[194 laparoscopic cholecystectomy. Anesthetic and surgical details]. / 194 de colecistectomii laparoscopice. Particularitfiti si aspecte ale actului chirurgical si anestezic.

In this clinic and prospective study we investigated the anesthetic and surgical particularities in laparoscopic cholecystectomy for 194 patients. Approximately the two third of patients have had a great mortality risk (ASA III and IV). 139 patients have had severe comorbid conditions. All patients were under general anesthesia with oro-tracheal intubation. The surgical time was between 27 and 148 minutes. The subjects of this study were old patients with acute cholecystitis and severe comorbid conditions. No significant incident or complication were noted, all patients have had a good outcome.

[Severity factors of acute renal failure in severe acute pancreatitis]. / Factori de gravitate in insuficienta renala acuta din pancreatitele acute severe.

AIM: assessment of the severity factors of the acute renal failure (ARF) in the severe acute pancreatitis (SAP). 28 (32.55%) severe acute pancreatitis with acute renal failure (19 males and 9 females, aged between 30 and 67), treated by hemodialysis, selected from 86 severe acute pancreatitis with acute renal failure, admitted in the Hemodialysis Department of ICU in the last 6 years, were analyzed. The severity of the pancreatitis was assessed using the following criteria: clinico-biologic scores (Ranson > 3 and APACHE II > 8), the CT-scan (Balthazar score D and E and CTSI > 4), the presence of the organ and system dysfunctions assessed by Tran and Cuesta criteria and the presence of the abdominal compartment syndrome (abdominal pressure > 25 mm Hg). 8 dialyzed cases (28.5%) were operated on: 2 cholecystostomy, 2 cholecystectomy+choledocho-lithotomy+T tube drainage, 4 exploring laparotomy + drainage. RESULTS: The following severity factors were identified: 1. the association of the ARF with other system and organ dysfunctions, the highest mortality rate being provided by the following associations: ARF + more than 3 organ and system dysfunctions and ARF + ARDS in assisted ventilated patients; 2. the abdominal compartment syndrome with abdominal pressure > 25 mm Hg; 3. severe sepsis and altered biological status of the patients. We registered a general mortality rate of 53.57% (15 deaths) and a postoperative mortality rate of 75% (6 deaths from 8 operated patients). CONCLUSIONS: 1. Summing up the pathologic changes proper to the acute pancreatitis (enzymes and mediators releasing) with sepsis and abdominal compartment syndrome worsens the humoral and metabolic syndrome of the ARF. 2. The simultaneous presence of other organ and system dysfunctions makes the ARF in SAP one of the most severe forms. 3. ARF with anuria + ARDS in assisted ventilated patients and ARF + more than 3 associated organ and system dysfunctions are the clinical forms with the highest mortality rate. 4. The abdominal compartment syndrome is an important severity factor of the ARF because of its direct impact against the kidney and the organ and system dysfunctions which produces and worsens.

[Cardiac penetrating wound with the section of the top of the heart and and other visceral injuries]. / Plaga înjunghiata cardiaca cu amputarea vârfului inimii si alte leziuni viscerale.

The case which we present is the most recent of a personal statistics on 10 cardiopericardiac plagues and the decision to be related separately was requested by some particularities with special points of view: a) anatomo-lesional, transfixiant plague with the lost of the top of the heart and the section of the left coronary artery, left diaphragmatic penetrating plague, left hepatic transfixiant plague, penetrating gastric plague. b) some aspects of surgery techniques. c) the evolution of acute septic complications (mediastinopleuroparietal suppuration) which has requested special care and 97 days of hospitalisation. d) healing, good evolution after 14 months from the accident.

[Rectal lesions in children. Clinico-therapeutic considerations of 12 cases]. / Leziunile rectului la copil. Consideratii clinico-terapeutice pe marginea a 12 cazuri.

The lesions of the anus and the rectum are not very really found in children, representing even a appreciable percentage; in the Pediatric Surgery Clinic of the University Hospital no. 1 of Craiova were admitted and operated 12 patients with lesions of the rectum between 1986 and 1998. The causes of these lesions were: polytraumatism--3, falls in different sharp things--7, rectal perforations on the septic base from the peritoneal cavity--1, iatrogenic cause--1. The surgical treatment were consisted in: the suture of wounds on the perineal way, lavage, drainage, antibiotherapy--6 cases, the iliac left anus with the re-establishing of the continuity--3 cases, the suture of wounds on the perineal and abdominal ways--2 cases. The conditions were good in 9 cases--cured, and 3 deceases (2 polytraumatism, 1 case malformed new-born with perforation produced by using haegar).

[Posttraumatic duodenal lesions in children. The therapeutic considerations]. / Leziunile posttraumatice ale duodenului la copil. Consideratii terapeutice.

The posttraumatic lesions of the duodenum in children represent rare cases in the surgical field. 4 cases of duodenal lesions were registered and operated upon in the Pediatric Surgery and Orthopedic Clinic, in cooperation with the ICU Clinic, 2 of them having postoperative complications (duodenal fistulae), these cases being initially situated in a retroperitoneal position (lateral and posterior). The ICU therapy was directed in the first step towards the traumatic and septic shock, in the second one to the immediate postoperative care and in the third step towards late complications. For the 2 cases having postoperative complications, the care was directed towards the elements of local complications (retroperitoneal abscess, fistulae), MSOF, sustaining the immune system correcting the nutritional deficiencies. Surgical methods used for sustaining the ICU therapy were: endovenous catheterisation, gastro-duodenal aspiration, solving the fistulae through catheters and suture. The results, using the methods described above, were good.

[Resuscitation principles in severe acute pancreatitis complicated by multiple organ dysfunctions]. / Principii de reanimare în pancreatitele acute grave complicate cu disfunctii multiorganice.

The first part renders very synthetically a few of the principal pathogenetical mechanisms implicated in PA, as well as general data about MODS, and then tackles therapeutical principles of great organic disfunction, the therapy of septic states and nutrition in PA. Hemodynamics dysfunction--the therapeutical objectives are correlated with the principal mechanisms implicated in cardio-vascular disfunction (the grown level of some myocardial depressive factors, the shortcoming of peripheral vascular resistance, a.s.o.). The therapeutical principles covets the volemic restoration, inotropic therapy, the correction of hydro-ionic and acido-basic disorders, the vasomotor therapy, the CID's correction, the myocardium protection against the free radicals of oxygen. The therapy is recommended to be individualized depending on the clinical data and the monitoring of some parameters (T.A, P.V.C., intrapulmonary pressure, EKG, hematocrit value, a.s.o.). Pulmonary disfunction--includes the therapy of some clinical forms of pulmonary complications, the restrictive syndrome, infections, the pulmonary shunt, the atelectasis and insists on ARDS which is a complication with vital implications. The therapy of curdling disorders--recommends blood, derivatives, antiprotease, the substitution of the consumed curdling factors, as well as the removal of the pathogenic factors which disturb the coagulation-coagulolysis equilibrium. Purge proceedings--covet the elimination from the organism of the toxic agents which generate cell-organic lesions. That's why it is moot the elimination of the pancreatic toxins before reaching the circulation (the thoracic tube draining and peritoneal lavage) as well as extrarenal purge proceedings (hemodialysis, hemofiltration and hemodiafiltration) with their benefits and limits. The sepsis and the immunotherapy--are tackled based on recent data from literature which besides antibiotherapy insists on the neutralization of various toxins and mediators by means of monoclonal and polyclonal antibodies, anti TFL antibodies, IL, a.s.o. Nutrition--is different presented, parenterally and enterally, each of them with their benefits and limits and with the recommendation to be used by means of the clinical form. There are mentioned some other additional treatments (pain removing, antagonisms of H2 receptors, inflammation and cytotoxicity inhibition, gastric decompression, a.s.o.).

[Severe acute pancreatitis. Its management and experience]. / Pancreatitele acute grave. Conduita si experienta.

The authors examined a group of 91 cases of acute pancreatitis hospitalised and treated between 1992 and 1996, using multiparametric bioclinical scores like Ranson, Imrie, Apache II systems and morphological scores obtained through C.T., they have divided the examined group into patients with A.B.P. (acute benign pancreatitis)--59 (64.84%), who don't require exquisite therapeutical means, with positive healing and A.S.P.--32 (35.16%), who require a complex medico-surgical therapeutics with unforeseeable evolution and results. The purpose of the paper was the one of establishing a diagnostical and therapeutical strategy for the A.S.P. adequate to actual conceptions. The correct diagnosis of acute pancreatitis initially has been established at 59 (64.83%) and erroneous at 32 (36.13%) cases. The diagnosis of A.S.P. has been established in 32 (35.16%). The etiology has been lithiasic (biliary) for 31.25% and nonbiliary for 68.75% patients. The C.T. examination in the best way to diagnose necrosis and infections, to follow the evolution and especially the surgical indication, achieved by the authors in 30% of cases. The initial medical treatment has been fulfilled at all the patients and the surgical one at 29 (91.63%). There have been implemented explorer laparotomies in 33.33% cases, interventions on the pancreas in 72.66%, operations associated on the biliary ways 41.37%, necessity operations 13.8%, with different types of draining (conventional and open abdomen). The results have been taxed by locoregional complications in 72.41%, general complications in 44.51% and a general rate of decrease of 43.75%. It is recommended initial surgical abstention and gravity estimations, the reanimation of all A.S.P. for prevention and treatment of general complications, surgical treatment of A.S.P. complications. The A.S.P. treatment of biliary (lithiasic) etiology after two months and after C.T. to confirm inflammatory process remission.

[Therapeutic considerations on a case of post-transfusion intravascular hemolysis]. / Consideratii terapeutice pe marginea unui caz de hemoliza intravasculara posttransfuzionala

A case is presented of intravascular hemolysis following incompatible transfusion of 500 ml hetero-group blood in a patient aged 29 years that had undergone emergency surgery for intra-abdominal hemorrhagic syndrome. Stress is laid on volemic therapy, on osmotic treatment and on the administration of alkalines in the first hours following the accident.