The time for surgery of peritonitis associated with peritoneal dialysis.

Peritonitis is the main complication of peritoneal dialysis (PD) and also an important factor for raising the cost of the method to the level of hemodialysis. Associated with PD, peritonitis is responsible for the increase of morbidity and mortality of the procedure and, at the same time, the main cause of the technique failure. Severe and prolonged peritonitis or repeated episodes of peritonitis lead to ultrafiltration failure. Peritonitis treatment should aim for a rapid remission of inflammation in order to preserve the peritoneal membrane functional integrity. The treatment of PD peritonitis consists mainly of antibiotic therapy, surgical intervention not being usually required. However, it is of outmost importance to differentiate the so-called "catheter related" peritonitis from secondary peritonitis due to visceral lesions, in which the surgical treatment comes first. The confusion between secondary and "catheter related" peritonitis may lead to serious errors in choosing the correct treatment, endangering the patient's life. The differential diagnosis between a refractory or secondary peritonitis in a peritoneal dialyzed patient may be very difficult. In front of a refractory PD peritonitis, surgical exploration must not be delayed. Also we have to keep in mind that the aim of peritonitis treatment is the saving of the peritoneal membrane and not the catheter.

Preoperative radiotherapy in rectal cancer treatment -- is it really a gold standard?

Preoperative radiotherapy in the treatment of rectal cancer was thought to be an achievement of similar importance to total mesorectal excision (TME), for the therapeutic management of rectal malignancies. However, numerous criticisms have been discussed in this field lately. We have analysed the two main purposes of preoperative radiation: possible sphincter preservation and the conversion of a non-resectable tumor into a resectable one in a series of 31 consecutive patients, operated in our clinic. In 20 of them, preoperative radio chemoradiotherapy was applied, while 11 patients were firstly operated and then irradiated. The surgical procedure included total mesorectal excision in 30 patients, as part of a low anterior resection,in 13 cases and of an abdominal perineal resection, in the other 17 cases. We have found that preoperative radiotherapy improves the local recurrence rate but has no influence on the overall survival rate. However, we should not overlook the adverse effects of this method: toxicity of radiotherapy on the small bowel and the urinary bladder, the healing of the perineal wounds and the risk of anastomotic leaks. We concluded in favor of elective preoperative radiotherapy in selected cases: any T4 tumors, T3 tumors which threaten the mesorectal fascia on MRI, whenever there is a suspicion of nodal involvement and also for very low tumors.

Encapsulating Peritoneal Sclerosis - A rare and serious complication of peritoneal dialysis: Case series.

INTRODUCTION: Encapsulating peritoneal sclerosis is a pathological entity mainly associated with peritoneal dialysis (PD). The clinical syndrome is characterized by various degrees of intestinal obstruction due to thickening, sclerosis and calcification of peritoneum resulting in the encapsulation and cocooning of the bowel. It is a rare but potentially devastating complication associated with a considerable morbidity and mortality. MATERIALS AND METHODS: Cases of encapsulating peritoneal sclerosis (EPS), diagnosed in the Surgical Clinic of "Cantacuzino" Hospital, between 2007 and 2014 were retrospectively reviewed. During this interval, 432 surgical interventions related to peritoneal dialysis were performed: 306 peritoneal access interventions and 124 complications, of which 15 patients with EPS. RESULTS: In all but two cases, the EPS diagnostic was established at the time of the surgical intervention addressed to other complication or pathology. Moreover, in 2 of the 15 patients the diagnostic was established approximately 5 months after PD was discontinued, and, in one of these patients at the time of the extraction of the dialysis catheter. 12 of 15 patients were diabetic. Most patients had a history of multiple peritonitis episodes. All the patients required the passing from peritoneal dialysis to hemodialysis. There were 4 deaths (26,6%) of which one was around two months from the diagnosis. CONCLUSIONS: The timely diagnosis of the condition and the appropriate phase-specific treatment is of utmost importance in EPS. In advanced stages, the surgical intervention performed by a well-trained team could achieve good long-term results.

The new prognostic-therapeutic index - an easy method of establishing surgical indication in the pathology of the diabetic foot.

UNLABELLED: HYPOTHESIS AND AIM: The large number of invalidating surgical interventions in patients suffering from lesions of the diabetic foot, the late recognition of the lesions and sometimes the wrongful interpretation of their severity, have made necessary a multi-parameter study of these types of patients and the elaboration of a therapeutic-prognostic index to guide the physician in adopting the adequate method of treatment. Starting with the therapeutic-prognostic index imagined by professor Traian Patrascu, we have elaborated a new therapeutic prognostic index, by adding new, statistically significant parameters, for the purpose of facilitating the surgical indication, depending on the lesion type. METHODS: A number of 929 patients who were admitted at the Surgery Clinic of the "Dr. I. Cantacuzino" Hospital, between January 2013 and June 2014, have been analyzed, of whom 450 were evaluated retrospectively and 479 prospectively. RESULTS: The new therapeutic prognostic index has been calculated for the retrospective lot, resulting into a concordance between the actual surgical intervention and the prognostic index of 79.4% and, for the patients evaluated prospectively, we have found a confirmation of the relation of 82.6% between the performed surgical intervention and the forecasted surgical intervention, by calculating the index. DISCUSSION: The new therapeutic-prognostic index represents an easy method of establishing the therapeutic conduct of the patient suffering from lesions of the diabetic foot. It is of major use in preventing the execution of such surgical interventions that may be disproportionate compared to the severity of the lesions, especially in facilities where the pathology of the diabetic foot is less known.

Diagnosis characteristics and therapeutical options of infectious complications associated with peritoneal dialysis.

INTRODUCTION: The infectious syndrome associated with peritoneal dialysis is the most important complication of this substitution method of the renal function, also being the main cause of method failure. Refractory peritonitis can cause real problems in the differential diagnosis with secondary peritonitis, which can delay the surgical intervention and endanger the patient's life. MATERIALS AND METHODS: The patients with an end stage renal disease under peritoneal dialysis, who were admitted to "I. Juvara" Surgical Clinic of "Dr. I. Cantacuzino" Clinical Hospital, between 2007 and 2011, were retrospectively analyzed for catheter removal/ replacement due to infectious complications or ultrafiltration failure. RESULTS: 55 patients were identified: 33 with infectious complications (exit-site, tunnel infections 4 and peritonitis 29) and 22 with loss of peritoneum ultrafiltration capacity. The patients with ultrafiltration failure had a longer duration of PD and a smaller number of peritonitic episodes (0.28 episodes/ year at risk in the ultrafiltration failure group vs. 0.98, in the group of infectious complications). The removal of the catheter was the only surgical procedure performed for the patients with ultrafiltration failure, while the patients with peritonitis needed additional gestures like an exploratory laparotomy with peritoneal lavage and drainage and adhesiolysis in the majority of cases. In the group with infectious complications, 4 patients died: 2 by multisystem organ failure due to prolonged sepsis, one developed an upper gastrointestinal bleeding followed by respiratory insufficiency and one had in cataclysmic gastrointestinal bleeding which rapidly led to death. CONCLUSIONS: The immediate operative approach for an infectious peritoneal syndrome under peritoneal dialysis is seldom necessary. The surgical observation is absolutely mandatory in every case. The absence of a response to the proper medical treatment is an indication of peritoneal cavity exploration including laparoscopy/ laparotomy. Any delay in the diagnosis and definitive treatment gives an extremely high mortality rate.

[Hydatid cysts with hepatic and pelvic synchronous location--clinical case]. / Chisturi hidatice cu localizare sincrona--hepatica si pelvina.

About 75% of all hydatid cysts are located in the liver and they are singular. Extrahepatic hydatid cysts are rare pre- and intra-operative findings. The majority of such locations are consecutive from a hepatic primary. We present the clinical case of a 28-years woman, clinically diagnosed with a pelvic tumor. Ultrasonography and CT-scan showed two large tumors: a 17/10 cm left liver cyst, that contained free floating hyperechogenic hydatid sand and a 12/11 cm pelvic cyst, that displaced the urinary bladder, the uterus, the sigmoid colon and the rectum. The diagnosis of synchronous hepatic and pelvic hydatid cysts was suggested. Explorative laparotomy revealed a large cystic tumor of the left liver, 20/15 cm, with many daughter cysts. The cysts were aspirated through a closed suction system and flushed with hypertonic saline, then its cavity was unroofed and drained. We also found a voluminous hydatid cyst of the pelvis, which was treated in the same manner. After 2 days, a bile duct communication was diagnosed, with a medium biliary output--300-400 ml/day. The fistulography confirmed the connection with the biliary ducts. An endoscopic sphincterotomy was then performed, followed by a favourable evolution. According to the scientific criterias from the literature, we discussed the treatment and the outcome of these extrahepatic locations.

Therapeutical options in sigmoid diverticulitis. When should we operate?

Colonic diverticulosis is a benign disease whose incidence has been steadily increasing throughout the world, especially in the economically developed countries in Western Europe. This increase is connected to the population ageing process, the diverticulosis being characteristic in the elderly, and with nowadays' eating habits. Frequently, colonic diverticuli may cause complications, such as hemorrhage or diverticulitis, with pericolic abscesses or peritonitis. Consequently, efforts are being made to set up a therapeutic algorithm appropriate for the diverticular disease, the predominance of the conservative or surgical attitude being continuously adjusted. We have analyzed the therapeutic options, their advantages and their limitations, based on both the experience of the "Prof. I. Juvara" Surgical Department of the "Dr. I. Cantacuzino" Clinical Hospital and the latest data in medical literature.

[The management of postoperative pancreatic fistulas]. / Managementul fistulelor pancreatice post-operatorii.

Postoperative pancreatic fistula is the most common major complication after pancreatic surgery and it can lead to prolonged hospital stay, increased costs and mortality. Its incidence is between 2 and 30%. We present a series of 100 successive patients, operated in our clinic for different pancreatic diseases. Among them, 21 had pancreaticoduodenectomies, 24- enucleation procedures for insulinomas or pancreatic adenomas, 31- distal pancreato-spleenectomies and in 24 cases a pancreatic abcess or pseudocyst was drained. A pancreatic fistula occurred in 21 patients (21%); we analyzed the treatment and outcome of these fistulas, according to our experience and to the International Study Group of Pancreatic Fistula (ISGPF) classification. 10 patients needed only medical treatment, while in 11 cases one/more new surgical procedure(s) was/were required. 15 patients had a favourable evolution and 6 other patients deceased. In persistent fistulas, as well as in those with a high output, the resection of the pancreatic remnant appears to be the best surgical option.

[Acute acalculous cholecystitis--difficulties of diagnosis and treatment]. / Colecistita acuta alitiazica--dificultati de diagnostic si tratament.

Acute acalculous cholecystitis is defined by ultrasonographic, intraoperative and pathologic findings of acute cholecystitis, without evidence of gallstones. It is associated to recent operations, trauma, burns, multisystem organ failure and parenteral nutrition. It can also occur as the first episode, in patients with pathological conditions which generate local ischemia: diabetes mellitus, malignant disease, abdominal vasculitis, congestive heart failure. The authors present a series of 20 patients, operated in the Surgical Department of the Clinical Hospital "Dr. I. Cantacuzino", between 2004 and 2010. There are analysed the significant risk factors, the diagnostic methods and the surgical procedures--laparoscopic or classical cholecystectomies. Among the 20 patients, 14 had a favorable postoperative evolution, 4 had wound infections and in 1 patient a cerebral vascular stroke occurred in the 2nd day after the operation. Another patient died 3 days after the operation, due to an extended myocardial infarction. The medical literature referring to this subject is also reviewed.

[Acute appendicitis and empiric antibiotic therapy]. / Apendicita acuta si antibioterapia empirica.

Acute appendicitis is a well-known disease, which was described and systematically studied in the mid-19th century. Since then, many articles, studies and even books have been written upon this subject and it seems that nothing new can be added. And still... We present 2 clinical cases of male patients, 39 and 41 years old, who were operated in the Surgical Clinic "Prof. I. Juvara" of Clinical Hospital "Dr. I. Cantacuzino" in the same month. Both had no associated pathology and have suffered, for several months, episodes of abdominal pain, fever and (one of them) diarrhea, which were not investigated, but have been treated from time to time with antibiotics, mostly cephalosporins. The physical signs of acute abdomen were very atypical and soft. Intra-operative findings consisted in both cases in tumor-like appendiceal abscesses, situated behind ileocecal junction, with local inflammation and fibrosis, suggesting a long-term evolution. The surgical solutions were typical and were followed by favorable evolutions. We present these 2 clinical cases not only for their atypical history problems, but mainly because we consider that this kind of medical attitude could become an undesirable trend, and difficult and even mistaken diagnosis would occur more frequently, which is hard to accept for a benign disease.

[Synchronous tumors of the gastrointestinal tract]. / Tumori sincrone ale tractului digestiv.

The term "synchronous tumors" is reserved for simultaneous evolution of two or more tumors with distinct sites, in which the possibility that one tumor is a metastasis of the other has been excluded. In medical practice, the involvement of two different cavitary organs of the gastrointestinal tract is very rare. We present two clinical cases of synchronous tumors: one of a malignant degeneration of a colonic polyp, associated to a jejunal tumor; the other of a patient with a gastric adenocarcinoma, who also had a bulky rectal villous tumor. We tried to find out the etiology of the tumors and the frequency of these associations, mentioned in medical literature. Immunohistochemistry investigations, genetic analysis and familial screening must complete an individualized medical approach in which the surgical technique must be adequate for each case.

[Gastric melanoma--clinical case]. / Melanom gastric--prezentare de caz.

Malignant melanomas of the gastrointestinal tract and particulary of the stomach are very rare intra-operative findings. The majority of such melanomas are metastatic from a cutaneous primary. We present the clinical case of a 69-years-old woman with malignant melanoma of the left pectoral region resected in 1988, presented with epigastric pain, weight loss and anaemia. Endoscopy and CT-scan suggested the diagnosis of malignant tumor of the large curvature of the stomach. Explorative laparotomy revealed a large ulcerated tumor of the fornix, with spleno-pancreatic invasion. We also found several pigmented satellite nodules. The surgical solution consisted in a total gastrectomy and distal spleno-pancreatectomy. Histology revealed the tumor and the satellite nodules to be composed of nests of epithelioid cells with melanin pigment. After 3 months, the evolution was favorable. There are some articles in medical literature which present cases of primary gastric melanomas. According to these scientific criterias from the literature, we discussed the nature of this melanoma - a primary or a metastatic one.

[Surgical management of small bowel localization of Crohn's disease]. / Implicatii chirurgicale ale localizarilor intestinale în boala Crohn.

Crohn's disease is an inflammatory bowel disease, a chronic condition with recurrent relapses, difficult to diagnose and requiring a complex medical and surgical treatment. Analyzing 11 patients admitted in the surgical Clinique between 2003 and 2008 with Crohn's disease diagnostic, the authors study at the 7 patients operated the reason of the surgical interventions represented by the complications of the inflammatory disease--intestinal obstruction 2 cases, peritonitic syndrome in 3 cases, malignization 1 case, enterovesical fistulae--1 case. Intraoperatory the differential diagnosis between an inflammatory or tumoral etiology of the lesions was very difficult, and the surgical indication was in almost all cases for enteral resection. Postoperative evolution was in most cases with complications (5 cases)--unique anastomotic fistulae 2 cases, or recurrent fistulae in 3 cases, late bowel obstruction--2 cases. Studying the literature, it can be concluded that the surgical treatment is only one stage of the complex treatment that must be individualized for each case and applied only to the complications of the disease.

[Hartmann 's procedure. A 30 years one-centre clinical experience]. / Operatia Hartmann. Evaluarea unei experiente clinice de 30 de ani.

Henri Hartmann described in 1921 a resection procedure for extended neoplasma of the rectosigmoid junction, in patients who were not eligible for a primary anastomosis. Since then, the technique has been widely applied and well studied. We present a 30 years one-centre clinical experience, with a total amount of 221 patients, in 3 different series. The last series had 65 patients, operated in our clinic between 2000 and 2007. 60 of them had malign tumors of the rectum and colon, while 5 patients had benign diseases. We analysed the surgical indication, the technique details and the evolution. 49 patients had a favourable evolution, 13 of them had different complications and 3 other patients deceased. The reversal of Hartmann's procedure was possible in 24 patients. The method used by us in order to increase the safety of these re-anastomosis was the trans-anastomotic tube, which avoids a protective ileostomy or colostomy.

[Management of biliary fistulas in surgery for hepatic hydatid cyst]. / Managementul fistulelor biliare în chirurgia chistului hidatic hepatic.

One of the most important problems of the surgical treatment of the hydatid disease of the liver is the remaining cavity of the cyst. Its evolution is mainly decided by the existence and the debit of a biliary fistula. During 10 years (1997-2006), 138 patients with 166 hydatid cysts of the liver were admitted and operated in our clinic. Among them, 57 cysts had a biliary fistula, found during the operation, while in 11 other patients the fistula became obvious 1 or 2 days after the procedure. The incidence of biliary fistulas (68 of 166 cases, which means 41%) is higher, due to the location of the cysts, mainly in the central parts of the liver. There were 44 (65%) low debit fistulas and 24 (35%) high debit fistulas. Our surgical attitude regarding the cavities with biliary fistulas has considerably changed; while between 1997-2000 an anastomosis with a Y or Omega jejunal loop was the most frequent technique, nowadays we use the external drainage of the cavity, associated to endoscopic sphincterotomy, for fistulas with large volumes (more than 300 ml/day) and/or persistent. Whenever it is possible, we practice the direct suture of the biliary fistula.

[The necrotizing fasciitis of the leg in diabetic patients]. / Fasceitele necrozante ale membrului pelvin la pacientii diabetici.

The necrotizing fasciitis is a life threatening disease, since its mortality reaches 30-35%, in different studies. In diabetic patients, the incidence and severity of this illness are even higher. The authors present a series of 39 diabetic patients with necrotizing fasciitis of the leg, which were operated between 2001 and 2006 in the Surgical Department of "Dr. I. Cantacuzino" Clinical Hospital, from Bucharest. It is emphasized the importance of a complete diagnosis and the surgical treatment of all the suppurative processes. Sometimes, more than one procedure is required, in order to achieve this goal. In our series, 20 patients needed one operation, while 19 were operated for several times (2-6). The mortality rate was 20.6% and the average length of stay--22.6 days. It is presented the case of a 61 years male, with an unbalanced type II diabetes mellitus and an extensive necrotizing fasciitis of the thigh. The therapeutic attitude consisted in 6 consecutive surgical procedures (drainage, necrosectomy, large fasciectomy), which allowed a favourable evolution and the healing of the patient.

ATPase cycle controls the conformation of an archaeal chaperonin as visualized by cryo-electron microscopy.

Chaperonins are double-ring protein folding machines fueled by ATP binding and hydrolysis. Conformational rearrangements upon ATPase cycling of the group I chaperonins, typified by the Escherichia coli GroEL/GroES system, have been thoroughly investigated by cryo-electron microscopy and X-ray crystallography. For archaeal group II chaperonins, however, these methods have so far failed to provide a correlation between the structural and the functional states. Here, we show that the conformation of the native alphabeta-thermosome of Thermoplasma acidophilum in vitrified ice is strictly regulated by adenine nucleotides.

ATPase cycle of an archaeal chaperonin.

Recent structural data imply differences in allosteric behavior of the group I chaperonins, typified by GroEL from Escherichia coli, and the group II chaperonins, which comprise archaeal thermosome and eukaryotic TRiC/CCT. Therefore, this study addresses the mechanism of interaction of adenine nucleotides with recombinant alpha-only and native alphabeta-thermosomes from Thermoplasma acidophilum, which also enables us to analyze the role of the heterooligomeric composition of the natural thermosome. Although all subunits of the alpha-only thermosome seem to bind nucleotides tightly and independently, the native chaperonin has two different classes of ATP-binding sites. Furthermore, for the alpha-only thermosome, the steady-state ATPase rate is determined by the cleavage reaction itself, whereas, for the alphabeta-thermosome, the rate-limiting step is associated with a post-hydrolysis isomerisation into a non-covalent ADP*P(i) species prior to the release of the gamma-phosphate group. After half-saturation with ATP, a negative cooperativity in hydrolysis is observed for both thermosomes. The effect of Mg(2+) and K(+) nucleotide cycling is documented. We conclude that archaeal chaperonins have unique allosteric properties and discuss them in the light of the mechanism established for the group I chaperonins.

Stage-specific tyrosine phosphorylation of actin in Dictyostelium discoideum cells.

A 45 kDa protein in Dictyostelium discoideum cells that was recognized by a phosphotyrosine-specific antibody was identified by its binding activity to DNase I and its 2D-electrophoretic behavior as actin. The reactivity of actin with the antibody was transiently enhanced for about 30 minutes shortly after starving cells were reintroduced into nutrient medium. This effect indicates a modification of actin that is regulated under physiological conditions. A similar effect was obtained when growing cells were treated with phenylarsine oxide (PAO), an inhibitor of phosphotyrosine phosphatases. This effect was reversed and the cells fully recovered upon addition of the PAO antagonist 2,3-dimercaptopropanol. Starved cells did not show this enhancement of antibody labelling, which indicates that the response to PAO depends on the developmental stage. Phosphorylated amino acid residues were identified after in vivo labelling with [32P]phosphate in the presence of PAO. Part of the radioactivity in the actin band was recovered as phosphotyrosine, another part as phosphoserine. PAO caused the cells to form elongated blebs, to round up and finally to become immobilized. Fluorescence labelling with phalloidin of cells that were fixed at different times of PAO treatment revealed a progressive decrease in the staining for actin filaments and showed that these alterations in cytoskeleton organization were readily reversible, in accordance with the reversal of tyrosine phosphorylation at actin.

Phosphotyrosine-containing proteins in Dictyostelium discoideum.

Phosphotyrosine-containing proteins in Dictyostelium discoideum were detected by immunoblot analysis and immunoprecipitation using a monoclonal anti-phosphotyrosine antibody. The iodinated antibody recognized on bots a cluster of 205-220 kDa polypeptides and bands of 107 and 60 kDa. The 107 and 60 kDa polypeptides and, in addition, a 82 kDa one became phosphorylated on tyrosine when the immunoprecipitate was incubated with [gamma-32P]ATP. In preparations from differentiating cells the intensity of the label was increased in the 60 kDa band and decreased in the 107 and 205-220 kDa bands.