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The best way to start a paper like this is with a citation from W. Edwards Deming: Without data, you're just another person with an opinion. In the era of Evidence-Based Medicine (EBM) every surgical procedure has to be backed up by solid statistical data to offer our patients the best treatment. But is EBM always the path to truth? We decided to analyze the literature for achalasia and see if the guidelines and the data are reliable enough to justify a certain attitude. Practically, we engaged in this endeavor not because we do not trust the statements of the guidelines, but to see if a surgeon can find by themselves the proper attitude in this disease. Achalasia is a motility disorder of the esophagus characterized by deficient relaxation of the inferior esophageal sphincter that results in dysphagia. There are several methods of treatment, with various statements in the guidelines. Currently, every treatment should be sustained by data and statistics, evidence-based medicine being mandatory when a method is preferred over another. This article reviews several studies and also the available guidelines in search for an answer to the question which procedure is the best.
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Transtornos de Deglutição , Acalasia Esofágica , Acalasia Esofágica/diagnóstico , Acalasia Esofágica/cirurgia , Esfíncter Esofágico Inferior , Medicina Baseada em Evidências , Humanos , Resultado do TratamentoRESUMO
Anastomotic fistulae are the most common and dreaded postoperative complications of pancreaticoduodenectomy. Delayed gastric emptying (DGE) and slow recovery of bowel function are contributing causes for postoperative pancreatic fistula (PoPF) that should be taken into consideration. The present study evaluates data from 17 consecutive cases that underwent pancreaticoduodenectomy for pancreatic adenocarcinoma with pancreaticojejunal anastomosis and circular stapled mechanical gastrojejunal anastomosis instead of the standard terminolateral technique. Three patients developed Grade A DGE (one also developed grade B PoPF) and one patient required reinsertion of the nasogastric tube due to Grade B PoPF. Overall, the incidence of DGE was 23.5%. Three patients developed Grade B pancreatic fistulae that were successfully managed conservatively. Twelve patients resumed early bowel movement within 4 days, two reinterventions were required for postoperative bleeding. Mean hospital stay was 11.5 days. Patients with DGE had a mean hospital stay of 14.5 days. No gastrojejunostomy leak was encountered. Mortality was nil. Therefore we consider the posterior circular stapled gastrojejunostomy a simple, reproducible, safe technical alternative for avoiding DGE and consequently help lower the risk of PoPF, increased costs associated with prolonged hospital stay and an improved postoperative quality of life.
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Adenocarcinoma , Derivação Gástrica , Gastroparesia , Neoplasias Pancreáticas , Adenocarcinoma/complicações , Adenocarcinoma/cirurgia , Derivação Gástrica/efeitos adversos , Derivação Gástrica/métodos , Gastroparesia/etiologia , Humanos , Neoplasias Pancreáticas/complicações , Neoplasias Pancreáticas/cirurgia , Pancreaticoduodenectomia/efeitos adversos , Pancreaticoduodenectomia/métodos , Qualidade de Vida , Resultado do TratamentoRESUMO
Background: Pathological complete response (pCR) after neoadjuvant systemic treatment represents a good surrogate marker for the prognosis of Her-2 positive Breast Cancer (BCs). The results improved after adding anti-Her-2 therapy to chemotherapy in neoadjuvant setting. Methods: Our retrospective study enrolled a cohort of 56 invasive Her-2 positive non-metastatic BCs treated with neoadjuvant systemic therapy between 2001 and 2018. The patients received neoadjuvant chemotherapy with or without anti-Her-2 therapies before surgery and adjuvant endocrine and anti-Her-2 treatment together with adjuvant radiotherapy, based on clinical, pathological and hormonal receptor expression characteristics. The primary end point was pCR rate and disease-free-survival (DFS), defined as the interval between surgery and documented disease recurrence, progression, or death from any cause. Results: The rate of pCR for our patients was 41% independent of type of chemotherapy regimen and the anti-Her-2 therapy used. The results were improved by adding Trastuzumab in the neoadjuvant setting with statistical significance (p = 0.038). Median DFS was 68 months for the entire cohort. The risk of recurrence was higher in the group without pCR after neoadjuvant treatment (52% vs 17%; p = 0.003). 10 patients died (18%), all of them from group without pCR. The prognosis at 36-months was good, with 84% survival chance at 3 years follow-up. Conclusion: Our retrospective study underlines the positive impact of neoadjuvant systemic treatment on pCR rate and on disease-free survival in real-life Her-2 positive breast cancer patients.
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Neoplasias da Mama , Terapia Neoadjuvante , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Neoplasias da Mama/tratamento farmacológico , Quimioterapia Adjuvante , Intervalo Livre de Doença , Humanos , Recidiva Local de Neoplasia , Receptor ErbB-2 , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Surgical clip migration in the common bile duct with consecutive stone formation is a rare occurrence after laparoscopic cholecystectomy, less than 100 cases being reported so far. We report a case of a 55-year-old woman with obstructive jaundice due to bile duct stone formed around a migrated surgical clip 9 years after laparoscopic cholecystectomy. The patient presented with pain in the upper abdomen and jaundice. Abdominal ultrasound diagnosed dilation of the common bile duct and intrahepatic bile ducts. The diagnosis was confirmed by computed tomography which revealed a metal clip in the distal part of the common bile duct. The patient was managed successfully by endoscopic retrograde cholangiopancreatography (ERCP) and the surgical clip was retrieved using the Dormia basket. The exact mechanism of clip migration is not fully understood but may be explained by local inflammation and ineffective clipping. Although a rare occurrence, clip migration should not be excluded when considering the differential diagnosis of patients presenting with obstructive jaundice or cholangitis after laparoscopic cholecystectomy. Minimally invasive management by ERCP is the procedure of choice for migrated clips related complications but surgical common bile duct exploration may be necessary.
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Colecistectomia Laparoscópica/efeitos adversos , Coledocolitíase/etiologia , Ducto Colédoco/cirurgia , Migração de Corpo Estranho/etiologia , Icterícia Obstrutiva/etiologia , Instrumentos Cirúrgicos/efeitos adversos , Colangiopancreatografia Retrógrada Endoscópica , Colecistectomia Laparoscópica/instrumentação , Coledocolitíase/diagnóstico por imagem , Coledocolitíase/cirurgia , Ducto Colédoco/diagnóstico por imagem , Remoção de Dispositivo , Feminino , Migração de Corpo Estranho/diagnóstico por imagem , Migração de Corpo Estranho/cirurgia , Humanos , Icterícia Obstrutiva/diagnóstico por imagem , Icterícia Obstrutiva/cirurgia , Pessoa de Meia-Idade , Resultado do TratamentoRESUMO
Background and objectives: Clostridium difficile infection (CDI) is an important healthcare-associated infection, with important consequences both from a medical and financial point of view, but its correlation with anastomotic leaks after colorectal surgeries is scarcely reported in the literature. Materials and Methods: We conducted a retrospective study looking for patients who underwent open or laparoscopic surgery for colorectal cancers between January 2012 and December 2017, excluding emergency surgeries for complicated colorectal tumors. We also examined patient history for risk factors for CDI such as age, sex, comorbidities, and clinical findings at admission or during hospital stay as well as tumor characteristics. Results: A total of 360 patients were included in the study, out of which 320 underwent surgeries that included anastomoses. There were 19 cases of anastomotic leaks, out of which 13 patients were diagnosed with CDI, with a statistic significance for association between CDI and anastomotic leakage (p < 0.0001). Most patients who developed both CDI and anastomotic leaks had left-sided resections or a type of rectal resection, while none of the patients with right-sided resections had this association, but with no statistical significance possibly due to the limited number of cases. Conclusions: CDI is a relevant risk factor and should be taken into consideration when trying to prevent anastomotic leaks in patients undergoing gastrointestinal surgery for colon or rectal cancer. Thorough assessment of risk factors at admission should be mandatory in order to adequately prepare the patient and plan an optimal course of treatment. Further studies are needed to confirm our findings and a multidisciplinary approach, with a team which should always include the surgeon, is mandatory when it comes to CDI prevention.
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Infecções por Clostridium/etiologia , Cirurgia Colorretal/efeitos adversos , Infecção Hospitalar/etiologia , Complicações Pós-Operatórias/etiologia , Idoso , Idoso de 80 Anos ou mais , Anastomose Cirúrgica/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de RiscoRESUMO
Introduction: Complicated colon cancer most frequently presents as obstruction and needs emergency surgery. Most of these patients receive their diagnosis when presenting for complicated disease and by that time the disease is usually advanced. While concerned first with the survival of the patient, the curative intent of the resection following the principles of oncologic resection may come in second place. Materials and methods: We retrospectively analyzed 68 consecutive patients with complicated colon cancer that suffered emergency surgery between January 2017 and September 2018. The principles of oncologic resection were analyzed in terms of resection margins and retrieved lymph nodes and/or multivisceral resections in order to achieve clear margins. Intestinal obstruction was observed in 58 patients (85.3%), perforation was found in 8 patients (11.8%) while lower gastrointestinal bleeding complicated 2 cases (2.9%). Twenty-two patients had distant metastases at presentation, and overall 29 patients (42,6%) had stage IV disease. Clear circumferential margins were achieved in 55 cases while longitudinal margins were found to be invaded in 2 cases and the mean number of retrieved lymph nodes was greater than 13.7. The mean hospital stay was 13.9 days and the observed in hospital mortality was 19.1%. Results: The outcomes of surgery for complicated colon cancer in our department fall within the reported literature results. Conclusion: The principles of oncologic resection in terms of surgical margins and retrieved lymph nodescan be respected during emergency surgery and offer the intent of cure for these patients with advanced disease.
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Neoplasias do Colo/cirurgia , Obstrução Intestinal/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias do Colo/complicações , Neoplasias do Colo/diagnóstico , Neoplasias do Colo/patologia , Emergências , Feminino , Humanos , Obstrução Intestinal/etiologia , Linfonodos/patologia , Linfonodos/cirurgia , Metástase Linfática , Masculino , Margens de Excisão , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Peritoneal encapsulation (PE) is a rare anatomic anomaly which occurs due to an accessory peritoneal sac covering the small bowel which can cause chronic recurrent abdominal pain and even small bowel obstruction, most often in children or patients with no previous surgical history. The diagnosis is usually made during surgery, but recently it has been suggested that mindful examination of the abdominal CT may be helpful in considering PE beforehand. We present the case of a 21-year old patient who was admitted due to intense abdominal pain, asymmetrical abdominal distension, air fluid levels on the abdominal X-ray, but no specific findings on the abdominal CT. He underwent emergency surgery and PE was found and the peritoneal sac was excised. The postoperative course was uneventful. Histopathologic examination of the specimen confirmed the diagnosis. PE is often misdiagnosed as abdominal cocoon or sclerosing encapsulating peritonitis, but it is a pathology with a much lower rate of recurrence and postoperative complications, which can be treated successfully if the surgeon is aware of this pathology when making the differential diagnosis.
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Obstrução Intestinal/cirurgia , Intestino Delgado , Doenças Peritoneais/congênito , Doenças Peritoneais/cirurgia , Peritônio/anormalidades , Peritônio/cirurgia , Humanos , Obstrução Intestinal/diagnóstico , Obstrução Intestinal/etiologia , Intestino Delgado/cirurgia , Masculino , Doenças Peritoneais/complicações , Doenças Peritoneais/diagnóstico , Peritônio/diagnóstico por imagem , Resultado do Tratamento , Adulto JovemRESUMO
The current concept of complete resection of thyroid parenchyma shifted the practice from subtotal thyroidectomy to total thyroidectomy for a wide range of benign and malignant thyroid affliction and brought the tubercle of Zuckerkandl once again into attention. This embryological remnant has been shown to have a constant relationship with the recurrent laryngeal nerve and the superior parathyroid gland and may be used as a landmark for safe dissection. In order to assess if the presence of the tubercle of Zukerkandl has an impact on the most important complications of thyroid surgery, we have prospectively studied 128 patients diagnosed with nodular goiter who underwent total thyroidectomy. Grade 0 or the absence of the tubercle of Zuckerkandl, according to Pellizo et al, was noted in 42 cases (32.8%). During surgery, we identified 38 grade 1 tubercles (29.7%), 31 grade 2 tubercles (24.2%) and 16 grade 3 tubercles (12.5%). Out of 11 bilateral tubercles, 4 were measured as grade 3.Of all 47 patients with grade 2 and 3 tubercles, 18 (38.3%) developed transient postoperative hypocalcemia (p 0.0001, r=0.47) and 10 (21.3%) transient postoperative nerve palsy (p=0.004, r=0.25). All patients fully recovered during follow-up. The tubercle of Zuckerkandl, when present and of significant macroscopic size is associated with increased rates of transient postoperative hypocalcemia and recurrent laryngeal nerve palsy.
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Bócio Nodular/cirurgia , Hipocalcemia/etiologia , Traumatismos do Nervo Laríngeo Recorrente/etiologia , Glândula Tireoide , Tireoidectomia/efeitos adversos , Paralisia das Pregas Vocais/etiologia , Humanos , Nervo Laríngeo Recorrente/anatomia & histologia , Glândula Tireoide/anatomia & histologia , Glândula Tireoide/embriologia , Tireoidectomia/métodosRESUMO
Since its first description in 1992, laparoscopic adrenalectomy has become the standard of treatment for most benign and low grade small adrenal tumors but due to the low incidence of adrenal disease, it remains a rarely performed intervention outside referral or excellence centers. Although laparoscopic surgery had a positive impact on complications of adrenalectomy, surgical risk should be thoroughly assessed when it comes to secreting or large tumors. This is a retrospective analysis of laparoscopic adrenalectomies performed in the first 4 years of practice 2007-2010 - the early experience including the learning curve of the senior surgeon, and our late experience from 2016 to 2019. All interventions were performed by a single team led by a senior surgeon with extensive experience in advanced laparoscopic surgery, using the lateral transperitoneal approach. In total, 82 cases were included, out of 153 laparoscopic adrenalectomies performed between 2007 and 2019. Only one conversion was recorded during the early experience and two laparoscopic reinterventions were needed for hemostasis and drainage. Non-secreting adenoma was the most frequent indication for surgery (26 cases) followed by Cushing's Syndrome (22 cases) while adrenocortical carcinoma was diagnosed in 3 cases. Significant differences were found between the two periods regarding operative time and length of postoperative hospital stay (p 0.001). With growing experience in laparoscopic transperitoneal adrenalectomy, less complications and shorter operative time and postoperative hospital stay are to be expected.
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Neoplasias das Glândulas Suprarrenais/cirurgia , Adrenalectomia/métodos , Adrenalectomia/estatística & dados numéricos , Humanos , Laparoscopia , Curva de Aprendizado , Tempo de Internação , Duração da Cirurgia , Peritônio/cirurgia , Estudos Retrospectivos , Medição de RiscoRESUMO
Esophageal foreign bodies are a relatively frequent pathology which does not need any kind of treatment in up to 80% of cases. Ten to 20% of patients are treated endoscopically, while less than 1% need surgery either due to perforation or to treat complications. We address the case of a 50 year old male who presented with an impacted esophageal foreign body which had perforated the esophageal wall. Flexible endoscopy confirmed the diagnosis and identified a large fish bone that was stuck transversally in the distal cervical esophagus and could not be mobilized. Surgery was mandatory in this case, with the extraction of the bone and double-layer suture, which did not prevent the appearence of an esophageal leakage more than two weeks postoperatively, which was treated conservatively. Even if it is rarely employed in the treatment of gastrointestinal foreign bodies, surgical treatment is unavoidable in cases of irretrievable esophageal foreign bodies or esophageal perforation.
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Perfuração Esofágica/etiologia , Perfuração Esofágica/cirurgia , Esofagoscopia , Corpos Estranhos/complicações , Corpos Estranhos/cirurgia , Animais , Osso e Ossos , Ingestão de Alimentos , Perfuração Esofágica/diagnóstico , Peixes , Humanos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Resultado do TratamentoRESUMO
Laparoscopic adrenalectomy became the gold standard for adrenal disease, from incidentaloma to cancer. Partial adrenalectomy is difficult to accept due to its technical difficulties as well as hemorrhagic risk and a consensus has not been reached. On the other hand, in selected cases of benign adrenal tumors, adrenalectomy may be futile, partial resections being perfectly justified and with lower hemorrhagic risks. For functioning tumors smaller than 3 cm with an anterior or lateral location, partial adrenalectomy may be indicated. The key points reside in adenoma identification, preservation of the remaining glandular parenchyma and its blood supply with dissection in the space between the adenoma and the normal parenchyma. Laparoscopic partial adrenalectomy is feasible and effective for the treatment of benign tumors. Although partial resections have clear-cut advantages over conventional adrenalectomy especially for bilateral tumors, it remains a difficult intervention.
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Doenças das Glândulas Suprarrenais/cirurgia , Adrenalectomia/métodos , Laparoscopia , Neoplasias das Glândulas Suprarrenais/cirurgia , Estudos de Viabilidade , Humanos , Resultado do TratamentoRESUMO
INTRODUCTION: Laparoscopic cholecystectomy (LC) is probably one of the most frequent surgical procedure performed worldwide. Intraoperative cholangiography (IOC) is required more often than in open procedures due to the need to clarify the anatomy or to diagnose common bile duct (CBD) stones. AIM: The present study analyzes the value of IOC performed on selective basis following preoperative and intraoperative criteria. Our experience covers 15 years of surgical activity in Elias Surgery Department and, as a result of a continuous scientific concern on the matter, we developed a set of criteria that are analyzed and discussed. MATERIAL AND METHOD: We studied the patients subjected to LC in our department between January 2013 and December 2014. A group of 945 patients was analyzed; IOC was performed in 147 cases. All IOC were selective procedures. The criteria were divided in two groups: Preoperative criteria (clinical, lab tests and imaging findings); Intraoperative criteria (dilated biliary ducts and obscure biliary anatomy). RESULTS: IOC was performed in 147 cases. We had a positive result, a finding that changed surgical management of the patient after IOC in over 50% of cases. The biliary tree anatomy was cleared in 100% of cases. IOC required a median period of time of 11 minutes. There were no complications caused by IOC. CONCLUSIONS: Intraoperative cholangiography, performed either routinely or selectively, represents an important tool in diagnosing unsuspected CBD stones during laparoscopic cholecystectomy. Criteria for selective IOC may significantly reduce the number of useless cholangiograms and are to be considered in daily practice. The main predictive factors used for selective intraoperative cholangiography in our study were: history of jaundice, elevated values of ALP, GGTP, SGO, SGP, and CBD diameter.
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Colangiografia/estatística & dados numéricos , Colecistectomia Laparoscópica/estatística & dados numéricos , Cálculos Biliares/diagnóstico por imagem , Cálculos Biliares/cirurgia , Cuidados Intraoperatórios , Seleção de Pacientes , Seguimentos , Humanos , Cuidados Intraoperatórios/estatística & dados numéricos , Estudos Retrospectivos , Romênia , Resultado do TratamentoRESUMO
INTRODUCTION: Small bowel obstruction represents up to 16% of surgical emergencies. Mortality and morbidity depend on early recognition, correct diagnosis and timely surgical management. The most frequent causes of small bowel obstruction are adhesions, malignant tumors, hernias and volvulus. Although laparoscopic surgery is not promoted for the management of small bowel obstruction, it may address many of the mentioned causes. In the same time, it represents a useful diagnostic tool that does not affect the integrity of the abdominal wall. MATERIALS AND METHODS: The current study resumes the experience of a medium volume primary center. Between March 2010 and October 2015, 38 patients were diagnosed with small bowel obstruction and suffered laparoscopic interventions. In 7 cases conversion to open surgery was necessary. RESULTS: Mortality was 0% and specific morbidity was 12%. The mean operating time was 87.2 minutes with wide variations depending on etiology and the mean postoperative hospital stay was 4.7 days. CONCLUSION: The laparoscopic approach of small bowel disease is feasible and safe in selected cases and offers evident benefits regarding to the integrity of the abdominal wall, rapid return of bowel function and shorter hospital stay.
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Obstrução Intestinal/cirurgia , Intestino Delgado/cirurgia , Laparoscopia , Adulto , Idoso , Conversão para Cirurgia Aberta/estatística & dados numéricos , Estudos de Viabilidade , Feminino , Hospitais Universitários , Humanos , Obstrução Intestinal/diagnóstico , Obstrução Intestinal/epidemiologia , Obstrução Intestinal/etiologia , Laparoscopia/métodos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Prevalência , Estudos Retrospectivos , Fatores de Risco , Romênia/epidemiologia , Resultado do TratamentoRESUMO
BACKGROUND: Surgical site infections (SSIs) represent a noteworthy contributor to both morbidity and mortality in the context of patients who undergo colorectal surgery. Several risk factors have been identified; however, their relative significance remains uncertain. METHODS: We conducted a meta-analysis of observational studies from their inception up until 2023 that investigated risk factors for SSIs in colorectal surgery. A random-effects model was used to pool the data and calculate the odds ratio (OR) and 95% confidence interval (CI) for each risk factor. RESULTS: Our analysis included 26 studies with a total of 61,426 patients. The pooled results showed that male sex (OR = 1.45), body mass index (BMI) ≥ 25 kg/m2 (OR = 1.09), American Society of Anesthesiologists (ASA) score ≥ 3 (OR = 1.69), were all independent risk factors for SSIs in colorectal surgery. Conversely, laparoscopic surgery (OR = 0.70) was found to be a protective factor. CONCLUSIONS: The meta-analysis conducted revealed various risk factors, both modifiable and non-modifiable, associated with surgical site infections (SSIs) in colorectal surgery. These findings emphasize the significance of targeted interventions, including optimizing glycemic control, minimizing blood loss, and using laparoscopic techniques whenever feasible in order to decrease the occurrence of surgical site infections in this particular group of patients.
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Cystic echinococcosis is a zoonotic parasitic disease that affects the liver in more than 70% of cases, and there is still an underestimated incidence in endemic areas. With a peculiar clinical presentation that ranges from paucisymptomatic illness to severe and possibly fatal complications, quality imaging and serological studies are required for diagnosis. The mainstay of treatment to date is surgery combined with antiparasitic agents. The surgical armamentarium consists of open and laparoscopic procedures for selected cases with growing confidence in parenchyma-sparing interventions. Endoscopic retrograde cholangiopancreatography (ERCP) is extremely useful for the diagnosis and treatment of biliary fistulas. Recent relevant studies in the literature are reviewed, and two complex cases are presented. The first patient underwent open surgery to treat 11 liver cysts, and during the follow-up, a right pulmonary cyst was diagnosed that was treated by minimally invasive surgery. The second case is represented by the peritoneal rupture of a giant liver cyst in a young woman who underwent laparoscopic surgery. Both patients developed biliary fistulas that were managed by ERCP. Both patients exhibited a non-specific clinical presentation and underwent several surgical procedures combined with antiparasitic agents, highlighting the necessity of customized treatment in order to decrease complications and successfully cure the disease.
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Colangiopancreatografia Retrógrada Endoscópica , Equinococose Hepática , Feminino , Humanos , Fístula Biliar/diagnóstico por imagem , Fístula Biliar/etiologia , Equinococose Hepática/diagnóstico por imagem , Equinococose Hepática/complicações , Equinococose Hepática/cirurgia , Laparoscopia/métodos , Fígado/diagnóstico por imagem , Fígado/patologia , Tomografia Computadorizada por Raios X/métodosRESUMO
Adhesive joints are widely used for structural bonding in various industrial sectors. The performance of bonded joints is commonly attributed to the cleanliness of the substrate and the pre-treatment of the surfaces to be bonded. In this study, the Matrix Assisted Pulsed Laser Evaporation (MAPLE) deposition technique was used for surface modification of aluminum (Al) plates by the deposition of poly(propylene glycol) bis(2-aminopropyl ether) (PPG-NH2) of different number average molecular weights (Mn) of 400 g mol-1, 2000 g mol-1, and 4000 g mol-1, respectively. Fourier-transformed infrared spectroscopy (FT-IR) analysis indicated the characteristic peaks for the deposited layers of PPG-NH2 of different molecular weights in all cases while scanning electron microscopy (SEM) revealed continuous layers on the surface of Al plates. In order to demonstrate alterations in the wettability of Al substrates, a crucial aspect in surface treatment and adhesive bonding, measurements of contact angles, surface free energies (SFE), and adhesion work (W a) were conducted. The tensile strength measurements were performed using the lap-joint test after applying the commercial silyl-based polymer adhesive Bison Max Repair Extreme Adhesive®. It was evidenced that at higher values of the SFE and W a, the tensile strength was almost 3 times higher for PPG-NH2 with Mn = 4000 g mol-1 compared with the untreated Al sample. This study provides valuable insights into the successful application of the MAPLE technique as a pre-treatment method for reinforcing adhesive bonding of Al plates, which can lead to improved mechanical performance in various industrial applications.
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Choledochal cysts (CCs) are rare occurrences presenting as dilatations of biliary structures, which can present as single or multiple dilatations and can appear as both intra- and extrahepatic anomalies. The most widespread classification of CCs is the Todani classification, but there have been numerous reports of cysts that do not fall into any of the types described. We present such a case-a male patient 36 years of age who underwent preoperative CT, MRCP, and ERCP, which mistakenly indicated a type II Todani CC, and intraoperatively was found to be located at the confluence of the hepatic ducts and encompassed the origin of the common bile duct. Complete resection of the cyst and the proximal segment of the common bile duct was performed, and reconstruction was carried out by Roux-en-Y double-tutorized hepaticojejunostomy. Considering the risk of malignant transformation, the frequent preoperative misdiagnosis, as well as the technically challenging surgery required in such cases, we advocate for a revision of the classification and raise awareness of the need for guidelines regarding the proper short-term and long-term management of this disease to ensure adequate quality of life and disease-free survival for patients.
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Chronic wounds encompass a myriad of lesions, including venous and arterial leg ulcers, diabetic foot ulcers (DFUs), pressure ulcers, non-healing surgical wounds and others. Despite the etiological differences, chronic wounds share several features at a molecular level. The wound bed is a convenient environment for microbial adherence, colonization and infection, with the initiation of a complex host-microbiome interplay. Chronic wound infections with mono- or poly-microbial biofilms are frequent and their management is challenging due to tolerance and resistance to antimicrobial therapy (systemic antibiotic or antifungal therapy or antiseptic topicals) and to the host's immune defense mechanisms. The ideal dressing should maintain moisture, allow water and gas permeability, absorb wound exudates, protect against bacteria and other infectious agents, be biocompatible, be non-allergenic, be non-toxic and biodegradable, be easy to use and remove and, last but not least, it should be cost-efficient. Although many wound dressings possess intrinsic antimicrobial properties acting as a barrier to pathogen invasion, adding anti-infectious targeted agents to the wound dressing may increase their efficiency. Antimicrobial biomaterials may represent a potential substitute for systemic treatment of chronic wound infections. In this review, we aim to describe the available types of antimicrobial biomaterials for chronic wound care and discuss the host response and the spectrum of pathophysiologic changes resulting from the contact between biomaterials and host tissues.
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Acquired benign trachea-oesophageal fistula is a rare benign pathological entity with varying aetiologies that most often occurs post-intubation. This case report presents the case of a female patient, 31 years old, admitted to the emergency room with sepsis syndrome following bilateral aspiration pneumonia caused by a large trachea-oesophageal fistula. The fistula was the result of intra-tracheal migration of an oesophageal stent placed for post lye ingestion stenosis. Esophageal diversion and partial resection with oesophageal patch to repair the tracheal defect, under general anaesthesia with ventilation using rigid bronchoscopy and high frequency jet ventilation (HFJV), followed at a later date by esophageal replacement with colic graft were the procedures performed with a view to curing the patient. In conclusion, complex cases always require a tailored approach. It is important to note that HFJV may be applied for a longer period of time and the oesophagus can be used as patch for the posterior tracheal wall in selected cases. Staged surgery is also an option when the patients' poor health status does not permit major surgery.
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BACKGROUND: Laparoscopic cholecystectomy in situs inversus totalis (SIT) is a technically and physically demanding procedure for surgeons and there is still a lack of consensus regarding the best technical approach in such cases. We conducted a systematic review and meta-analysis to evaluate port placement, the dominant hand of the surgeon, preoperative imaging, morbidity, and mortality. METHODS: We searched MEDLINE, SCOPUS, Web of Science, and the Cochrane Library for studies of patients with SIT that underwent laparoscopic cholecystectomy. Of 387 identified records, 101 met our inclusion criteria, all of them case reports or case series of maximum of 6 patients. RESULTS: Out of the 121 patients included in the analysis, 94 were operated on using a "mirrored American" technique, 12 using the "Mirrored French", 9 employed single-port techniques, and 6 described novel port placements. Even though most surgeries were conducted by a right-handed surgeon (93 cases), surgeries performed by the seven left-handed surgeons yielded shorter intervention times (p = 0.024). Preoperative imaging (CT, MRI, MRCP, ERCP) also correlated with a lower duration of surgery (p = 0.038. Length of stay was associated with the type of disease, but not with other studied endpoints. Morbidity was less than 1%, and conversion rates and mortality were nil. CONCLUSIONS: Cholecystectomy in SIT is a safe but challenging procedure and surgeons should prepare in advance for the unfamiliar aspects of completing such a task. While preoperative imaging and a left-handed surgeon are beneficial in terms of surgery length, when these are not available surgeons should focus on achieving the most comfortable setting based on their experience and tailor their approach to the patient at hand. Further studies are needed in order to properly describe and evaluate intraoperative findings as well as surgeon-dependent factors that could improve future recommendations.