Invasive amebiasis.

Digestive amoebiasis with his invasive form is an unusual pathology encountered in the temperate zone. This could lead to a life threatening complication: systemic amoebiasis. A 55-year-old male was treated successfully of systemic amoebiasis in a third referral hospital. The diagnosis was established based on epidemiology data and microscopical identification of trophozoites of Entamoeba histolytica. The amoebicidal, antibiotic and supportive treatments was firstly administrated. The clinical picture of intestinal amoebiasis raised from dysenteric syndrome to necrotizing enteritis. The bowel perforation with localized peritonitis was followed by chronic enteric fistula. Amoebic liver abscess, as the most frequent extraintestinal complication, was concomitantly diagnosed and treated. Urinary amoebiasis was considered as complication in the context of systemic dissemination: any other location could become a site of an amoebic abscess. Multidisciplinary approach was the successful key in the management of the patient, including antiparasitic therapy and antibiotic prophylaxis, intensive care and multiple surgical approaches. The diagnosis of digestive amoebiasis and systemic complication may be delayed in nonendemic areas, leading to advanced and complicated stages of the disease. The surgical approach is most efficiently to treat a large liver amoebic abscess and intraperitoneal collections.

[Surgical treatment of hepatocellular carcinoma--indications, limitations, realities]. / Tratamentul chirurgical al carcinomului hepato-celular--indicatii, limite, exigente actuale.

The present study analyzes the importance of the factors in improving the resectability, obtaining morbidity and mortality rates in accordance to the actual exigencies. In The III-rd Surgical Clinic, "Sf.Spiridon" Hospital, Iasi, during 1998-2003, 24 cases of CHC (19 men, 5 women with a median age of 58.5 years), usually developed on a cirrhotic liver, benefited by surgical approach. The tumoral mass (median size 7.8 cm) was situated in the left liver (15 cases--62.5%), right liver--13 cases and for 1 case with multiple localization (the segments VI-VII and III). For 12 cases (50%) various extensions of liver resections have been undergone: left lobectomies II-III--4 cases, left hepatectomy--1 case, segmentectomies VI--3 cases, segmentectomy III + bisegmentectomy VI-III--1 case, atypical hepatectomy--3 cases. Only 2 cases benefited by right portal vein ligation prior to resection. In 12 cases intraoperative exploration and US examination (4 cases) contraindicated the resection. One patient deceased on the entire lot (4.16%); post-resection mortality--8.33%. In conclusion, the early diagnostic of CHC developed on cirrhotic liver, the patients selection, the use of laparoscopy and intraoperative US, the available devices (CUSA dissector), selective ligation of portal branch prior to resection represents imperative elements in improving the resectability in safe conditions for the patient.

[Minimally invasive treatment of pulmonary and pleural hydatid cyst]. / Tratamentul minim invaziv al chistului hidatic pulmonar si pleural.

The incidence of hydatid disease is increased in Balkan region and Eastern Europe. The global incidence in Romania is 5-6 cases of 100,000 populations. The etiological agent is Taenia echinococcus. The pulmonary localization is about 30% from all cases with hydatic disease. The only efficient treatment is represented by surgical intervention with minimal visceral and parietal destruction. We will present 4 cases with pulmonary and pleural hydatic cysts that were treated with minimally invasive techniques. New minimally invasive approaches are developed to reduce physical discomfort, to offer a better intraoperative visibility, for the esthetic aspect of incisions, shorten hospitalization and quick socio-professional reintegration. The mean duration of hospitalization in these 4 cases was 8.5 days (limits between 7-12 days). The rate of complication and the necessary of analgesics were reduced. The medical treatment with Albendazole 10 mg/kg/day, 14 days in preoperative and 3 months postoperative period was followed in all patients. After discharge, imaging evaluation in the first 24 months is very important. The obtained results were excellent and we conclude that minimally invasive surgery in pulmonary hydatid disease represent a better method of surgical treatment.

[Laparoscopic adhesiolysis]. / Adezioliza laparoscopica.

The laparoscopic approach of the postoperative adhesions represents not only a way of diagnosing the pathogenic adhesions but also a superior alternative to the surgery of classical dissection of adhesions by laparotomy because of its obvious advantages: the evolution is simple, the bowel activity is quickly restored, the brief period of hospitalisation, the reduced risk of recurrence. The authors present their experience derived from the 29 laparoscopic adhesiolysis: 3 urgent cases with subocclusions, 6 when the surgical intervention was programmed, with a painful postoperative suffering, and 20 with laparoscopic cholecystectomy. From among these cases, a conversion and a postoperative complication were recorded. The result after a period of time are satisfactory.

[Laparoscopic adhesiolysis]. / Adezioliza laparoscopica.

The laparoscopic approach of the postoperative adhesions represents not only a way of diagnosing the pathogenic adhesions but also a superior alternative to the surgery of classical dissection of adhesions by laparotomy because of its obvious advantages: the evolution is simple, the bowel activity is quickly restored, the brief period of hospitalization, the reduced risk of recurrence. The authors present their experience derived from the 29 laparoscopic adhesiolysis; 3 urgent cases with subocclusions, 6 when rhe surgical intervention was programmed, with a painful postoperative suffering, and 20 with laparoscopic cholecystectomy. From among these cases, a conversion and a postoperative complication were recorded. The result after a period of time are satisfactory.

[Laparoscopic appendectomy: the indications, limits and results]. / Apendicectomia laparoscopica: indicatii, limite, rezultate.

A total of 10 young women with suspected acute appendicitis were studied. We investigated the value of laparoscopy in the diagnostic evaluation for possible appendicitis in women of reproductive age. At laparoscopy, appendicitis was diagnosed in seven patients (acute-6, subacute-1). Three women had a normal appendix and a pelvic inflammatory disease, a ruptured ovarian cyst and an ovarian cyst with torsion. Laparoscopic appendectomy was performed in 7 cases; a conversion to open operation were because of torsion of ovarian cyst; a laparoscopic cystectomy was necessary. There were no intraoperative and postoperative complications (no wound infections). Reintroduction of normal diet and discharge from hospital occurred earlier after laparoscopic than open surgery. It is concluded that diagnostic laparoscopy permits earlier definitive diagnosis and prompt institution of appropriate therapy for disease of the female reproductive tract that simulates appendicitis; laparoscopic appendectomy is practical and may have advantages over conventional operation (reduction of wound infections and earlier return to normal activities).

[The value of laparoscopic cholecystectomy in the treatment of gallbladder pathologies]. / Valoarea colecistectomiei laparoscopice în tratamentul colecistopatiilor.

We have prospectively studied all cholecystectomies performed in one year in our clinic in two groups: 190 cases performed laparoscopically and 98 open. We used standardized records and the EPI 5 program on an IBM compatible computer. There were no significant differences between groups regarding weight, sex and proportion of cases with acute cholecystitis. There were however major differences regarding age, type of habitat, ASA score and association with acute pancreatitis, obstructive jaundice and angiocholitis. Conversion of laparoscopic cholecystectomy to open procedure was imposed in 17 cases (not included in statistical analysis) due to technical difficulties (12 cases), haemorrhagic accidents (6 cases), injury of the common bile duct (1 case), stones lost in the abdominal cavity (3 cases), local peritonitis (5 cases). Laparoscopic cholecystectomy lasted a mean of 74 minutes. We encountered 3 specific complications: one CBD injury recognized intraoperatively and managed by Kehr's procedure (one CBD injury in the open cholecystectomy group), one small bowel perforation and one of biloma. Mortality averaged 0.5% in the LC group (one case of late postoperative stroke considered not related to the procedure) and 1% in the open cholecystectomy group. The hospital admission period was significantly reduced in the LC group (5 days vs. 12 days). LC appears as a safe procedure with a low complication rate. Conversion to open procedure is not a complication. Our study recommend LC as the method of choice in the treatment of gallbladder lithiasis.

[Anesthesia in laparoscopic surgery]. / Anestezia în chirurgia laparoscopica.

The use of laparoscopic techniques in general surgery is increasing in popularity. The anesthesiologist's goals during laparoscopic surgery are hemodynamic and respiratory stability, appropriate muscle relaxation, control of diaphragmatic excursion, intraoperative and postoperative patient analgesia. The implications are that the anesthesiologist must use a technique that not only allows for optimal surgical conditions but also provides intraoperative patient comfort and safety and a rapid postoperative anesthetic recovery. Laparoscopy is not a benign procedure. It is associated with major and minor surgical and non surgical complications, including death. Therefore, it is imperative that the anesthesiologist and surgeon thoroughly understand the physiopathology and immediate treatment of these potential complications and communicate effectively about their management.

[Laparoscopic cholecystectomy in acute cholecystitis]. / Colecistectomia laparoscopica în colecistita acuta.

Contrary to earlier opinions, the laparoscopic cholecystectomy (LC) is not a contraindication in the acute cholecystitis. The most important parameter in determining the feasibility of attempting laparoscopic cholecystectomy in the setting of acute inflammation appears to be the experience of the surgeon. 59 cases with LC are analyzed: 50 LC and 9 conversion. The operations were more difficult and lasted longer. The patients appeared to be at a greater intraoperative risk and the conversion rate was also higher. Neither lesions of the common bile duct nor deaths were recorded. The advantages of the method (the hospital stay was reduced, less postoperative pain, and early return to normal activities) should not make the surgeon disregard the risks and stubbornly employ LC in acute cholecystitis.

[Mechanical anastomoses in esophagogastric surgery for malignant tumors]. / Anastomoses mécaniques dans la chirurgie oeso-gastrique pour des tumeurs malignes.

The authors present their experience in employing for the first time the mechanical circular suture with I.L.S. stapler in the surgery of 10 malignant esophagogastric tumors sited in C (4 cases) and M areas (6 cases). The disease was in stage II in 2 patients and in stage III in the remainder of 4. Three upper polar esophagogastrectomies (Akiyama technique) and 7 total gastrectomies were performed in old patients (mean age 63 years) at high surgical risk. Neither death nor fistulas were recorded. The average hospital stay was 14 days. A series of 17 patients (mean age 59 years), at medium surgical risk, with total gastrectomy for gastric carcinoma and classical suture served as controls. Five fistulas, two deaths and a two times longer hospital stay were recorded. Although the high cost of staplers prohibits the routine use of this technique, the authors demonstrate the great advantages resulting from mechanical suture in esophagogastric surgery.

Effects of ceruletide on post-operative intestinal atony: a manometric study.

The effects of ceruletide on jejunal motor activity were studied in seven patients with postoperative intestinal atony. Jejunal pressures were recorded by three perfused catheters with orifices spaced 5 cm apart, the proximal one being positioned 10 cm beyond the ligament of Treitz. Ceruletide (0.05 microgram/Kg i.v.) significantly (p less than 0.0001) increased the number and amplitude of jejunal contractions. The action of ceruletide was most obvious the first 15-minutes after administration, then its effect diminished progressively and ceased after 65-75 minutes. The adverse reactions of ceruletide were minimal and self-limiting.