Choledochal Lithiasis. Multidisciplinary Therapeutic Target. Past and Present.

Introduction: Cholelithiasis still remains one of the most frequent pathologies encountered in surgical practice. The authors review the stages which marked the evolution of the treatment of choledochal lithiasis (CL) during the last 50 years, based on their own experience. From the exclusively surgical choledochus, we have reached a multidisciplinary therapy in which both endoscopy and interventional radiology have found their place. Material and Method: The authors studied 2 groups of patients: Group 1 included patients from the period 1959-1997 (38 years - 982 cases of choledocholithiasis) who underwent classical surgery. Group 2 included patients treated between 1997-2017 (20 years â?" 347 cases) in whom both endoscopic surgery and classic surgery were used to obtain choledochal clearance. The types of choledochal lithiasis (CL) according to which the method of obstruction clearance was decided upon and chosen are presented here. Results: All the patients in group 1 underwent classical surgery, representing 9.8% of operations for biliary lithiasis. In group 2, classical surgery was recorded in 23.4% of patients, and endoscopic surgery in 76.6% of them. We mention that there was no laparoscopic approach for the treatment of CL due to the absence of experience. In group 2 we recorded 26.3% endoscopic failure, while in the classical approach group there was 12.3% failure of obstruction clearance, the solution being biliodigestive anastomoses. Conclusions: The authors propose three categories of therapeutic indications in CL. A first category is represented by the "endoscopic choledochus", which includes migrated lithiasis. A second category is the "surgical choledocus". It is the situation of complex and complicated lithiases. Finally, there would be a third category - the "lithogenic choledocus". This last group includes the most aggressive lithiases with repeated relapses, panlithiases, etc. For categories 2 and 3, endoscopic - laparoscopic clearance attempts have no chance of success or are even contraindicated.

Specific Septic Complications after Rectal Cancer Surgery: A Critical Multicentre Study.

The postoperative septic complications in gastrointestinal surgery impact immediate as well as long-term outcomes, which lead to reinterventions and additional costs. The authors presented the experience of three surgery clinics in Romania regarding the specific septic complications occurring in patients operated on for rectal cancer. The study group comprised 2674 patients who underwent surgery over a 5-year period (2017-2021). Neoplasms of the middle and lower rectum (76%) were the majority. There were 85% rectal resections and 15% abdominoperineal excisions of the rectum. In total, 68.54% of patients were operated on laparoscopically, and 31.46% received open surgery. Without taking wound infections into account, 97 (3.67%) patients had abdominal-pelvic septic complications. The aim was to evaluate the causes of the complications. The percentage of suppurations after surgery of the rectum treated by radiochemotherapy was considerably higher than after surgery of the non-radiated upper rectum. The fatality rate was 5.15%. The risk of fistulas was significantly associated with the preoperative treatment, tumour position and type of intervention. Sex, age, TNM stage or grade were not significant at 0.05 the threshold. The risk of fistulas is reduced with low anterior resection, but the gravity of these complications is higher in the lower rectum compared with the superior rectum. Preoperative radiochemotherapy is a contributing factor to septic complications.

Groin Hernia Repair during the COVID-19 Pandemic-A Romanian Nationwide Analysis.

Background and Objectives: Groin hernia repair surgery (GHRS) is among the most common elective interventions. The aim of this three-year nationwide study on GHRS is to provide a thorough analysis of the impact that the COVID-19 pandemic had on the Romanian Health System in regard to elective procedures. Materials and Methods: 46,795 groin hernia cases obtained between 2019 and 2021 from the DRG database using ICD-10 diagnostic codes. The data were collected from all 261 GHRS performing hospitals nationwide, including 227 public hospitals (PbH) and 34 private hospitals (PvH). The 42 variables taken into account were processed using Microsoft Excel 2021, applying Chi square, F-Test Two-Sample for variances, and Two Sample t-Test. The significance threshold considered was p < 0.001. Results: Of the grand total of cases, 96.2% were inguinal hernias, 86.8% were performed on men, 15.2% were laparoscopic procedures, and 6.88% were in PvH. Overall, due to the pandemic, the total number of GHRS decreased with 44.45% in 2020 and with 29.72% in 2021 compared to pre-pandemic year 2019. April 2020 shows the steepest decrease in GHRS (91 procedures nationwide). In the private sector, there was an opposite trend with increases in the number of cases by 12.21% and a 70.22% in both pandemic years. The mean admission period (MAP) for all procedures was 5.5 days. There was a significant difference between PbH and PvH (5.75 vs. 2.8 days, p < 0.0001). During the pandemic, the MAP in PbH decreased (6.02 in 2019, 5.82 in 2020 and 5.3 in 2021), remaining stable for PvH (2.9 days in 2019, 2.85 days in 2020 and 2.74 days in 2021). Conclusions: The COVID-19 pandemic significantly reduced the overall number of GHRS performed in Romania in 2020 and 2021, compared to 2019. However, the private sector thrived with an actual increase in the number of cases. There was a significant lower MAP in the PvH compared to PbH throughout the three-year period.

Augmented Reality in Surgical Oncology. A Literature Review.

Introduction: Augmented reality (AR) devices enable doctors to associate visualizing diagnostic data, to establish therapeutic procedures in order to improve work efficiency and safety and to develop the surgical training of young doctors. This new approach may contribute to an increase in the quality of medical training and a decrease in the costs of surgeries. This paper assesses whether augmented reality can improve the results of surgical procedures as well as its possible progress in the future. Methods and results: The intra-operative use of augmented reality by using Google Glass glasses, on which we projected MRI/CT images of the anatomical areas invaded by tumors and/or images of normal anatomy, helps us to perform surgeries, as well as to present them as teaching material. We have also performed a review of the available literature, beginning with 2011 and ending with November 2021, by looking up the terms "augmented reality" and "surgical oncology" in PubMed. The results of the search were 308 studies in this field which prove the utility of the method. Many papers show that the performance of the augmented reality systems is superior and compatible with traditional imaging techniques. Conclusions: The specialty literature reveals a growing interest on the part of surgeons regarding the use of augmented reality during surgery. This procedure enables the improvement of the safety and efficiency of surgical techniques, as well as their presentation to students and residents alike. The method is innovative and has to be carefully approached before being introduced into routine practice.

The Portosystemic Shunt for the Control of Variceal Bleeding in Cirrhotic Patients: Past and Present.

Based on an experience of more than 50 years in the treatment of portal hypertension (PHT), the authors review and analyze the evolution of the surgical portocaval shunt (PCS). We would like to provide an insight into the past of PCS, in order to compare it with the current state of the treatment of PHT complications. As a landmark of the past, we shall present statistics of more than 500 cases of PHT operated between 1968 and 1983. From this group, 238 patients underwent surgical portocaval shunting during a fifteen-year period. The behavior of the portal hemodynamics following PCS was studied and the postoperative decrease in portal pressure (PP), as well as the residual PP, were recorded. The portal manometric determinations were made by electronic recordings using the Hellige device and direct intraoperative recordings through the catheterization of a ramus in the portal area. The results of PCS are superposable, in terms of hemodynamic efficiency, with those of the intrahepatic shunt (TIPS-transjugular intrahepatic portosystemic shunt). The authors discuss the current place of PCS, in obvious decline in comparison with the situation 50 years ago. The current methods of controlling variceal bleeding represent obvious progress. PCS remains with very limited indications, in specific situations when the other therapeutic methods have failed or are not recommended.

Unusual Complicated Gastric Ulcers.

We here draw attention to a practical issue: the approach to certain unusual gastric ulcers with haemorrhage- or perforation-induced complications. This category of ulcers, i.e., giant (over 2-3 cm) and multiple ulcers, is rarely encountered. We discuss the circumstances determining the occurrence of such lesions, their diverse aetiology and pathogenesis, their common manifestations, and the severity of their evolution. Some of the lesions are benign (chronic or acute ulcers), whereas others are neoplastic: carcinoma, stromal tumours, and lymphomas. In gastric ulcers, the characteristics of this particular and rare category of lesions strictly places them in the surgical field, requiring primary surgical intention. Conservative treatments are not effective in such cases, and preoperative biopsies are not appropriate for emergency interventions. Whether these unusual ulcers are benign or malign, they need to be surgically removed.