Quality of life after laparoscopic fundoplication for gastroesophageal reflux disease. Preliminary study.

Laparoscopic fundoplication (LF) is the treatment of choice for gastroesophageal reflux disease (GERD).Our paper evaluates post LF quality of life (QL). Patients treated between January 2008 and May 2011 by the same surgeon were asked to fill in the Velanovich questionnaires for Gastro - Oesophageal Reflux Disease - Health Related Quality of Life (GERD-HRQL). The 10 questions were designed to assess GERD specific symptoms prior to (part A) and after surgery (part B). The Velanovich score is 0 if the patient is asymptomatic and 50 if the symptoms are at maximum intensity. Only 32 out of the 54 patients operated during the study filled in the questionnaire:28 patients (87.5%) had hiatus hernia (HH), 16 cases were associated with reflux erosive esophagitis (EE), 4 patients had non-erosive reflux disease (NERD) and one had Barrett's esophagus (BE). We used Toupet partial posterior fund oplication for 12 patients and Nissen total fundoplication for 20 patients. The short gastric vessels were divided in all patients.The female - male ratio was 21:11 with a mean age of 55.13 years and the mean follow up period for questionnaire B was of25.2 months. The Velanovich A score was 29.9 Â+-10.9, and the follow up B score was 3.4Â+-2.4 (CI (95%) 22.9-39.9; p 0.05).There were no B score statistical differences between sex ratio(3.9 vs 2.4) and type of fundoplication (Nissen 3.2 vs Toupet4.1). 29 patients (90.62%) declared that their QL improved after surgery. The main indication for surgery present in almost every patient included in this study was the presence of theHH and RE. LF improved the quality of life of patients with GERD. There were no statistical differences of the Velanovich score according to GERD stage (EE, NERD with or without HH), sex ratio and type of LF, Toupet or Nissen.

[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.

Anastomotic dehiscence (AD) in colorectal cancer surgery: mechanical anastomosis versus manual anastomosis.

INTRODUCTION: Anastomotic dehiscence (AD) is the "Achilles heel" for resectional colorectal pathology and is the most common cause of postoperative morbidity and mortality. AD incidence is 3-8%; mortality rate due to AD two decades ago was around 60% and at present is 10%. This paper analyzes the incidence of AD after colorectal resection performed both in emergency and elective situations, depending on the way it is done: manually or mechanically. METHODS: Retrospective, single-center, observational study of patients operated in the period from 1st of January 2009 to 31th of December 2011 for malignant colorectal pathology in the Emergency Clinical Hospital of Bucharest. We evaluated the incidence of digestive fistulas according to the segment of digestive tract and time from hospital admission, to the way the anastomosis was achieved (mechanical vs. Manual), to the complexity of intervention, to the transfusion requirements pre/intra or postoperative, to the past medical history of patients (presence of colorectal inflammatory diseases: ulcerative colitis and Crohn's disease), to the average length of hospital stay and time of postoperative resumption of bowel transit. RESULTS: We included 714 patients who had surgery between 1st of January 2009 and 31th of December 2011. 15.26% (109/714) of the cases were operated in emergency conditions. Of the 112 cases of medium and lower rectum, 76 have "benefited" from preoperative radiotherapy with a fistula rate of 22.36% (17/76). The incidence of anastomotic dehiscence in the group with preoperative radiotherapy and mechanical anastomosis was 64.7% (11/17) versus 35.3% (6/17) incidence recorded in the group with manual anastomosis. Colorectal inflammatory diseases have been found as a history of pathology in 41 patients--incidence of fistulas in this group was of 12.2% (5/41), compared to only 6.83% (46/673) incidence seen in patients without a history of such disease. For the group with bowel inflammatory disease, anastomotic dehiscence incidence was of 13.8% (4/29) when using mechanical suture and 8.3% (1/12) when using manual suturing. The period required for postoperative resumption of intestinal transit was of 3.12 days for mechanical suturing and 3.93 days in case of manual suture. The mean time (MT) to perform the ileocolic and colocolic mechanical anastomosis is 9 ± 2 minutes. If anastomosis is "cured" with surjet wire or separate threads, MT is 11 ± 5 minutes. MT to perform the ileocolic and colocolic manual anastomosis is 9 ± 3 minutes for surjet wire and 18 ± 5 minutes for separate threads. MT to perform the colorectal mechanical anastomosis is 15 ± 4 minutes. MT to perform the colorectal manual anastomosis is 30 ± 7 minutes (using separate threads). Detailing the nature of the surgical reinterventions, we have found: 7 reinterventions for AD post mechanical anastomoses (1 case of suture defect, 2 cases of resection and re-anastomoses, 4 cases with external branching stoma); 5 reinterventions for AD post manual anastomoses (0 cases of suture defect, 1 case of resection with re-anastomosis, 4 cases of external shunt stoma). In the analyzed group, we recorded a total of 57 deaths from a total of 714 cases resulting in a mortality rate of 7.98%. CONCLUSIONS: Mechanical suture technique is not ideal for making digestive sutures. With the exception of low colorectal anastomoses where mechanical sutures are preferable, we cannot claim the superiority of mechanical anastomoses over those manually made, for colorectal neoplasia.

[Temporary loop-ileostomy for distal anastomosis protection in colorectal resections]. / Ileostomia temporara pentru protectia anastomozelor în rezectiile colonice si rectale.

Temporary loop-ileostomy (TLI) is an efficient modality to protect distal anastomosis in colorectal resections. TLI reduces the consequences of distal anastomosis leakage. We present the technique of construction and closure of TLI, the indications, postoperative complications and personal experience in early closure.

Is laparoscopy still needed in blunt abdominal trauma?

INTRODUCTION: Laparoscopy, as a minimally invasive diagnostic and therapeutic tool in blunt abdominal trauma (BAT), is not commonly used and has been shown to be controversial. The aim of this study is to assess the role of laparoscopy in the diagnosis and therapy of BAT. METHODS: A systematic review and a comprehensive literature search was performed at the U.S. National Library of Medicine site in Medline and PubMed from January 2000 to 31 December 2007. This article attempts to outline the efficacy, the indications, contraindications, surgical technique and therapeutic possibilities of laparoscopy in BAT. Pediatric surgery articles and those addressing penetrating abdominal wounds, nontraumatic abdominal emergencies and iatrogenic injuries were excluded from this review. RESULTS: Sixty-six articles were reviewed, which included 22 case studies, 27 case reports, 17 reviews and 2 guidelines. The reviewed articles comprised 343 patients with BAT and laparoscopic approach. Therapeutic laparoscopy was possible in 168 cases (48.98%), 51 cases were converted (14.87%), overlooked injuries were absent, 6 patients had complications (1.75%), no mortality laparoscopy-related. The main indications for laparoscopy in BAT include the confirmation of suspected diaphragmatic defects, suspected hollow viscus and mesenteric injuries, in patients with inconclusive clinical exams and abdominal imaging. Diagnostic laparoscopy (DL) is also indicated in patients with suspected intra-abdominal injuries when advanced emergency imaging investigations are unavailable. Laparoscopy allows the surgeon to perform hemostasis, resections, suturing, autotransfusion, etc. CONCLUSION: Although is not widely used, laparoscopy could still be useful in selected patients with BAT who have equivocal findings on clinical exam a nd imaging investigations in order to clarify the lesional diagnosis, thus avoiding unnecessary laparotomies. Multicenter prospective studies are needed to better assess the role of laparoscopy in blunt abdominal trauma.

[Conversion in laparoscopic cholecystectomy for acute cholecystitis]. / Conversia în colecistita acuta abordata laparoscopic.

INTRODUCTION: By definition, conversion means giving up laparoscopic surgery and continuing the operation with open, conventional surgery no matter the reason, nor the moment of the operation. PURPOSE: To evaluate the causes and the moment of conversion, the technique used to perform the cholecystectomy after conversion, analysing the experience of the surgical team in deciding the moment of conversion. METHOD: A retrospective study performed on patients which underwent a laparoscopic operation for acute cholecystitis between January 1st 2004 - December 31st 2007. Clinical examination, biological parameters, surgical proceedings, histopathological examination of the pieces removed and the patient's postoperative evolution were analysed. FINDINGS: There were performed 1522 laparoscopic cholecystectomies for acute cholecystitis, out of which 108 (7.1% of all) were converted to open surgery. Analysing the experience of the surgical team, we can say that the converted laparoscopic cholecystectomies are found mainly in teams formed by senior surgeons assisted by junior surgeons--43% (46/108), in comparison with teams formed by residents assisted by senior surgeons--22% (25/108). The nondissecable fibrotic shirt front, woody inflammation of the pedicle, adhesions after past surgery and suspicion of a fistula are the most frequent causes of conversion--45.35% (49/108). The distribution according to the gender was analysed in patients which underwent conversion, showing a significant difference: 5.39% (60/1112) in women and 11.7% (48/410) in men. The percentage of conversion was significantly higher for operations performed at more than 96 hours away from the beginning of the symptoms--15.1% (29/192). The highest number of conversions occurred for gangrenous acute cholecystitis--72% (77/108). 82.40% of all the acute cholecystitis which were converted were complicated with shirt front (89/108). CONCLUSIONS: Conversion performed for laparoscopic cholecystectomies is a proof of ripening and professional responsibility, a fit solution for cases in which the advantages of laparoscopic surgery are overwhelmed by the risks found during surgery; gangrenous acute cholecystitis is one of the most important causes of conversion--72%; the shirt front around the gallbladder was converted in 82.4% of cases; conversion is more frequent in men--11.7%; acute cholecystitis with symptoms found for more than 96 hours are converted in 15.1% of cases.

[Laparoscopic modified partial posterior Toupet fundoplication]. / Tehnica fundoplicaturii partiale posterioare Toupet modificata.

We describe the technique of the laparoscopic posterior partial fundoplication used by us for the treatment of gastroesophageal reflux disease. We use the division of short gastric vessels for the mobilisation of the gastric fundus in addition to the Toupet partial posterior fundoplication modified by Coster. The fundoplication is achived with only 5 stiches, 3 for the right hemivalve and 2 for the left one. We also present the advantages, the indications, the contraindications and the main complications of the procedure.

[Laparoscopic repair of abdominal ventral hernias]. / Tehnica abordului laparoscopic al defectelor parietale abdominale ventrale mediane.

This paper presents the surgical technique for ventral abdominal hernia repair, including median incisional hernia, umbilical hernia and epigastric hernia. The main stages of the surgical procedure are as follows: pinpointing the parietal defect, insufflation of pneumoperitoneum and placing the trocars, inspection and adhesiolysis of the peritoneal cavity, closure of the defect with extracorporeal transparietal U reverse stitches, preparing the mesh, introducing the mesh in the peritoneal cavity and fixing it with transfascial sutures and tackers. Postop care measures, postop complications and controversies regarding mesh composition and fixation method are also discussed.

[Endoluminal fundoplication (ELF) with EsophyX2 for gastroesophageal reflux desease (GERD)]. / Fundoplicatura endoluminala (FEL) cu esophyX2 in terapia bolii de reflux gastroesofagian (BRGE).

GERD is a frequent, evolving, life quality-impairing disease. In addition to medication and laparoscopic fundoplication we have recently added endoluminal fundoplication (ELF). The EsophyX2 is currently the most efficient device for endoluminal fundoplication. This device produces a partial, anterior valve, redesigning the antireflux barrier and the Hiss angle geometry, thus improving the activity of the lower esophageal sphincter (LES). This paper presents the operative technique, the patient selection criteria and published results. It has been shown that this technique is both secure, reproductible and effective in patients followed for 12-24 months: life-quality improvement, decreased acid exposure, suppression of antiacids, reduced hospitalization and recovery. Compared to antiacid therapy, ELF is far more effective and less invasive than laparoscopic fundoplication. For the moment we have no long-term results. ELF with EsophyX2 is a minimally invasive and efficient therapy for GERD that requires further evaluation.

Demetrius Cantemir: the first account of transabodominal approach to repair groin hernia.

The first description of the transabdominal approach for hernia repair was written by Demetrius Cantemir, Prince of Moldavia and encyclopedic scholar, in his 1716 Latin manuscript "Incrementa et decrementa Aulae Othomaniae" ("The history of the Growth and Decay of the Ottoman Empire"). This manuscript was one of the most important in Eastern Europe at the time. It was first translated in English in 1734 by N. Tyndal, and all subsequent translations into various other languages were based on this english version. The original manuscript now belongs to the Houghton Library of Harvard University, where it was recently discovered in 1984 by V. Candea. Our article presents for the first time the complete account of the surgical procedure performed by Albanian physicians in the prince's palace in Constantinopol. The patient was the Prince's secretary. There is a detailed description of the operation, postoperative therapy and the medical course to recovery. The text presented is translated in English from Annotations of Volume Two, chapter four. We consider it worthwhile to present to the medical community this valuable but less known contribution to the history of medicine.

Laparoscopic repair of post-traumatic diaphragmatic hernia: a case report.

In a large number of cases, post-traumatic diaphragmatic hernias (PTDH) are a consequence of occult diaphragmatic injuries associated with penetrating abdominal trauma. We present a case of a 26-year-old male patient who, 2 months prior to the current admission, sustained a non-penetrating stab wound to the left anterior chest below the nipple. Upon presentation the patient complained of epigastric pain radiated to the left shoulder, and nausea and vomiting. The chest X-ray, and abdominal and thoracic CT scan were inconclusive. The patient was sutured and discharged. The laparoscopic approach was selected as a diagnostic and minimally invasive therapeutic method. The suspected diagnosis of PTDH was confirmed. The herniated organs (transverse colon, small bowel loops, and greater omentum) were reduced, and the diaphragmatic defect was sutured by placing 3 non-resorbable 2.0 knots. The suture was reinforced with a composite mesh affixed with resorbable clips. Postoperative period was uneventful, and the patient was discharged 4 days later.

[Demetrius Cantemir in the history of surgery: the first account of transabdominal approach to repair groin hernias]. / Dimitrie cantemir în istoria universala a chirurgiei: prima descriere a caii transabdominale în cura herniilor.

The first description of the transabdominal approach for hernia repair was written by Demetrius Cantemir, Prince of Moldavia and encyclopedic scholar, in his 1716 Latin manuscript "Incrementa et Decrementa Aulae Othmanicae". This manuscript was one of the most important of Eastern Europe at the time. It was first translated in English in 1734, and all subsequent translations into various other languages were based on this English version. The original manuscript now belongs to the Houghton Library of Harvard University, where it was recently rediscovered in 1984 by V. Candea. D. Slusanschi has made the first Romanian translation of the first two volumes based on the original latin manuscript. This translation is now in press. Our article presents for the first time a fragment of this Romanian translation from the Annotations of Volume two, chapter four. In this fragment, Demetrius Cantemir describes the surgical procedure practiced by Albanian physicians in the prince's palace in Constantinopol. The patient was the secretary of the prince. There is a detailed description of the postsurgical therapy and the medical course to recovery. It was first partially reproduced by Mercy in his book on hernia published in 1892, and more recently by Meade in 1965. We consider useful to present to the medical community this valuable but less known contribution to the history of medicine.

[Postoperative early enteral nutrition in a patient with polytrauma and late duodenal perforation]. / Nutritie enterala postoperatorie precoce la un politraumatism cu perforatie duodenala tardiva.

We present the case of a 51 years old multiple injured female patient who was transferred from another hospital. She suffered a car accident and at admission, the diagnosis was anterior flail chest with fractured sternum, blunt abdominal trauma with IIIrd grade kidney laceration, multiple extremities fractures, ISS = 50. We performed emergency nephrectomy, surgical fixation of the flail chest and bilateral pleurostomy. Postoperatively the evolution was difficult, she was intubated and mechanically ventilated. We started early enteral nutrition (EEN), at 24 hours with 20 ml/hour Fresubin (Fresenius-Kabi, Bad Hamburg, Germany) and then with 40 ml/hour. In the fourth postoperative day, CT scan identified no supplementary lesions. In the seventh postoperative day, jaundice became apparent and the CT exam identified gas in the retroperitoneum. At surgery, we identified a IInd degree D2 rupture. We practiced duodenal suture, pyloric exclusion, latero-lateral gastro-entero-anastomosis. We passed a naso-gastro-entero-duodenal tube into D2 for active suction and we performed a fine needle catheter jejunostomy. Difficult postoperative evolution, intubated, febrile, with hemodynamic instability. EEN on the jejunostomy at 20-40-60 ml/hour. 10 days after the reoperation, the general condition ameliorated. Enteral nutrition was continued for 22 days after reoperation. The patient was discharged after 44 days. The particularities of this case are the complexity of the traumatic lesions: anterior costal flail chest, left kidney rupture, late duodenal perforation, multiple extremities fractures (APACHE II score = 34). The treatment involved internal pneumatic stabilization and surgical fixation of the flail chest, duodenal suture with pyloric exclusion and fine needle catheter jejunostomy, left nephrectomy. We consider that the use of EEN was of real help in this case and we recommend it in all polytraumatised patients and in all the cases where it can be used.

Laparoscopic suture repair of perforated duodenal peptic ulcer for patients without risk factors.

BACKGROUND: Suture repair became the standard treatment for perforated duodenal ulcer (PDU) due to the efficacy of modern anti-ulcer therapy. This study compared short-term outcomes of open versus laparoscopic suture repair of PDU in patients without risk factors. METHOD: Patients with perforated duodenal ulcer were selected for open or laparoscopic suture repair. Patients with either one or more of the following risk factors were excluded: age > 50 years, interval between perforation and operation > or = 12 hours, presence of major comorbidities (American Society of Anesthesiologists [ASA] III-IV), and previous abdominal surgery. RESULTS: 174 patients underwent open surgery (OSG) and 85 underwent laparoscopic surgery (LSG). The two groups were similar in regard to age, sex, ulcer disease history, time between onset of surgery, ASA score, and presence of free air on X-ray. There were statistical differences between OSG and LSG in the duration of operating time (55 vs 85 min), analgesic doses (16 vs 9) and hospital stay (7.8 vs 6.1 days). During the night (10:00 PM - 06:00 AM), 129 patients were operated: 107/174 in OSG and 22/85 in LSG. In LSG we performed suture repair in 37 patients and suture repair with omental patch in 41 patients. In OSG, 7 patients had a wrong preoperative diagnosis of acute appendicitis. Five patients (5.8%) in LSG group and 15 patients (8.6%) in OSG had postoperative complications and 2 respectively 1 patient needed reoperation. The two reoperated patients in LSG presented suture repair leak and a right subphrenic abscess. Both had only suture repair. There were no mortalities. CONCLUSION: We believe that suture repair with omental patch associated with anti-ulcer medical therapy is the standard therapeutic solution in PDU for young patients without risk factors.

[Multimodal analgesia in elective laparoscopic cholecystectomy. A double-blind randomized controlled trial]. / Analgezia multimodal in colecistectomia laparoscopica elective. Studiu prospectiv randomizat dublu-orb.

BACKGROUND: The aim of this study was to test the effects of preincisional parietal and intraperitoneal infiltration with ropivacaine (R) on postoperative pain after elective laparoscopic cholecystectomy. METHODS: 60 patients scheduled for laparoscopic cholecystectomy performed by the same surgeon were enrolled in a randomized, controlled double-blind trial. All patients received the same general anesthesia protocol and Ig i.v. paracetamol was infused after induction of anesthesia for postoperative analgesia, repeated postoperatively each 6 hours, up to 4 g/ 24 h. After induction of anesthesia, the patients were randomized in 4 groups (15 patients each): group A received preincisional parietal infiltration of 20 ml normal saline (NS) solution and 20 ml R0, 25% intraperitoneal instillation; group B, 20 ml R0, 0.25% preincisional parietal and 20 ml NS intraperitoneal; group C, 20 ml R0, 25% preincisional parietal and 20 ml R0, 25% intraperitoneal; group D (control), 20 ml NS preincisional local and 20 ml NS intraperitoneal. Tramadol was used as a rescue analgesic Primary end points: were postoperative pain at Oh, 2h, 6h, 12h, 24h on visual analogue scale (VAS 0-100 mm) score and rescue analgesic requirements. RESULTS: We found no differences in demographics, length of surgery time and hospital stay (total 3.38 +/- 0.22 days). VAS was significantly lower at all intervals in groups C versus D and at Oh, 6h and 12 h in group C versus group A and B (p < 0.05). We found no influence on shoulder pain. Tramadol doses required were significantly lower in group C vs. D (0,73 +/- 1.10 vs 1,93 +/- 1.03, p = 0.017). CONCLUSION: Ropivacaine shows significant favorable effects on postoperative pain after laparoscopic cholecystectomy when using both parietal and intraperitoneal instillation in combination with perioperative i.v. paracetamol.

[Progress of surgical treatment in the last 10 years. Comparative study of surgical interventions performed between 1993-1995 versus between 2003-2005]. / Evolutia terapiei chirurgicale în ultima decada. Studiu comparativ al interventiilor 1993-1995 vs. 2003-2005.

In the last decade of the past century, as laparoscopy was introduced in our clinic in 1993, minimal access therapy (MAT--endoscopy, angiography, interventional imagery) had a positive and constant evolution. Our paper retrospectively evaluates the interventions performed between 2003-2005 (group A) compared to those performed between 1993-1995 (group B). We observed a 17.08% (7056 vs 6026 interventions/year) raise in the total number of interventions in group A, with a significant 66% decrease (195 vs. 588 interventions/year) of interventions for gastro-duodenal ulcer and a 18% decrease (1211 vs 1490 interventions/year) of appendectomies, but a 63% increase (1560 vs. 955 interventions/year) of cholecystectomies, 53% increase (1186 vs. 773 interventions/year) of interventions for parietal defects and a 62% (626 vs. 325 interventions/year) increase of oncological interventions. The most frequent interventions were, in the order of frequencies: cholecystectomies (79.8% laparoscopically), appendectomies, interventions for hernia and eventrations, oncological operations and trauma surgery. The incidence of laparoscopic interventions was greater in group A, counting for 19% of the total number of interventions. In group A were performed 2334 endoscopies, 149 diagnostic and therapeutic angiographies. Postoperative mortality dropped with 29.64% and hospital stay dropped to 4.7 days. We believe that the incidence of MAT should rise, by performing more laparoscopic interventions and this change should lead to a revision of the surgical residents training program.

[Small bowel perforation caused by compound pelvic fracture found in diagnostic laparoscopy]. / Perforatie intestinala prin fractura complexa de bazin diagnosticata laparoscopic.

Small bowel perforations in blunt abdominal trauma (BAT), especially in multiply injured patients, are difficult to diagnose in the first hours after the accident, either clinically or by imagistic studies. A less encountered diagnostic modality is diagnostic laparoscopy (DL), selectively indicated. We present the case of a patient with BAT and complex pelvic fracture, hemodynamically stable, with TS= 15, who clinically had abdominal tenderness and on ultrasound (US) and CT scan, had free intra-abdominal fluid (FIAF), without any injuries of a solid viscus, which led us to suspect a hollow viscus injury. We proceeded with a DL, imposed by the equivocal diagnosis, taking advantage of the general anesthesia needed for the femoral and pelvic fracture immobilization. We identified an ileal perforation and decided to convert to open surgery, and we found a second perforation. Segmentary ileal resection was performed. Orthopedically, in emergency, the femoral fracture and the posterior arch of the pelvis were immobilized, but due to the septic risk, the anterior arch was immobilized 10 days later. DL is a valuable tool in BAT with FIAF on US and CT scan with suspicion of hollow viscus perforation in the hemodynamically stable patients, in order to decide between laparotomy and observation. In equivocal diagnosis cases, DL avoids unnecessary or delayed laparotomy. Whenever possible and indicated, orthopedic lesions will be dealt with in emergency ("early total care"), in order to reduce the recovery and hospitalization period.

[Needle catheter jejunostomy versus "Witzel" tube jejunostomy for early postoperative enteral nutrition in surgical patients. Prospective randomized study]. / Jejunostomia minimmacu cateter versus jejunostomia cu tub de politen ("á la Witzel") pentru nutri,tie enterala postoperatorie precoce la pacientii chirurgicali subnutriti. Studiu prospectiv randomizat.

Malnutrition in surgical patients can be present since their admission into hospital or can appear in the postoperative period. Early postoperative enteral nutrition (EPEN) is recommended to these patients as often as possible. In cases where the patients are severely malnourished with major digestive surgical interventions which we estimate that will be unable to feed orally efficient minimum 7-10 days postoperatively, we recommend EPEN on jejunostomy. Prospective randomized evaluation of 37 patients (75.6% severely malnourished): 19 with needle catheter jejunostomy (NCJ), group A, respectively 18 with standard "Witzel" tube jejunostomy (STJ), group B. 22 patients presented malignant tumors and 15 serious benign problems. On 7 patients the jejunostomy was done at the reoperation. Postoperative major complications were observed on 54.05% of the patients (independent of the jejunostomy) and the postoperative mortality rate was of 13.33% on the patients that had jejunostomy and EPEN on their first operation, and 57.14 respectively on the patients where jejunostomy was done at the reoperation. The two groups were similar with respect to age, sex, length of EPEN and hospital stay, presence of malnutrition, complications and mortality. Postoperative complications were statistically more frequent in anemic patients (68.8%) respectively anemic and severely malnourished (76.47). Minor complication related to the jejunostomy occurred in 5.6% of the group A and 22.2% of the group B. NCJ was done rapidly the same as STJ (7 min vs. 15 min). In conclusion, EPEN on jejunostomy on surgically malnourished patients, who have suffered major superior digestive interventions is beneficial. Postoperative complications have been more frequent on anemic and severely malnourished. NCJ is easier to perform and safer.