Surgical technique in the laparoscopic repair of Morgagni hernia in adults. How do we do it?

INTRODUCTION: Adult Morgagni hernias are rare congenital diaphragmatic hernias, which can present with an array of symptoms based on the size and the contents of it. This article focuses primarily on the laparoscopic repair with transfascial suturing. METHODS: A number of five patients over the course of 10 years were admitted in our clinic, one of them being admitted with emergency symptoms. Four of the patients were treated laparoscopically, one of them requiring conversion to open approach. RESULTS: The median age was 53 (range 44-71), 80% of the patients being females. Four of the patients received laparoscopic treatment with transfascial suturing, the fifth being converted, but respecting the same technique. The median surgery duration was 110 min, with a median blood loss of 30 ml. Removal of the sac was attempted in two cases. Median hospitalization stay was 3 days, with a median follow-up of 21 months, with no postoperative complications reported. CONCLUSIONS: Laparoscopic repair with transfascial suturing provides an feasible and efficient repair, compared to the other laparoscopic techniques. Although no postoperative complications were reported, the removal of the sac still remains an controversial issue.

Risk factors for complications after duodenopancreatectomy. Initial results after implementing a standardized perioperative protocol.

INTRODUCTION: During 1993-2008 period, in the Surgical Clinic III were conducted several retrospective studies, in order to identify risk factors for complications after cephalic duodenopancreatectomy(DP). As a result of these studies, a preoperative protocol was developed for preparation of patients proposed for DPC, as well as a number of intraoperative technical changes in order to improve postoperative morbidity and mortality. Implementation of the protocol was gradually and inomogenic done in our service. METHODS: The study is prospective, conducted in 2009-2012, ina group of 180 patients and aims to evaluate immediate results after DPC for periampular malignancy, looking to analyze the effects of implementation of the protocol mentioned above.We analyzed the rates of complications (pancreatic fistula,blunt pancreatitis, bleeding from the pancreatic blunt, delayed gastric emptiness), and the factors that might influence their occurrence. RESULTS AND CONCLUSIONS: of the 180 patients, 10 (5.5%) developed pancreatic fistula and 24 (13.3%) had delayed gastric emptiness. Among the factors that have been significant associated with these complications we mention: the pancreatico-jejunalanastomosis and gastro-jejunal transmesocolic assembly. With the implementation of the protocol, the risk factors previously identified in retrospective studies performed in our service(elevated transaminases, experienced surgical team, etc.) have lost significance, but they have not disappeared entirely, due to fact that the conduit proposed was not entirely followed. We believe that the homogeneous application of a perioperative guide, together with a standardized surgical technique, will lead to improve immediate results after DP.

THE EFFECT OF SEED TREATMENT ON THE MAIN PATHOGENS PRESENT IN WHEAT AGROECOSYSTEMS.

Wheat crop (Triticum aestivum L.) from Poaceae family is affected by many diseases that cause yield losses. The present paper addresses a topic of economic, agrotechnics and social importance of wheat crop (occupying the first place among the Romanian cultivated crop, feeding 35 to 40% of world population). The study had as main objective product testing like Yunta 246 FS (imidacloprid 233 g/l + tebuconazol 13 g/l), Team Micorriza Plus (Glomus intraradices 150 spore/g + Glomus mosseae 150 spore/g + organic matter 56% and Rhizosphere Bacteria 107 UFC/g) and Condor (Trichoderma spp. 1 x 109 spore/g + Glomus sp. 10 spore/g + Rhizosphere Bacteria 1 x 107 UFC/g and organic matter 7%) applied in the pathosystem wheat/pathogens. The research was conducted in the western part of Romania, in 2010-2012, experience was placed after Latin rectangle method with 10 variants (they are different by product and dose applied) and the data were statistically interpreted. Results showed the presence of pathogens Septoria tritici, Drechslera tritici repentis and Drechslera teres in experimental variants. Statistical analysis showed that the most effective chemical mixture was imidacloprid + tebuconazol at the highest dose tested (3 l/t). Regarding the non-chemical product testing, the product Condor gave positive results. The highest values of quality parameters (protein and gluten) were obtained in the variants treated with Yunta 246 FS.

Pre-operative hypoalbuminemia in colorectal cancer patients undergoing elective surgery - a major risk factor for postoperative outcome.

BACKGROUND: The incidence of hypoalbuminemia in surgical patients varies in different studies with age, tumor stage, time interval to the first referral to a doctor, symptoms of disease and nutritional habits of the population. The main objective of this study was to evaluate the incidence of hypoalbuminemia in colorectal cancer patients undergoing scheduled surgery in an academic hospital in Romania and the impact of hypoalbuminemia on perioperative outcome. The secondary objective was to identify other possible risk factors for the post operative outcome. MATERIAL AND METHODS: 252 patients undergoing scheduled colorectal surgery with anastomosis have been enrolled in the study. Incidence of hypoalbuminemia (serum albumin 3.5 g dL), fistulas and other postoperative complications (e.g.infections) has been evaluated. LOS and 30-days mortality have also been evaluated comparatively in patients with normal and low serum albumin. RESULTS: 28.9% of our patients were hypoalbuminemic. The incidence of fistulas was 5.5 % in the study group and 2.3% and 13.3% in patients with normal serum albumin and hypoalbuminemic patients, respectively (p=0.001). Multivariate analysis showed that the OR was 6.65 [95% CI:2.01-21.96] inpatients with moderate hypoalbuminemia and 24.75 [95% CI:6.75-90.67] in patients with severe hypoalbuminemia.Association between alcohol consumption and smoking increased risk ratio to 1.96 [95% CI: 0.51-7.46]. CONCLUSION: The high incidence of hypoalbuminemia in our patients justifies preoperative nutritional interventions and specific surgical protocols in emergency cases. Further studies are needed to exactly quantify the impact of smoking and alcohol consumption on postoperative outcome.

[Non-ulcerous duodenal perforations: a clinical analysis of 23 cases]. / Perforatiile neulceroase ale duodenului: analiza a 23 de cazuri.

Non-ulcerous duodenal perforations are a rare and seldom studied pathology. The present retrospective study analyses a group of 23 patients, over a 10 year period (Jan 1st 2000 - Dec 31st 2009) with this pathology. The most frequent etiology was iatrogenic (52.17 % after ERCP and 17.39% after upper gastrointestinal endoscopy). Other rare etiologies included were tumoral perforations, penetrating wounds, and ingestion of foreign bodies. The lesions vary from millimetric perforations to total necrosis of the wall of a duodenal segment and are often associated with other complex lesions. The overall mortality was 52.17%, a little lower for the post ERCP injuries (40%). Usually the iatrogenic lesions are diagnosed earlier (ex. 54.54% of the post ERCP lesions undergo surgery during the first 24 h), probably increasing the chance of surviving. 43.47% of cases undergo surgery in the condition of severe sepsis, with multiple organ failure, thus aggravating the prognosis. Sometimes the patient required multiple interventions (with a maximum of 8 in our group). In 26% of the cases the primary intervention was just paraduodenal and/or retroperitoneal drainage, suture of the duodenum (6 cases - 26%), usually under the protection of a gastro-enteroanastomosis (4 cases - 17.39%), suture of the duodenum around a decompression tube (26%), sometimes suture of the duodenum with a jejunal serous patch or duodeno-jejunal anastomosis. The bile drainage and the jejunostomy were associated sometimes. The procedures in this pathology have a significant morbidity, with a high rate of reinterventions (30.4%).

[Intrabiliary rupture of hepatic hydatid cysts: results of 17 years' experience]. / Chisturile hidatice hepatice rupte în arborele biliar: experienta a 17 ani.

UNLABELLED: Between 1990 and 2006 in the III-rd Surgical Clinic Cluj-Napoca, 366 pacients with hepatic hydatid cyst were admitted and underwent surgery; 81 (22.13%) of them, who had a cyst-biliary comunication, were retrospectively reviewed: 52 (64.2%) had an occult communications and 29 (35.8%) had a frank intrabiliary rupture. The sex ratio was M/F=46/35 with a mean age of 44.5 years and with ages between 17 and 73 years. Choledochotomy, evacuation of parasitic material and lavage of the CBP were performed in all patients with frank intrabiliary rupture. In 25 patients, partial pericystectomy and choledochoduodenostomy/T-tube drainage of CBP was performed. Internal drainage by a Roux-en-Y pericystectojejunostomy and biliodigestive anastomosis was carried out in 2 patients, while other two patients underwent external drainage of cystic cavity and T-tube drainage of CBP. 15 patients (51.7%) had postoperative external bile leaks (fistulas). Occult communications were managed by partial pericystectomy +/- narrowing of the residual cavity (capitonage with an omentum flap or invagination of the fibrosis capsule margins into the cavity) in 35 patients (67.3%) while in 10 patients (19.2%) internal drainage by a Roux-en-Y pericystectojejunostomy was carried out. Regional resection of the liver was performed in 4 cases (7.7%) and external drainage of residual cavity in 3 patients (5.7%). 13 patients (25%) had postoperative external bile leaks (fistulas). The mean postoperative hospitalisation was 20 days with the range 5-85 days. The mortality rate was 2.4% (2 patients): one died due to septicemia and MOFS and the other due to pulmonary thromboembolism. CONCLUSION: Postoperative bile leaks (fistulas) fallowing conservative surgery of ruptured hydatid hepatic cyst into the biliary tract are not rare regardless of the type of rupture (frank or occult). Although the opening of the biliary duct is sutured, the risk of biliary fistulas is not clearly corelated with this approach; in such cases internal drainage provides a good alternative with low morbidity.

[Clinical aspects with prognostic value in gastric cancer--analysis of 468 cases with gastric adenocarcinoma]. / Aspecte clinice cu implicatie prognostica în cancerul gastric--analiza a 468 cazuri de adenocarcinom gastric.

The aim of this study is to assess clinico-pathological parameters and find out the correlation between them and their possible prognostic value. We made a retrospective analysis of a group of 468 patients with gastric adenocarcinoma which were operated in the 3rd Surgical Clinic--Cluj Napoca--01.01.1998-31.12.2003. The median age was 62 years. Patients in pTNM 0 stage were significantly younger than the rest of patients, with an average of 7.5 years. The male/female ratio was 1.7:1, this ratio being significantly higher in cases with proximal gastric cancers. There was not found any significant correlation between the interval : onset of symptoms and surgery, and pTNM stage. The most frequent signs and symptoms were epigastric pain, weight loss, indigestion, fatigue, pallor and loss of appetite, each of them were found in more than 40% patients. Multivariate analysis of symptoms showed that weight loss (p=0.00638) was independently correlated to advanced pTNM stages. The number of signs and symptoms was significantly correlated to advanced pTNM stages (p=0.000026). This significant group of patients studied has maintained characteristics encountered in populations with higher incidence of gastric adenocarcinoma, men being more frequently affected, distal localization and intestinal histologic type being encountered more frequently.

[Morbidity and mortality in gastric cancer surgery--analysis of 468 cases with gastric adenocarcinoma]. / Morbiditate si mortalitate în chirurgia cancerului gastric--analiza a 468 cazuri de adenocarcinom gastric.

The aim of this study is to evaluate the morbidity and mortality in the surgical treatment of gastric cancer and the factors that could influencing them. We made a retrospective analysis of a group of 468 patients with gastric adenocarcinoma which have been operated in the 3RD Surgical Clinic-Cluj Napoca--01.01.1998-31.12.2003. We analyzed parameters related to patient, pTNM stage and type of treatment. Morbidity was significantly higher in these circumstances: elder patients, cases with lower serum levels of hemoglobin and total proteins, after Billroth II procedures; we found no significant differences of morbidity depending on gender, pTNM stage, type of intervention: simple or multiorgan resection, subtotal or total gastrectomy, radical or palliative procedure or only exploratory laparotomy, presence or absence of splenectomy or caudal pancreatectomy, D1 or D2 lymphadenectomy (in radical procedures), palliative resection or gastrojejunal bypass. Elder patients and male patients have had a mortality significantly higher; we found no significant differences of mortality depending on serum levels of hemoglobin and total proteins, pTNM stage, type of intervention: simple or multiorgan resection, subtotal or total gastrectomy, radical or palliative procedure or only exploratory laparotomy, presence or absence of splenectomy or caudal pancreatectomy, D1 or D2 lymphadenectomy (in radical procedures), type of restoring of the digestive continuity after subtotal gastrectomy, palliative resection or gastrojejunal bypass.

[Procedures for preventing postoperative nausea and vomiting after laparoscopic cholecystectomy: dexamethasone and ondansetron].

This randomized double-blind study was undertaken to evaluate the efficacy of ondasetron and dexamathesone in reducing the incidence of postoperative nausea and vomiting after laparoscopic cholecystectomy. The study covered 60 patients (ASA I/II) who had undergone laparoscopic cholecystectomy under general anesthesia. The patients were divided into two groups: 1) 30 patients who received dexamethasone, 4 mg i.v.; and 2) 30 patients who took ondansetron, 4 mg i.v., prior to general anesthesia. Postoperatively, nausea, vomiting, and severe pain (VAS) were observed every 6 hours within the first 24 hours. Postoperative nausea and vomiting occurred in 6 (20) patients in Group I and in 13 (43.33) patients in Group 2 (p < 0.05), while vomiting did only in 5 (16.66%) patients in Group I and 4 (13.33%) in Group 2 (p > 0.05). The least intensity of postoperative pain was observed in Group 1, but the difference between the study groups was insignificant. It is concluded that dexamethasone is more effective in preventing postoperative nausea and vomiting after laparoscopic cholecystectomy than ondansetron. This is mainly determined by a significant reduction in the incidence of postoperative nausea.

[Gastrojejunocolic fistula--a rare complication of stomach surgery]. / Fistula gastrojejunocolica--complicatie rara a chirurgiei stomacului.

The gastrojejunocolic fistula represents a clinical entity that occurs very rarely following gastro-jejunal anastomoses and manifests itself clinically and paraclinically by a severe malabsorption syndrome. The results of the physiopathological approach may be summed up as follows: reduced level of seric proteins, fluid and electrolytic depletion, deficiencies in the absorption of the vitamins soluble in fats and water, which may all vary from mildness to severeness, depending on the flow rate of the fistula. Most often, the diagnosis is set by performing barium enema, which is positive for all cases, whereas the barium passage is less efficient, enabling diagnosis in only 33% of the cases. The radiological image may be reduced on principle to one single sign: the abnormal fistulous trajectory (barium passes from the stomach directly into the colon or the enema fills the gastric lumen). It is recommended that surgical treatment be performed in a single stage, by resecting the entire fistula and re-establishing the gastro-jejunal and colic continuity. We report a case of gastrojejunocolic fistula in a patient that underwent 2/3 gastric resection for gastric ulcer 9 years ago.

[A possible protocol for postoperative management in laparoscopic cholecystectomy]. / Posibil protocol de abordare perioperatorie a colecistectomiei laparoscopice.

The goal of the "Prospect" programme (sponsored by Pfizer) is to create possible evidence-based protocols related to the management of postoperative pain after certain type of surgical intervention (e.g. hernia repairs, hysterectomies, etc.). This article is introducing the protocol for laparoscopic cholecystectomy for both day-case and longer hospital admission cases. The protocol is designed for preoperative, intra and postoperative period, choosing only those measures which were effective for postoperative pain, published in the literature. We are also presenting an analyze of our 13,000 laparoscopic cholecystectomies, from "Prospect" protocol point of view, and what we should do to improve the management of postoperative pain.

[Sandostatin treatment in postoperative external digestive fistulae]. / Tratamentul cu Sandostatin în fistulele digestive externe postoperatorii.

The aim of the conservative treatment of postoperative external digestive fistulae is to obtain a reduction of the output, thus favoring spontaneous closure and shortening outcome. A retrospective comparative study has been performed on two groups of patients with postoperative anastomotic gastrointestinal and pancreatic fistulae. Group A included 18 cases (14 anastomotic, 4 pancreatic fistulae) receiving conventional treatment only. Group B included 25 cases (18 anastomotic and 7 pancreatic fistulae) in which Sandostatin was associated to conventional therapy, using daily doses ranging from 0.1 mg to 0.3 mg, administered after variable intervals after fistulas' occurrence. Duration of treatment ranged from 1 to 25 days. In group A, 27.77% of the cases were cured in comparison with group B in which the healing rate increased to 56%. Global hospital mortality rate was 25.58% (11 cases). In group A this was 44.44% (8 cases) in comparison with group B with 12% (3 cases) only. As a conclusion of our study, the use of Sandostatin is remarkable effective in the treatment of external digestive postoperative fistulae. Thus a doubling of healing rate and a reduction by 73% of mortality rate was achieved.