Isolated Ileum Perforation Following Veal Attack in a Pacient with an Undiagnosed Inguinal Hernia: Case Report and Review of the Literature.

We present a rare case of a 74 year old man admitted by ambulance to our department following a blunt minor abdominal trauma (veal attack). He complained of pain in the left abdominal flank and in the lower abdomen. The lower abdomen was tender, moderate distended but not rigid. He also had a left inguinal uncomplicated hernia. Because he was hemodynamic stable we performed a CT - scan who revealed several pockets of free air anteriorly in the midline. One hour and a half after admission the pacient underwent exploratory laparotomy, revealing a antimesostenic perforation of the ileum about 120 cm from the ileo-cecal valve. Simple closure in one layer was performed. The inguinal hernia wasn't repaired at the time of the first surgery. The postoperative course was favorable, the pacient being discharged on the 8th postoperative day.

Can the Principles of Oncological Surgery be Complied with in Haemorrhagic Gastric Cancer?

AIM: To discover if in the case of bleeding gastric cancer the principles of oncological surgery could be applied to gastric cancer. METHODS: We studied two groups of patients, one with haemorrhagic gastric cancer and the second with uncomplicated gastric cancer. We took into account gender, age, number of days from admission to surgery, tumour location, type of intervention,haemoglobin on admission, haemorrhage externalization pathway, comorbidities, intervention type, extension of lymphadenectomy, stage, tumour type degree of differentiation there of, number of excised lymph nodes, perineural and vascular invasion, preoperative transfusion, postoperative complications, deaths. RESULTS: The rate of postoperative complications is higher for patients in group 1 who presented upper gastrointestinal bleeding, an increase in the number of days of hospitalization and care, with a higher risk of surgical re-intervention and a higher mortality for these patients. CONCLUSIONS: in the case of haemorrhagic gastric cancer surgery,we can apply the principles of malignant stomach cancer surgery, but with a higher rate of postoperative complications,more hospitalization days and higher mortality.

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.

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.

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.

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.

Hematochezia due to Caecal Angiodysplazia led to Diagnosis of a Transverse Colon Cancer in a Young Female Patient: Case Report and Literature Review.

We present an unusual case of a caecal angiodysplasia whose bleeding determined the discovery of a mid-transverse colon cancer in a 26 years old female patient. After the initial successful angiographic treatment of the caecal lesion the patient underwent laparoscopic - assisted transverse colectomy. The postoperative evolution was favorable, without resumption of bleeding episodes and rapid social reintegration. The histopathology revealed mucinous adenocarcinoma that penetrates the visceral serous with 7 lymph nodes invasion of 18 examined. As a result of the advanced stage, pT4aN2bM0 - stage IIIC, the life expectancy at 5 years is between 30 to 50%.

The role of angiography and embolization in blunt splenic trauma.

The spleen is one of the most vulnerable organs in the event of an abdominal trauma. Preservation of the spleen and of course its functions has been a continuing challenge familiar not only for trauma surgeons but also for all those for whom the integrity of this organ was a well-founded goal. Therefore nonoperative management (NOM) of spleen trauma injury has faced a continuous development, gradually becoming an option of healing by first intention among Trauma Centers. Through the development of modern technology it has become possible to keep observation documents on the evolution of blunt splenic injuries and, also, minimally invasive therapeutic approach has become possible. Out of these approaches angiography and consecutive embolization are gaining more and more ground considering the increasing experience and the convincing results that have been constantly reported in the last few years.

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.

Involvement of reactive oxygen species in the mechanisms associated with cervical cancer specific treatment.

Cervical cancer represents a genuine health issue in Romania.The courses of treatment applied are complex, and the accompanying biochemical mechanisms are yet to be fully understood. Thus, radiotherapy, which induces reactive oxygen species, can lead to failure of treatment in hypoxic tissues,tissues which are difficult to identify due to the small quantity in which these cytotoxic species are produced. As a result, the aim of this paper is to identify the production and role of reactive oxygen species, as well as the manner of activation of endogenous antioxidant defense mechanisms in cervical cancer patients admitted to the Oncologic Institute of Bucharest. To this purpose the biochemical parameters of oxidative stress were identified in 30 patients with cervical tumour localization, prior to surgery. The results obtained have showed that a production of reactive oxygen species is identifiable in these patients, having lipids as a primary target and leading to their peroxidation. The extension of protein oxidative degradation takes place at a much lower value, as well as the activation of endogenous antioxidant defence systems, comparing to our expectations. To conclude,we consider that when the production of active oxygen metabolites takes place in small concentrations, associated with hypoxia, the signals transmitted are towards modifying the phenotype under anaerobic conditions into one activating neo vascularization, angiogenesis initiation, new cell growth and proliferation. The moment that this phase is overcome anew oxidative stress is installed, one potentially destructive for biomolecules essential to life, but also useful for further treatment, such as radiotherapy.

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.

Splenic implant assessment in trauma.

Trauma is a global health issue, being the 4th death cause after cardio-vascular disease, malignancies and chronic pulmonary diseases and the main death cause among young people, under 45 years (1). The frequency of abdominal trauma is 10-12% of all polytrauma, and from all abdominal organs, the spleen and liver are the most often involved in polytraumatized patients case (2). The first purpose of a successful operational management is the control of active bleeding, and the second is preserving as much as possible of the destroyed organs. Over the last decades, the treatment of spleen traumas had been diversified,from nonsurgical treatment to surgical, also complex and diversified: from conservative treatment to splenectomy.Currently, from a therapeutic standpoint, the trends in spleen trauma are orientated towards conservative methods as the clinical and experimental data have shown that €œit is better with the entire spleen than part of it, and better with a part of it than with none at all (Raymond Hinshaw) (3).

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.

A rare cause of acute massive lower gastrointestinal bleeding.

Even if lower gastrointestinal bleeding (LGIB) can present as trivial haematochezia, massive hemorrhage with shock may occur. Acute massive LGIB is defined as bleeding of recent duration that originates beyond the ligament of Treitz and encompasses: passage of a large volume of red or maroon blood through the rectum, haemodynamic instability and shock, initial decrease in haematocrit level of 6 g/dL or less, transfusion of at least 2 U of packed red blood cells, bleeding that continues for 3 days or significant rebleeding in 1 week. This report presents the case of a 58-year-old man with massive LGI bleeding. Colonoscopy was performed in emergency with a poor colonic preparation, but the examiner fortunately and with difficulty managed to identify the source of the haemorrhage- a Dieulafoy's lesion of the right colon. The bleeding was successfully stopped permanently by injecting sclerosing agents into the spurting vessel. We have preferred colonoscopy as our first choice of investigation due to the facile availability and the opportunity of endoscopic haemostasis in case of finding the source of bleeding. Angiography was planned in case of failure of the first method. The definition, clinical presentation, and treatment of Dieulafoy's lesion are further discussed.

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.

[Mechanism of injury--trauma kinetics. What happend? How?]. / Mecanismul lezional--cinetica in trauma. Ce s-a intâmplat? Cum?

INTRODUCTION: Understanding the mechanism of injuries represents a key element in blunt and penetrating trauma management. METHOD: Systematic review of the main types of the modem trauma mechanisms, using Medline, Cochrane Library and Embase databases. RESULTS: To properly understand the road car accident injuries, trauma surgeon should know as many details from the scene: the speed of cars, impact direction, if the car rolled over, if occupants were restrained, if airbags exploded, vehicle telemetry, extrication time. Motorcyclists are 20 to 30 times more at risk for severe injuries or death than the four-wheel vehicle occupants. Current evidence shows a significant decrease in injuries severity by increasing use of seat-belts, motorcycle helmets, childrestrains and speed limit. Despite this, few countries around the world have road safety laws relating to key factors that can be considered sufficiently comprehensive in scope. Many modern trauma systems use for prehospital triage mechanism of injury criteria. CONCLUSIONS: The trauma surgeon should know the mechanism of injury. This allows a high suspicion for potential injuries, their early diagnosis and increased quality in the care of trauma patients.

A clinical case of Fournier gangrene.

OBJECTIVE: To present a case of Fournier gangrene and the specific surgical therapy CASE PRESENTATION: A 71-year old patient with a two days history of pain in the perineal region, swelling, developing necrosis and foul-smelling lesions was examined in emergency settings. The swelling of subcutaneous plane involved the flank regions, mainly on the left side. The investigations were performed (full blood count, blood urea, electrolytes, coagulation profile). A Fournier gangrene was diagnosed and surgery performed under general anesthesia. Broad spectrum antibiotics were given concomitantly. The first surgical procedure consisted in surgical debridement and excision of all the necrotic tissue. Cultures were taken. We performed counter incisions bilaterally on both flanks. The communication through the fascial planes was clearly demonstrated, especially on the left side. A loop colostomy was also performed. Multiple re-excisions were further employed. Due to a precarious evolution, the patient were on mechanical ventilation for 13 days. Inotrope medication was given for a total of 19 days and, the antibiotherapy adapted to the antibiogram (Bacterioides eggerthii was identified). The reconstruction of the perineum was later performed and, after 3 months, the colostomy was closed in good conditions without further complications. CONCLUSION: Early recognition and aggressive surgical excision are mandatory for success in patients with Fournier gangrene. Colonic diversion can be very useful if employed from the beginning.

[Perforation of hollow organs in the abdominal contusion: diagnostic features and prognostic factors of death]. / Perforatiile organelor cavitare prin contuzie abdominala: particularitati diagnostice si factori prognostici de deces.

UNLABELLED: Blunt hollow viscus perforations (HVP) due to abdominal contusions (AC), although rare, are difficult to diagnose early and are associated with a high mortality. MATERIALS AND METHODS: Our paper analyses retrospectively data from patients operated for HVP between January 2005 and January 2009, the efficiency of different diagnostic tools, mortality and prognostic factors for death. RESULTS: There were 62 patients operated for HVP, 14 of which had isolated abdominal contusion and 48 were poly trauma patients. There were 9 women and 53 men, the mean age was 41.5 years (SD: +17,9), the mean ISS was 32.94 (SD: +15,94), 23 patients had associated solid viscus injuries (SVI). Clinical examination was irelevant for 16 of the 62 patients, abdominal Xray was false negative for 30 out of 35 patients and abdominal ultrasound was false negative for 16 out of 60 patients. Abdominal CT was initially false negative for 7 out of 38 patients: for 4 of them the abdominal CT was repeated and was positive for HVP, for 3 patients a diagnostic laparoscopy was performed. Direct signs for HVP on abdominal CT were present for 3 out of 38 patients. Diagnostic laparoscopy was performed for 7 patients with suspicion for HVP, and was positive for 6 of them and false negative for a patient with a duodenal perforation. Single organ perforations were present in 55 cases, multi organ perforations were present in 7 cases. There were 15 deaths (15.2%), most of them caused by haemodynamic instability (3 out of 6 patients) and associated lesions: SOL for 9 out of 23 cases, pelvic fracture (PF) for 6 out of 14 patients, craniocerebral trauma (CCT) for 12 out of 33 patients.Multivariate analysis showed that the prognostic factors for death were ISS value (p = 0,023) and associated CCT (odds ratio = 4,95; p = 0,017). The following factors were not confirmed as prognostic factors for death: age, haemodynamic instability, associated SVI, thoracic trauma (TT), pelvic fractures (PF), limbs fractures (LF) and admission-operation interval under 6 hours. CONCLUSIONS: Hollow viscus perforations due to abdominal contusions have a high mortality, early diagnosis is difficult, repeated abdominal CT and the selective use of diagnostic laparoscopy for haemodynamic stable patients with ambiguous clinical examination and diagnostic imaging are salutary. Prognostic factors for death were the ISS value and associated craniocerebral trauma.

[Trauma scores: a review of the literature]. / Scorurile traumatice: revizie a literaturii.

BACKGROUND: A quantitative method for measuring trauma severity has many potential applications: patient triage, a common terminology about injuries severity, prognosis assessment, trauma care audit and epidemiological. METHOD: Systematic review of the literature using computer searching of Library of Medicine and the National Institutes of Health International MEDLINE database using PubMed Entre interface. We have selected articles about the main scoring systems used in today's trauma care. RESULTS: Trauma scores were introduced more than 30 years ago, for assigning numerical values to anatomical lesions and physiological changes after an injury. Physiologic Scores describe changes due to a trauma and translated by changes in vital signs and consciousness. Anatomical Scores describe all the injuries recorded by clinical examination, imaging, surgery or autopsy. If physiological scores are used at first contact with the patient (for triage) and then repeated to monitor patient progress, anatomic scores are used after the diagnosis is complete, generally after patient discharge or postmortem. They are used to stratify trauma patients and to measure lesion severity. Scores that include both anatomical and physiological criteria (mixed scores) are useful for patient prognosis. CONCLUSIONS: Despite their imperfections, trauma scores are very important tools in trauma patients management and research. Using large national databases allow a better research, validation and development of scoring systems.