Gallstone ileus: analysis of eight cases and review of the literature.

OBJECTIVE: We hereby analyzed a series of gallstone ileus cases operated on in our department starting from a Bouveret syndrome case. METHOD: Retrospective analysis of all gallstone ileus cases who underwent surgery in our department during the last 26 years. We took into consideration diagnostic elements, time from admission to surgery, type of surgery and post-operative outcome. RESULTS: During this period 9,143 gallstones were deferred to surgery; 27 biliary-digestive fistulae were discovered during surgery; gallstone ileus complicated fistula in 8 patients. Gallstone ileus was exclusively present in elderly women with associated comorbidities. Diagnosis was suggested by clinical features of acute or incomplete intestinal obstruction; it was sustained by imagistic studies with different degrees of relevance. The average time from admission to surgery was 2.6 days. Surgical approach varied from simple enterolithotomy to additional fistula repair. The outcome was uneventful in most of the cases with only one exception. CONCLUSIONS: gallstone ileus is a rare condition, occurring in elders with important comorbidities. The choice for surgical procedure depends on the obstructive syndrome's gravity and associated comorbidities; the type of intervention does not significantly influence post-operative morbidity and mortality rates.

[Diabetic gangrene]. / Gangrena diabetica.

The large variety of the lesions in diabetic gangrene which require different therapeutical decisions explains our attempt to determine an useful way for the approach of the surgical treatment. Our aim was to avoid both an underestimation of the lesion, which may lead to an insufficient procedure, followed by reinterventions, as well as an overestimation--generating avoidable amputations. We have elaborated a scale of indices of therapeutical prognosis (ITP), using a computer programme, with the main risk factors. The result was a scale between 1 and 10; the value is proportional to the severity of each lesion. We have also analyzed the fiability of ITP on a prospective study including 72 patients with diabetic gangrene. The result was 93%, which has encouraged us to consider ITP useful in establishing a therapeutical attitude.

[Acute abdomen and diabetic patients--difficulties of diagnosis and therapeutical decision]. / Abdomenul acut si bolnavul diabetic--difficultati ale diagnosticului si deciziei terapeutice.

We present a retrospective study based on 50 diabetic patients with acute abdominal diseases. Usually, clinical features were not typical, without defining signs of acute abdomen, despite frequent severe anatomo-pathological forms (6 of 12 acute appendicitis were gangrenous, with generalised or localised peritonitis; 15 of 22 acute colecystitis were gangrenous). In diabetic patients, with metabolic disorders and cetoacidosis, positive diagnosis and the decision of laparotomy are difficult problems, often delated, with a negative influence on the evolutions and prognosis of these patients.

[Malignant anorectal melanoma. Apropos 1 case]. / Melanom malign anorectal. In legatura cu 1 caz.

A case of malignant anorectal melanoma is reported, which was treated by anorectal-sigmoid amputation, operation which did not prevent the occurrence, after 6 months, of metastases in the inguinal lymph nodes. On the basis of the reported case, the main etiological, histogenetic, prognostic and therapeutic aspects of these rare tumours are discussed.

[The direction and motivation for an evolution in methods of antiulcer surgery]. / Directia si motivatia unei evolutii în metodele chirurgiei antiulceroase.

A 23-year retroactive analysis of a heterogeneous series of observations with unfavourable tardy results after antiulcer surgeries showed that the most failures requiring a second surgery appear after large resections with gastrojejunal or gastroduodenal anastomosis and after vagotomies associated with gastric drainage. The most favourable tardy results followed the vagotomy associated with limited gastric resection (hemigastrectomy). This kind of intervention prevents the appearance of the ulcerous relapses and lowers significantly the incidence of the other type of post-surgical iatrogenic complications. The optimal protection against the ulcerous relapse given by vagotomy associated with hemigastrectomy permits a tactical adaptation of the intervention to the lesional and physiopathological characteristics of each case.

[Primary acute peritonitis in adults]. / Peritonitele acute primitive ale adultului.

The authors report 12 cases of primary acute peritonitis-that were operated over a period of 10 years, representing 2.8% of the total number of acute cases of peritonitis, with the exclusion of cases of postoperative peritonitis. Since they are so rare it is understandable that primary acute peritonitis of the adult are less well known by the general practitioner in surgery. The particular background of these patients, frequently involving other forms of pathologic features, and the generally depressed immunological background explains the atypical clinical evolution, with attenuated local abdominal signs, a fact which retards the diagnosis, and hence the therapy. As a general rule adults come rather late in surgical departments, usually transferred from another department (diabetes, internal medicine, gynecology, communicable diseases, etc.). The surgeon also has difficulties in making a diagnosis. When the decision to operate has been taken--in most of the cases this happens at a late stage-peritonitis is usually is the purulent phase and careful drainage of the peritoneal cavity is necessary, associated to antibiotherapy that should be applied on the surgical table, and with massive doses. Preoperative etiological diagnosis is difficult. Direct bacterioscopy of the peritoneal exudate is decisive and it should be asked for by the surgeon even in the early stage of surgery. Exhaustive visceral surgical exploration, which should, in principle, eliminate secondary peritonitis is neither easy to perform, nor without risks in these patients, usually aged, obese, with multiple interventions in antecedents. Appendectomy, as a complementary gesture, is contraindicated. The prognosis in the adult, in contrast with that of children, is severe, with very high perioperative morbidity and mortality (above 50% in the authors' experience).

[Complications of surgery of cancer of the colon]. / Complicatiile chirurgiei cancerului de colon.

In the paper a systematic analysis is carried out of postoperative complications of colon surgery, 118 patients had complications, out of a total of 400 interventions on the colon. The complications are studied in relation with the time of their occurence and the localization of the neoplastic process, as well as from the point of view of the influence exerted by age and the "background" of the patients. A review is also made of the therapeutic attitudes required by the various complications, of the results obtained and finally a detailed analysis is presented of the causes that led to death of operated patients.

[Anatomical bases of incomplete vagotomy]. / Bazele anatomice ale vagotomiei incomplete.

The results are presented, of an intraoperative anatomical study concerning the variable disposition of the vagal nerves in the abdominal section of the oesophagus. This study was carried out in a large number of patients with ulcers in which vagotomy was performed. All the patients were followed and in all periodical controls were made after surgery in view of detecting possible ulcerative relapses. The authors conclude that the negative results of vagotomy are due to the fact that this is usually incomplete. The study demonstrated the existence of many variants of the anatomical disposition of the vagal nerves at the level of the abdominal oesophagus, which the authors synthesize in a practical scheme which is available to any surgeon. The risk of an incomplete vagotomy is the highest when the patient presents an anatomical variant with a large number of branches.

[Postbular duodenal ulcer. Problems of diagnosis and treatment. Role of vagotomy in surgical treatment]. / Ulcerele duodenale postbulbare. Probleme de diagnostic si tratament. Locul vagotomiei în tratamentul chirurgical

A number of 43 cases is presented, of post-bulbar duodenal ulcers in which surgery has been performed between 1965 and 1974, of which 30 were located in the first portion of the duodenum, in the postbulbar area, and 15 in the second portion, above the ampula of Vater. Problems of terminology and pathological anatomy are discussed, especially in connection with the symptomatology, complications, methodology of investigations and treatment of post-bulbar ulcers. The particular frequency is stressed, of complicated clinical forms, with stenosis and hemorrhagies, and a detailed description is made of atypical forms, with misleading, predominantly biliary or pancreatic symptomatology. Conditions are stressed, of the radiologic gastroduodenal exploration, of major importance in the diagnosis preceding surgery, as well as of pre- and intra-surgery cholangiography. The risk must be carefully evaluated, in the choice of the surgical method, and exeresis of the ulcer must be balanced with the risk of its continued presence. Priority should be given to th risks entailed by surgery. The choice solution in many cases is vagotomy associated to exclusion resection or to gastric derivation.

[Surgical reoperation after vagotomy]. / Reinterventii chirugicale dupa vagotomie

In 39 cases of re-interventions carried out after vagotomy (of which 31 were patients hospitalized in the Clinic and represent 8,6% of the total 358 vagotomies performed), the experience, the viewpoints and the recommendations of the authors are presented. Early re-interventions were necessayr because of complications which are common to abdominal surgery and only in a much lower degree to accidents that can be attributed to vagotomy or the associated intervention. Late re-interventions (26 cases) were necessary in 20 cases for ulcer recidives (13 for vagotomies performed in the Clinic and 7 for vagotomies performed in other units) while late-re-interventions for dumping syndrome, cholelythiasis, etc. represented only isolated cases in these statistics.