Spontaneous rupture of gastroduodenal artery aneurysm.

Gastroduodenal artery (GDA) aneurysm is a rare entity, comprising only 1.5% of all 3000 cases of visceral artery aneurysms that have been reported in literature. We report a case of a 55-year-old Caucasian man, diagnosed with right inguinal hernia. He was admitted to our department for surgical treatment. His medical history was remarkable for hypertension, and angina. He was operated the next day. A external oblique right inguinal hernia was diagnosed intraoperative. The Halsted technique was used for primary inguinal hernia. Immediate postoperative evolution was favorable, systolic blood pressure of 120 mmHg, pulse of 68 beats/minute. 16 h postoperative there was a sudden alteration of the general condition with signs of hemodynamic shock, with a systolic blood pressure of 60 mmHg, tachycardia of 110 beats/min. Physical examination revealed a pale, cold, and clammy patient. His hemoglobin had dropped from 14 g/dL on admission to 6 g/dL. A bedside ultrasound identified pelvic free fluid. An exploratory laparotomy revealed hemoperitoneum, and over 2 500 ml of blood and clot, a large hematoma was identified that was occupying the transvers colon mesentery and retroperitoneum. A clot was removed, revealing ruptured gastroduodenal artery aneurysm with active hemorrhage. The opening was isolated and closed. The contents were returned to the abdomen, which was irrigated and closed. Postoperative laboratory evaluation revealed hyperamylasemia (1543 IU/L, Normal Value (NV) = 15-95 IU/L). He remained normotensive throughout his 8-day hospitalization and was discharged home in good condition. In conclusion, gastroduodenal artery aneurysm rupture is a rare and patients can present with nonspecific symptoms. Rapid diagnosis, localization, and surgical or endovascular intervention are necessary to avoid devastating consequences.

'Pole test' measurements in critical leg ischaemia.

BACKGROUND: For the quantification of critical limb ischaemia (CLI) most vascular surgery units use sphygmo-manometric and transcutaneous oxygen pressure (TcPO2) measurements. However, measurements obtained by cuff-manometry can be overestimated especially in diabetic patients because of medial calcification that makes leg arteries less compressible. TcPO2 measurements present a considerable overlap in the values obtained for patients with different degrees of ischaemia and its reproducibility has been questioned. Arterial wall stiffness has less influence on the pole test, based on hydrostatic pressure derived by leg elevation, and this test seems to provide a reliable index of CLI. OBJECTIVE: The objective of this study was to evaluate the pole pressure test for detection of critical lower limb ischaemia, correlating results with cuff-manometry and transcutaneous oxygen pressure. DESIGN: University hospital-prospective study. MATERIALS AND METHODS: Seventy-four patients (83 legs) with rest pain or gangrene were evaluated by four methods: pole test, cuff-manometry, TcPO2 and arteriography. CLI was present if the following criteria were met: (a) important arteriographic lesions+rest pain with an ankle systolic pressure (ASP) < or = 40 mmHg and/or a TcPO2 < or = 30 mmHg, or (b) important arteriographic lesions+tissue loss with an ASP < or = 60 mmHg and/or a TcPO2 < or = 40 mmHg. Fifty-seven lower limbs met the criteria for CLI. RESULTS: Measurements obtained by cuff-manometry were significantly higher to those obtained by pole test (mean pressure difference: 40 mmHg, p<0.001). The difference between the two methods remained statistically significant for both diabetics (50.73, p<0.001) and non-diabetics (31.46, p<0.001). Mean TcPO2 value was 15.51 mmHg and there was no important difference between patients with and without diabetes. Overall, there was a correlation between sphygmomanometry and pole test (r = 0.481). The correlation persisted for patients without diabetes (r = 0.581), but was not evident in patients with diabetes. Correlation between pole test and TcPO2 was observed only for patients with diabetes (r = 0.444). There was no correlation between cuff-manometry and TcPO2. The pole test offered an accuracy of 88% for the detection of CLI. The sensitivity of this test was 95% and the specificity 73%.

[The limits of surgery in the treatment of the icteric patients due to pancreatic head cancer]. / Limitele tratamentului chirurgical al neoplasmului de cap de pancreas la pacientii icterici.

Aim is to present the limits of surgery, determined by the dimension of the tumor and vascular invasion, in the treatment of the icteric patients with pancreatic head cancer. This paper is a retrospective study realized in Timisoara City Hospital, Surgery Clinic, on 68 patients, hospitalized for icteric syndrome due to pancreatic head cancer. Surgery was performed in 66 patients: 4 (6%) pancreaticoduodenectomy, Whipple modified technique, 62 (94%) palliative surgery which consists in a biliodigestive shunt associated with a gastroenterostomy, and 2 patients were not operated. In palliative treatment, 10 (15%) patients had complications and 3 (4.5%) died within 1 month after surgery. In the case of the patients with duodenopancreatectomy, there was no morbidity or mortality. Survival after one year was 0% in palliative treatment and 100% in pancreaticoduodenectomy. In icteric patients due to pancreatic head cancer, the possibility of pancreaticoduodenectomy without vascular resection is reduced (6%). Modified Whipple technique was imposed by the dimensions of the tumor (more than 3 cm) and vascular invasion, determining in the first place, the dissection of the vascular tree: portal, mesenteric, caval; and pancreaticoduodenectomy was performed only if there was no invasion.

[Synchronous sigmoid and superior rectal resection and left hepatic lobectomy extended to Spiegel lobe for a sigmoid cancer with hepatic metastasis. Case report]. / Rezectie sincrona, de colon sigmoid si lobectomie hepatica stângâ extinsa la segmentul I pentru un neoplasm sigmoidian cu metastaze hepatice.

The recent developments of surgical technologies allowed the achievement of some standardized interventions with anatomical and functional visa, which based on the improvement of anesthesia and intensive care, and not least by elaboration of efficient chemotherapy protocols, determined new horizons in the treatment of advanced cancers. This work presents a case witch was hospitalized at the Department of Hepatic Surgery, of City Hospital from Timisoara for a colorectal cancer stage IV (T3N1M1), with hepatic metastasis localized at the left hepatic lobe (II and III segments) and Spiegel lobe. A surgical intervention was performed, when in the same operating time was practiced a sigmoid and superior rectal resection (Hartmann) and also a left hepatic lobotomy extended to the first segment. The post operating evolution of the patient was favorable and also after fourth month from the surgery, when no signs of relapse were established at reevaluation.