURES: standard appendicectomy in 1407 (95.77%) cases; laparoscopic appendicectomy in 30 (2.04%) cases; extraperitoneal approach in 15 (1.02%) cases; associated with surgical interventions on other organs in 75 (5.10%) cases. POST-OPERATORY MORBIDITY:128 (41.08%) cases out of 306; septic parietal complications in 102 (33.33%) cases; intraperitoneal complications in 26 (8.49%) cases. POST-OPERATORY MORTALITY: 6 deaths in patients aged over 68. AVERAGE LENGTH OF STAY IN HOSPITAL: 4 days for uncomplicated AA and 14.6 days for complicated ones. Perioperative septic complications are the result of evolution of late diagnosed disease, unjustified postponing of operation, surgical technique, patient health condition.

[Differentiated thyroid carcinoma. Diagnosis and therapeutic aspects]. / Carcinomul tiroidian diferentiat. Aspecte diagnostice si terapeutice.

The significant increase in incidence of thyroid cancer in the last decade, augmented the interest in reevaluation of treatment and diagnosis methods. Those aspects let us into making this retrospective study regarding the differentiated thyroid carcinoma. The clinical material consist in 70 C.T. patients, of which 54 (77.14%) C.T.D. patients, ages between 17-80 year old, sex ratio W/M 3.5/1.9. Preoperatively malignancy diagnosis was made by FNAC in 38.88%, intraoperatively by extemporaneous pathological exam 42.59%, postoperatively by paraffin exam 18.51%. Papillary CTD 30 (55.55%), follicular 20 (41.25%), Hürthle cells carcinoma 4 (7.2%). From the therapeutical point of view, the elective procedure of thyroidectomy was dictated by the histological type, staging and specific prognostic factors. There was 41 (75.9%) patients with total thyroidectomy (T.T), with a specific morbidity of 7 (12.96%) and 5-years survival rate of 88.88%. Preoperatively diagnosis of C.T was suspected through clinic, ultrasonography and scintigraphy arguments and confirmed by FNAC. The non conclusive cases were diagnosed intraoperatively by extemporaneous exam or postoperatively by paraffin exam. In most cases total thyroidectomy remains the essential surgical procedure. Also clinical, imaging and biological postoperative monitoring as well as suppress and substitution hormonotherapy are mandatory.

Abnormal von Willebrand factor secretion, factor VIII stabilization and thrombus dynamics in type 2N von Willebrand disease mice.

Essentials Type 2N von Willebrand disease involves impaired von Willebrand factor to factor VIII binding. Type 2N von Willebrand disease mutations exhibit qualitative and mild quantitative deficiencies. Type 2N von Willebrand disease mice exhibit unstable venous hemostatic thrombi. The factor VIII-binding ability of von Willebrand factor regulates arteriole thrombosis dynamics. SUMMARY: Background von Willebrand factor (VWF) and factor VIII (FVIII) circulate as a non-covalent complex, with VWF serving as the carrier for FVIII. VWF indirectly influences secondary hemostasis by stabilizing FVIII and transporting it to the site of primary hemostasis. Type 2N von Willebrand disease involves impaired binding of VWF to FVIII, resulting in decreased plasma levels of FVIII. Objectives In these studies, we characterize the impact of three type 2N VWD variants (R763A, R854Q, R816W) on VWF secretion, FVIII stabilization and thrombus formation in a murine model. Methods Type 2N VWD mice were generated by hydrodynamic injections of mutant murine VWF cDNAs and the influence of these variants on VWF secretion and FVIII binding was evaluated. In vivo hemostasis and the dynamics of thrombus formation and embolization were assessed using a murine tail vein transection hemostasis model and an intravital thrombosis model in the cremaster arterioles. Results Type 2N VWD variants were associated with decreased VWF secretion using cell and animal-based models. FVIII-binding to type 2N variants was impaired in vitro and was variably stabilized in vivo by expressed or infused 2N variant VWF protein. Both transgenic type 2N VWD and FVIII knockout (KO) mice demonstrated impaired thrombus formation associated with decreased thrombus stability. Conclusions The type 2N VWD phenotype can be recapitulated in a murine model and is associated with both quantitative and qualitative VWF deficiencies and impaired thrombus formation. Patients with type 2N VWD may have normal primary hemostasis formation but decreased thrombus stability related to ineffective secondary hemostasis.

[194 laparoscopic cholecystectomy. Anesthetic and surgical details]. / 194 de colecistectomii laparoscopice. Particularitfiti si aspecte ale actului chirurgical si anestezic.

In this clinic and prospective study we investigated the anesthetic and surgical particularities in laparoscopic cholecystectomy for 194 patients. Approximately the two third of patients have had a great mortality risk (ASA III and IV). 139 patients have had severe comorbid conditions. All patients were under general anesthesia with oro-tracheal intubation. The surgical time was between 27 and 148 minutes. The subjects of this study were old patients with acute cholecystitis and severe comorbid conditions. No significant incident or complication were noted, all patients have had a good outcome.