European guidelines from the EHTG and ESCP for Lynch syndrome: an updated third edition of the Mallorca guidelines based on gene and gender.

BACKGROUND: Lynch syndrome is the most common genetic predisposition for hereditary cancer but remains underdiagnosed. Large prospective observational studies have recently increased understanding of the effectiveness of colonoscopic surveillance and the heterogeneity of cancer risk between genotypes. The need for gene- and gender-specific guidelines has been acknowledged. METHODS: The European Hereditary Tumour Group (EHTG) and European Society of Coloproctology (ESCP) developed a multidisciplinary working group consisting of surgeons, clinical and molecular geneticists, pathologists, epidemiologists, gastroenterologists, and patient representation to conduct a graded evidence review. The previous Mallorca guideline format was used to revise the clinical guidance. Consensus for the guidance statements was acquired by three Delphi voting rounds. RESULTS: Recommendations for clinical and molecular identification of Lynch syndrome, surgical and endoscopic management of Lynch syndrome-associated colorectal cancer, and preventive measures for cancer were produced. The emphasis was on surgical and gastroenterological aspects of the cancer spectrum. Manchester consensus guidelines for gynaecological management were endorsed. Executive and layperson summaries were provided. CONCLUSION: The recommendations from the EHTG and ESCP for identification of patients with Lynch syndrome, colorectal surveillance, surgical management of colorectal cancer, lifestyle and chemoprevention in Lynch syndrome that reached a consensus (at least 80 per cent) are presented.

Erratum to: The management of intra-abdominal infections from a global perspective: 2017 WSES guidelines for management of intra-abdominal infections.

[This corrects the article DOI: 10.1186/s13017-017-0141-6.].

Severe pulmonary arterial hypertension associated with congenital cardiac shunts: evolution under specific treatment.

Objective: The aim of this study was to compare the effects of Sildenafil, Bosentan and combined therapy in patients with congenital cardiac shunts associated pulmonary artery hypertension (CCS-PAH). Design: Prospective observational study (February 2011 - January 2014) with a historical control group (January 2009 - January 2011). Setting: "CC Iliescu" Institute for Emergency Cardiovascular Diseases of Bucharest, a tertiary university-affiliated center. Patients: All cases with CCS-PAH. Interventions: Specific vasodilatory therapy: Sildenafil, Bosentan or combined therapy. Outcome Measures: The primary outcome was the overall survival at 24 months. Results: Out of 108 patients with pulmonary arterial hypertension, there were 79 patients with CCS-PAH, 55 presenting a severe form of the disease. The mean age of the patients was 34.42±21.15 years, with 37 (67,3%) female patients. 23 patients received specific vasodilatory treatment (thirteen Sildenafil, seven Bosentan, three combined treatment), with 32 patients in the control group, without specific vasodilatory therapy. The specific vasodilatory therapy was associated with improved WHO/ NYHA functional class (p=0.025), oxygen saturation at the end of the six-minute walk test (p=0.011), decreased pulmonary artery systolic (p=0.002) and diastolic (p=0.004) pressures, and an increased S' wave in Tissue Doppler Imaging (p=0.008). Conclusions: Despite the complexity of CCS-PAH, with a complex constellation of underlying congenital heart defects, there are short-term benefits of a specific vasodilatory therapy.

Diabetes and collision risk. A meta-analysis and meta-regression.

AIMS: The main objective of this study was to see whether diabetes is associated with an increased collision risk and to test the effect of age and gender on the overall collision risk for diabetes drivers. MATERIALS AND METHODS: Twenty-eight studies were included in meta-analysis, using mean age, gender, continent and the prevalence of fatal road incidents as covariates. RESULTS: The collision risk for diabetes drivers was small and not statistically significant - RR = 1.11 (1.01-1.23) with a prediction interval (PI) or 0.77-1.65. Age and gender were not associated with an increased overall risk. Insulin-dependent diabetes patients had a slightly increased effect size compared with the overall diabetes population, but the effect was not statistically significant. European diabetes drivers had a lower collision risk compared with their North American counterparts, the main cause being the difference of collision risk in the countries in which the studies were performed. CONCLUSIONS: Overall, diabetes patients do not have a statistically significant increased risk for unfavourable traffic events. Old age and insulin-dependent patients tend to have a higher risk. Advances in diabetes care, associated with advances in road safety regulations, and automotive industry have not decreased significantly the collision risk in the last 50 years for drivers with diabetes.

High Grade Penetrating Pancreatic Trauma - Case Report and Review of the Literature.

INTRODUCTION: The pancreatic injuries have fortunately a low frequency, but when present associate multiple intraabdominal lesions, and carry a significant morbidity and mortality. The aim of this study is to underline the significant morbidity associated with high grade pancreatic injuries. CASE REPORT: Female patient, 36 years old, with penetrating abdominal trauma due to domestic violence was referred to our center from a regional county hospital, after multiple laparotomies, hemodynamically unstable, with multiple organ failure. Abdominal clinical exam revealed evisceration, with massive pancreatic leakage at the level of the median laparotomy and through the stabbing wounds from the right flank. Emergency Computed Tomography showed multiple intraabdominal collections, with laceration of the liver, right kidney and pancreatic head. Abdominal exploration was decided. After a thorough abdominal debridement was revealed a deep laceration of the pancreatic head, with active extravasation of pancreatic secretion, correlating with a grade IV injury. Peritoneal lavage and large drainage of the lesser and greater peritoneal cavity was performed. The postoperative recovery was uneventful, with progressive decrease in pancreatic fistula output and discharge after 35 days. CONCLUSIONS: High grade pancreatic traumas associate a significant morbidity. Efficient drainage of the pancreatic head injuries and patients management in high volume centers for pancreatic surgery maximize the survival rate.

Traumatic Tricuspid Valve Rupture after Blunt Chest Trauma - A Case Report and Review of the Literature.

INTRODUCTION: Despite the high frequency of thoracic injuries secondary to traffic related accidents, the blunt cardiac valve rupture is extremely rare. METHOD: Case report and review of the literature using PubMed/MEDLINE and EMBASE databases. RESULT: A 38 year old female patient, victim of car accident was admitted. On primary survey the patient was conscious, cooperative and hemodynamic and respiratory stable. On secondary survey was found a bilateral open leg fracture and a seat belt sign. Whole body Computed Tomography revealed minimal haemorrhagic contusion of the cortex, left hemopneumothorax and right pneumothorax, bilateral rib fractures, liver contusion, left femoral neck fracture and fracture to the lumbar spinal column. After bilateral pleurostomy, the patient becomes hemodynamically unstable, but with no signs of external bleeding. The transthoracic echocardiography revealed an acute severe tricuspid regurgitation with hepatic veins reflux. After orthopaedic surgeries, the tricuspid valve rupture was managed by replacing the valve with a bioprostheses. The hospital stay was 122 days. CONCLUSION: Only a high index of suspicion may reveal blunt cardiac lesions as a cause for hemodynamic instability in acute setting.

Massive intraoperative bleeding after laparoscopic assisted abdominoperineal resection: a case report and systematic review of the literature.

INTRODUCTION: The laparoscopic-assisted abdominoperineal resection (LAPR) has been proved to be associated with a shorter postoperative recovery, with equivalent oncological results and similar survival when compared with conventional open surgery, for patients with low rectal cancer. METHOD: Case report of a massive intraoperative bleeding during LAPR and systematic review of the English language literature, using PubMed Medline, ISI Thopmson, OVID and EMBASE databases. RESULTS: 58 years old patient admitted in emergency setting or rectal bleeding. Rectal examination revealed a protruding,frail tumor, located 2 cm from the anal verge. Total colono scopy revealed an infiltrative, protruding tumor, situated at 2 cm from the anal verge, with a 5 cm cranial extension,without any additional colonic lesions. Computed Tomography showed a 4,5 cm circumferential rectal wall thickening, without any enlarged mesorectal or abdominal lymph nodes. The patient was transported to operating room for a LAPR. During final hemostasis, at the level of perineal surgical wound, an acute massive bleeding occurred from the presacral vessels with severe blood loss. This bleeding couldnot be managed laparo scopicaly and conversion to laparotomywas decided, with pelvic packing. At 48 hours after the initial surgical approach, the tamponing packs were removed, without signs of active bleeding. There were applied haemostatic agents and the perineal wound was sutured, without further rbleeding during in-hospital stay. CONCLUSIONS: A rapid and effective control of the presacral bleeding is mandatory to prevent a fatal outcome. Pelvic packing remains a life-saving procedure and the treatment of choice in severe cases.

Epidemiology of diverticular disease -- systematic review of the literature.

INTRODUCTION: Associated with the Western diet and life style,diverticular disease is affecting more and more developing countries worldwide. Recent studies show an increase in incidence of the disease at young age, that raises the risk of complications, along with major consequences for the patient but also for the healthcare system. METHOD: Systematic review of the literature with US National Library of Medicine and National Institutes of Health International PubMed Medline, using abstracts and articles available in PubMed Medline, Cochrane databases searching for ("Diverticulosis, Colonic epidemiology" [MeSH] OR"Diverticulosis, Colonic etiology" [MeSH] OR "Diverticulosis,Colonic genetics" [MeSH] OR "Diverticulosis, Colonic history" [MeSH]). RESULTS: Even from the rise of diverticular disease as a public healthcare problem, at the end of the previous century, it was associated with a diet rich in refined sugars, lacking vegetable fibres. The higher incidence in countries like U.S.A., Canada, United Kingdom and the northern states compared with its rare occurrence in the sub-Saharan African continent, strengthen the anterior assumptions. In regions like Asia, the disease pattern is characterized by are latively low incidence of colonic diverticular disease, with distribution of diverticula mainly on the right colon. The different incidence by sex and age show the possible existence of hormonal protective factors. Studies from countries with a rich ethnic diversity, bring into question the probable genetic predisposition to diverticular disease, fact backed-up by the few studies on twins and 1st degree relatives available in the literature. DISCUSSION: The rising incidence of colonic diverticular disease in Romania makes our country adhere the epidemiologic model existing in countries with a close socio-economic status.Although with a lower incidence than countries that have adopted a Western diet, Romania is likely to encounter a public health problem, if certain measures to identify and minimise the population exposure to risk factors are not taken.

Trauma registry -- a necessity of modern clinical practice.

INTRODUCTION: Traumas represent the cause of 10 % of deaths in the entire world. The successful development of trauma systems, including the use of trauma registries, played a significant part in lowering the mortality and the disabilities due to injuries resulted from trauma. METHOD: Review of the literature using computerized database of National Library of Medicine and the International Institutes of Health MEDLINE using PubMed interface. There were selected the articles that address the issue of trauma registry from the different world trauma systems. RESULTS: Trauma registries have developed once they were introduced in centers and trauma systems in the United States of America in 1970. First trauma database processed on computers was created in 1969 in Cook County Hospital in Chicago. This database became the prototype of trauma registry in Illinois which started gathering information from 50 designated hospitals across the entire state in 1971.Countries with limited resources were able to start useful trauma registers. Continuous financing and dedicated personnel inside the team are two essential factors in the success of a trauma registry. NISS (New Injury Severity Score) higher than 15 is a widely used inclusion criteria in the trauma register. Exclusion is represented by patients admitted at over 24 hours after the accident, those declared dead before hospital arrival or with no signs of life on arrival in hospital. In addition, it is recommended that asphyxia,drowning and burns to be excluded. CONCLUSION: The improvements regarding the treatment of multi-traumatized people in developing countries depend on establishing and performance of trauma systems, where trauma registry represents a part of these systems infrastructure.

Splenic implant assessment in trauma.

Trauma is a global health issue, being the 4th death cause after cardio-vascular disease, malignancies and chronic pulmonary diseases and the main death cause among young people, under 45 years (1). The frequency of abdominal trauma is 10-12% of all polytrauma, and from all abdominal organs, the spleen and liver are the most often involved in polytraumatized patients case (2). The first purpose of a successful operational management is the control of active bleeding, and the second is preserving as much as possible of the destroyed organs. Over the last decades, the treatment of spleen traumas had been diversified,from nonsurgical treatment to surgical, also complex and diversified: from conservative treatment to splenectomy.Currently, from a therapeutic standpoint, the trends in spleen trauma are orientated towards conservative methods as the clinical and experimental data have shown that €œit is better with the entire spleen than part of it, and better with a part of it than with none at all (Raymond Hinshaw) (3).

Current strategies in the therapeutic approach for adenocarcinoma of the ampulla of Vater.

INTRODUCTION: Ampulla of Vater tumors, neoplastic diseases located at the confluence of the common bile duct with the main pancreatic duct; represent 0.2% of all gastrointestinal cancers. METHOD: Retrospective study of all patients admitted in the Emergency Hospital of Bucharest Romania between January 2008 and January 2013, the only selection criterion used being a pathology report which describes an ampulla of Vater carcinoma. We have also performed a review of the medical literature up to 2013, using the PubMed/Medline, Proquest Hospital Collection, Science Direct, Cochrane Library and Web of Science databases. We have used different combinations of the following keywords: "ampulla of Vater", "carcinoma", "resection", reviewing the reference list of retrieved articles for further relevant studies. RESULTS: Forty eight patients with ampulla of Vater carcinoma were identified, of whom 59.6% men, 71% from urban areas, and a mean age of 66 ± 13.3 years. Most patients were admitted for obstructive jaundice (49%), right upper quadrant abdominal pain (19%), nausea and loss of appetite in 13%, loss of weight (13%) and upper digestive obstruction in 6% of cases. All patients were evaluated with abdominal transparietal ultrasonography and double contrast, pancreatic protocol, Mutidetector Row Computed Tomography. The abdominal Magnetic Resonance Imaging was performed in 10 cases, upper gastrointestinal endoscopy in 9 cases, and Endoscopic Retrograde Cholangiopancreatography in 39 cases. According to the AJCC Cancer Staging 9% were into stage I, 47% into stage II, 40% into stage III and 4% into stage IV of the disease. The therapeutic approach was surgical for 44 patients and an endoscopic palliation with stent insertion in 4 cases. The surgical procedure was represented by Whipple pancreatoduodenectomy in 27 cases, pylorus preserving pancreatoduodenectomy in 15 cases and exploratory laparotomy in 2 cases. Early morbidity was represented by pancreatic leakage in 4 cases. CONCLUSIONS: There are clinical scenarios in which it is quite challenging to distinguish a primary ampullary adenocarcinoma based on a preoperative workup. Nevertheless, an aggressive approach should be performed, knowing the higher resectability rates and a five-year survival for these patients. Complete surgical resection should be performed in all medically fit patients, candidates for pancreatoduodenectomy, by a high volume, trained surgeon, able to offer a low morbidity and mortality.

Prehospital trauma care: a clinical review.

INTRODUCTION: There are many controversies related to the trauma patient care during the pre-hospital period nowadays. Due to the heterogeneity of the rescue personnel and variability of protocols used in various countries, the benefit of the prehospital advanced life support on morbidity and mortality has been not established. METHOD: Systematic review of the literature using computer search of the Library of Medicine and the National Institutes of Health International PubMed Medline database using Entre interface.We reviewed the literature in what concerns the basic and advanced life support given to the trauma patients during the prehospital period. RESULTS: Although the organization of the medical emergency system varies from a country to another, the level of patient'scare can be classified into two main categories: Basic Life Support (BLS) and Advanced Life Support (ALS).There are many studies addressing what to be done at the scene.The prehospital care can be divided into two extremes: stay and play/treat then transfer or scoop and run/load and go. CONCLUSIONS: A balance between "scoop and run" and "stay and play" is probably the best approach for trauma patients. The chosen approach should be made according to the mechanism of injury (blunt versus penetrating trauma), distance to the trauma center (urban versus rural) and the available resources.

[Trauma scores: a review of the literature]. / Scorurile traumatice: revizie a literaturii.

BACKGROUND: A quantitative method for measuring trauma severity has many potential applications: patient triage, a common terminology about injuries severity, prognosis assessment, trauma care audit and epidemiological. METHOD: Systematic review of the literature using computer searching of Library of Medicine and the National Institutes of Health International MEDLINE database using PubMed Entre interface. We have selected articles about the main scoring systems used in today's trauma care. RESULTS: Trauma scores were introduced more than 30 years ago, for assigning numerical values to anatomical lesions and physiological changes after an injury. Physiologic Scores describe changes due to a trauma and translated by changes in vital signs and consciousness. Anatomical Scores describe all the injuries recorded by clinical examination, imaging, surgery or autopsy. If physiological scores are used at first contact with the patient (for triage) and then repeated to monitor patient progress, anatomic scores are used after the diagnosis is complete, generally after patient discharge or postmortem. They are used to stratify trauma patients and to measure lesion severity. Scores that include both anatomical and physiological criteria (mixed scores) are useful for patient prognosis. CONCLUSIONS: Despite their imperfections, trauma scores are very important tools in trauma patients management and research. Using large national databases allow a better research, validation and development of scoring systems.

[Mechanism of injury--trauma kinetics. What happend? How?]. / Mecanismul lezional--cinetica in trauma. Ce s-a intâmplat? Cum?

INTRODUCTION: Understanding the mechanism of injuries represents a key element in blunt and penetrating trauma management. METHOD: Systematic review of the main types of the modem trauma mechanisms, using Medline, Cochrane Library and Embase databases. RESULTS: To properly understand the road car accident injuries, trauma surgeon should know as many details from the scene: the speed of cars, impact direction, if the car rolled over, if occupants were restrained, if airbags exploded, vehicle telemetry, extrication time. Motorcyclists are 20 to 30 times more at risk for severe injuries or death than the four-wheel vehicle occupants. Current evidence shows a significant decrease in injuries severity by increasing use of seat-belts, motorcycle helmets, childrestrains and speed limit. Despite this, few countries around the world have road safety laws relating to key factors that can be considered sufficiently comprehensive in scope. Many modern trauma systems use for prehospital triage mechanism of injury criteria. CONCLUSIONS: The trauma surgeon should know the mechanism of injury. This allows a high suspicion for potential injuries, their early diagnosis and increased quality in the care of trauma patients.

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.

Open to laparoscopic conversion in hemoperitoneum of unknown origin.

PURPOSE: Demonstrating the potential, in spite of the current trend, of closing an open emergency surgical procedure and to convert it to a minimally invasive approach. METHODS: Case report of an open converted to a laparoscopic approach in an emergency setting for hemoperitoneum of unknown origin. RESULTS: A 28-year-old-female patient was transported to the operating room for suspected acute appendicitis. Through McBurney's incision, hemoperitoneum was found. She was hemodynamically stable. The open incision was closed and a laparoscopic approach established. The diagnosis was a ruptured right ectopic pregnancy with mild hemoperitoneum. After a laparoscopic salpingectomy, her recovery was uneventful. CONCLUSIONS: For selected cases, the conversion of an open procedure to a laparoscopic approach offers a real benefit for the patient, avoiding a large laparotomy and its associated morbidity.

[History of trauma care]. / Istoria îngrijirii pacientului traumatizat.

BACKGROUND: Since its inception, the man suffered injuries through falls, fire, drowning and interpersonal conflict. While the mechanism and frequency of different specific injuries has changed passing of millennia, trauma remains an important cause of mortality and morbidity in modern society. Although the war is presented as one of the four knights of the Apocalypse, we must emphasize the important developments of surgical experience during war. The purpose of this study is to highlight the lessons learned during the history and how they changed the modern trauma care. METHOD: Systematic review of English language literature using computer searching of Library of Medicine and the National Institutes of Health International MEDLINE database using PubMed Entre interface. RESULTS: The first historical record of a trauma medical care is 3605 years ago. Over the past decades, one of the most important changes in trauma patient care is the selective nonoperative management (SNOM) of significant abdominal visceral injuries. SNOM was first described in 1968, for splenic trauma, by Upadhyay and Simpson. It was accepted much later for liver injuries. Beginning from 1960 - 1970, SNOM was introduced for abdominal stab wounds. Exploratory laparotomy remains the standard approach for abdominal gunshot wounds until 1990, when centers from United States and South Africa first reported cases successfully managed nonoperatively. CONCLUSIONS: The trauma surgery has evolved continuously over the centuries, according to more and more severe modem injuries.

[Trauma--epidemiology: where are we today?]. / Epidemiologia traumatismelor--unde ne aflam astazi?

INTRODUCTION: Understanding the epidemiological data on injuries is the cornerstone of modern interventions targeting prevention and treatment to decrease their mortality and morbidity. METHOD: Systematic review of English literature using computer searching and selecting articles that describe the epidemiological data for the main causes of nowadays trauma. RESULTS: Trauma meets the conditions of a pandemy, 5.8 million people dying evey year and 8.4 million being expected in 2020. Trauma is one of the main five causes of mortality and morbidity for all age groups below 60 years. Most deaths caused by road car accidents occur in young adults aged 15-44 years. Over half of deaths by drowning occur between 0-14 years. Over 40% of mortality by falls occurs in people over 70 years. 60% of deaths by poisoning occurs in people 15-59 years. Over 60% of human aggression mortality occurs in young adults aged 15-44 years. Suicide occurs most often in people between 15-44 years. Alcohol consumption is closely correlated with mortality and morbidity due to trauma. CONCLUSIONS: Modem trauma system management should always consider that trauma mortality is the number most easily to measure and to reporte, but it represent only the tip of the iceberg.

[Laparoscopic approach in gallbladder agenesis--an intraoperative surprise]. / Abordul laparoscopic în agenezia veziculei biliare--o surpriza intraoperatorie.

INTRODUCTION: The congenital absence of the gallbladder in the absence of biliary atresia is extremely rare, world literature recognizing only 413 cases. The aim of this study is to clarify the diagnostic and therapeutic approach of this rare condition. METHOD: There were retrospectively analyzed the first 2 cases of gallbladder agenesis admitted and surgically approached in the Emergency Hospital, Bucharest. RESULTS: The first case (woman, 23 years old) had typically biliary complaints at admission, shrinked gallbladder and lithiasis on ultrasound. There was a laparoscopic approach but we didn't find any gallbladder. After a non-therapeutic laparoscopy the biliary symptoms disappeared. In the second case (woman, 52 years old) the admission was for upper abdominal quadrant colicative pain and the transparietal abdominal ultrasound showed chronic cholecystitis. Common bile duct dilatation was revealed during laparoscopy. After conversion to laparotomy there was performed intraoperative colangiography, but no other biliary pathology was revealed. The initial complaints also disappeared after surgery. CONCLUSIONS: We find the laparoscopic approach an effective method for the diagnosis of gallbladder agenesis. Postoperative Magnetic Resonance Cholangiopancreatography represents a very useful imagistic tool to rule out an intrahepatic gallbladder.

[Selective nonoperative management of solid abdominal visceral lesions]. / Managementul selectiv nonoperator al leziunilor viscerale parenchimatoase in traumatismele abdominale.

Selective nonoperative management of abdominal visceral lesions is one of the most important and challenging changes that occurred in the traumatized patient care over the last 20 years. The main advantage of this type of management is the avoidance of unnecessary/nontherapeutic laparotomies. The trauma surgeons who deal with this type of treatment are worried of missed abdominal injuries. Modern diagnostic tools (spiral CT, ultrasound, angiography, laparoscopy) allow the trauma surgeon to accurately characterize the lesions to be nonoperative addressed. This literature review discusses the main elements of selective nonoperative management of principle solid visceral lesions (liver, spleen, kidney). We highlight the advantages and limitations of the main diagnostic instruments used for evaluation of trauma patiens allocated to nonoperative management.