The Role of Ileostomy in the Prevention and Treatment of Anastomotic Leakage after Elective Rectal Cancer Surgery - A Retrospective Analysis of Specific Risk Factors, Outcomes, and Complications.

Background: The objective of this paper is to highlight the role and place of ileostomy from the perspective of the risk of anastomotic leakage (AL). Materials and method: This was a retrospective study of 74 (46.54%) low and ultra-low anterior resections from 159 cases of rectal cancer operated on in a seven-year interval (2015 - 2021). The cases were divided into two groups: Group A with protective ileostomy (47 cases = 63.51%) and Group B without protective ileostomy (27 cases = 35.49%). Results: The type of anastomosis was low colorectal for 15 cases and ileorectal for two cases, both in Group A, with either mechanical or manual sutures. Continuous loop ileostomy was the only fecal diversion procedure used for protection. The ileostomy-specific complications recorded in Group A were peristomal skin lesions (8 cases), early peristomal hernia (2 cases), and severe dehydration with acute renal-insufficency (7 cases). The closure of the ileostomy was performed in 42 cases (89.36%), with the time between the primary operation and the closure being 4.28 months on average, with limits between 12 days and 10 months. AL treatment was conservative in 13 (76.47%) cases and surgical in four cases, with the types of operations performed at reintervention being take-down of the anastomosis + left terminal colostomy + ileostomy closure in three cases (2 in Group A and 1 in Group B) and terminal ileostomy in one case in Group A. Conclusions: To reduce its specific complications, ileostomy should be performed in well-selected patients. Those with risk factors for leakage include males, the elderly, and those having important comorbidities, neoadjuvant chemoradiotherapy, low tumors below 5 cm from the anal verge, or complete circumferential stenosis and peritumoral inflammatory infiltrate.

Therapeutic Options in Postoperative Enterocutaneous Fistula-A Retrospective Case Series.

OBJECTIVES: The aim of the study was to present the results obtained in our experiment regarding the management of postoperative enterocutaneous fistulas (PECF). MATERIALS AND METHODS: We conducted a retrospective study on 64 PECF registered after 2030 abdominal surgeries (1525 digestive tract surgeries and 505 extra-digestive ones) over a period of 7 years (1st of January 2014-31th of December 2020) in the 1st and 2nd Surgery Clinics, Clinical County Emergency Hospital of Craiova, Romania. The group included 41 men (64.06%) and 23 women (35.34%), aged between 21-94 years. Of the cases, 71.85% occurred in elderly patients over 65 years old. Spontaneous fistulas in Crohn's disease, intestinal diverticulosis, or specific inflammatory bowel disease were excluded. RESULTS: The overall incidence of 3.15% varied according to the surgery type: 6.22% after gastroduodenal surgery, 1.78% after enterectomies, 4.30% after colorectal surgery, 4.28% after bilio-digestive anastomoses, and 0.39% after extra-digestive surgery. We recorded a 70.31% fistula closure rate, 78.94% after exclusive conservative treatment and 57.61% after surgery; morbidity was 79.68%, mortality was 29.68%. CONCLUSION: PECF management requires a multidisciplinary approach and is carried out according to an algorithm underlying well-established objectives and priorities. Conservative treatment including resuscitation, sepsis control, output control, skin protection, and nutritional support is the first line treatment; surgery is reserved for complications or permanent repair of fistulas that do not close under conservative treatment. The therapeutic strategy is adapted to topography, morphological characteristics and fistula output, age, general condition, and response to therapy.

About the Experimental and Virtual Analysis of Orthopedic Implant Systems for the Revision of the Hip Prosthesis with Morcellated Bone Graft and Reconstruction Net.

INTRODUCTION: Prosthesis loosening is an alteration of the function and position of a total hip prosthesis with reference to the initial surgical moment. The main mechanism unanimously accepted for aseptic prosthetic losses at the level of the cup is represented by the biological mechanism. MATERIAL AND METHOD: Experimental and virtual, interdisciplinary tools, techniques and methods were used to determine the behavior of the hip replacement prosthesis with the morcellated graft and the reconstruction net. Performing an orthopedic assembly with a morcellated bone graft and reconstruction net. An assembly was performed on a hip joint taken from an animal (cow). The biological material and the components of the prosthesis were prepared similarly to the revision prosthesis intervention. Experimental testing of orthopedic assembly with morcellated bone graft and reconstruction net. This assembly was tested on a universal machine to determine the maximum force at which it yields. This was 1790 Kgf, i.e. 17559 N. Virtual experimental testing of the hip joint with orthopedic revision assembly with a morcellated bone graft and reconstruction net for normal gait loading. The orthopedic assembly with the morcellated graft and the reconstruction net was reconstructed in the virtual environment. Normal load was used. Results maps were obtained. CONCLUSIONS: Analyzing the results from the two tests, experimental and virtual, and important conclusions were drawn regarding this orthopedic assembly.

Prevalence of musculoskeletal normal variations of the lower limbs in pediatric orthopedic clinic.

OBJECTIVES: To determine the rate of pediatric orthopedic clinic visits attributable to normal musculoskeletal (MSK) variations in children less than 12 years of age; to characterize the etiology and to characterize the etiology and management plan in this group in an attempt to identify areas that could be improved in pediatric orthopedic clinical practice. METHODS: The study was a retrospective evaluation of 2,321 consecutive patients who visited a private pediatric orthopedic specialty clinic in Jeddah, Saudi Arabia between 2011-2016. All consultations were recorded in accordance with the standard protocol  via data record form. RESULTS: We identified 764 (32.9%) patients with normal variation of the lower limbs, age birth to 12 years old. No significant association between gender and normal variation was noticed. The following types of normal variation were registered: 189 (24.7 %) genu varus or valgus, 257 (33.6%) in-toe gait, and 318 (41.6%) flexible flat foot. Seven hundred and thirty-seven (96.5%) cases were normal variations, while only 27 cases (3.5%) were deemed pathological and required further treatment. CONCLUSION: Normal variations represent the most common complaint in pediatric orthopedic private practice. Inappropriate referrals, useless follow-up visits, and excessive investigations were a common practice, overloading the health care system. None of the previous efforts made any notable improvement.

Müllerianosis of the urinary bladder: a rare case report and review of the literature.

The aim of this paper is to report a very rare case of müllerianosis (endosalpinx, endometrium, and endocervix) in a post-menopausal woman. Müllerianosis of the bladder is a very rare disease, which affects mainly the women of the reproductive age group, but with a good prognosis if the transitional bladder carcinoma is resolved. We present the case of a 64-year-old woman complaining of left lower abdomen pain, repeated lower and upper tract urinary infections, emergency urinary incontinence and hematuria. The surgical history shows that she underwent a hysterectomy, caesarean section and appendectomy. The clinical examination emphasizes a normal abdomen, with a normal aspect of the post-operative scars and a second-degree cystocele. An abdominal computed tomography (CT) scan with contrast and a cystography were performed and showed a 16 mm lesion-like tumor on the left bladder wall respectively a third-degree vesicoureteral reflux. These investigations were followed by a cystoscopy and transurethral resection of the bladder tumor (TURBT). The histopathology report described three types of tissues: endometriosis, endocervicosis and endosalpingiosis. Sequent to these results, a partial cystectomy with the re-implantation of the left ureter was performed. Once again, the results of the specimen confirm the diagnosis of müllerianosis. The immediate post-operative outcomes were good, the patient having no pains and no more hematuria. Six month later, a tension-free vaginal tape obturator (TVT-O) operation was carried out for urinary incontinence and two years later, a correction for a post-surgical abdominal hernia was performed. Müllerianosis of the bladder is a very rare disease, which affects mainly the women at the procreation age, but with a good prognosis. The differential diagnosis with a malignant tumor is very important to be carefully made. Currently, there is no golden standard to treat this disease. The cystoscopy and the histopathological examination of the specimen are indispensable for the certainty diagnosis.

The morphological profile of small bowel tumors - our experience.

AIM: The authors assessed the morphological profile of tumor masses belonging to the small bowel discovered in their daily practice. MATERIALS AND METHODS: 31 tumor masses located in different segments of small intestine operated between 2002 and 2013 in the 1st Surgical Department, Emergency County Hospital of Craiova, Romania, were analyzed. The investigated parameters were: tumor location and number, tumor dimensions, gross assessment, tumor extension and histological assessment. RESULTS: Tumor masses belonging to small intestine were rare. They usually expressed by their complications. In many cases, they were placed at the extremities of the small intestine. They were usually small but sometimes large and developing outwards intestinal wall. Commonly they had a fungating and ulcerated appearance. They were rather of mesenchymal origin than epithelial. However, some of them were inflammatory pseudotumors. Almost all neoplastic proliferations had a malignant phenotype, most often with regional extension. CONCLUSIONS: Our series of tumors had a morphological profile somehow similar with the profile described in the literature but with some particularities: the polarization to the extremities of the intestinal segment, a significant number of large tumors, clinical expression through different complications, the balance inclined in favor of mesenchymal origin of tumors and the clear predominance of malignant aggressive phenotype.

Prenatal diagnosis and perinatal outcome in congenital diaphragmatic hernia. Single tertiary center report.

PURPOSE: To evaluate the perinatal results for fetuses and neonates with left-sided congenital diaphragmatic hernia (CDH) and the role of the prenatal diagnosis in the pregnancy outcome. MATERIALS AND METHODS: We reviewed data from fetuses and neonates with left-sided CDH, managed from January 2009 and December 2013 in the University Clinic Hospital, Craiova, Romania. The following data were analyzed: the gestational age at the time of diagnosis, fetal karyotyping, presence of associated structural malformations, ultrasound (US) data (circumference and area of right lung, lung-to-head ratio - LHR, observed/expected LHR, hepatic herniation), the type of antenatal care, the pregnancy outcome, the place of birth and the conventional autopsy data, if performed. Perinatal outcomes were obtained by reviewing hospital documents. RESULTS: Twenty-one cases were identified. No fetal surgery was performed in our series. Mean gestational age at time of diagnosis was 29 weeks of amenorrhea (WA) (range, 16-37 WA). Associated structural malformations were noticed in nine (42.8%) cases, in which three fetuses had a normal karyotype and two had chromosomal abnormalities, and four fetuses were not investigated. Isolated congenital diaphragmatic hernia was confirmed in 12 (57.1%) cases. All early second trimester diagnosed cases were terminated. The overall mortality rate was 61.9%. Rates of fetal deaths, early neonatal deaths, late neonatal deaths, and survival were 28.5%, 19%, 14.2%, and 38%, respectively. The perinatal mortality rate was 19% in cases with isolated congenital diaphragmatic hernia. CONCLUSIONS: The overall and perinatal mortality rate in congenital diaphragmatic hernia was still high in our series. Early perinatal deaths are associated with early diagnosis and with the presence of other structural defects. The prevalence of chromosomal abnormalities in perinatal death could not be determined from these data. In isolated congenital diaphragmatic hernia, mortality is related to the presence of herniated liver and severe pulmonary hypoplasia, this being well correlated with antenatal ultrasound parameters used for the estimation of fetal lung volumes. The antenatal diagnosis allowed better counseling of the parents, description of associations and improving the neonatal care.

Gastrointestinal stromal tumors - a clinical-morphological study on 15 cases.

AIM: The authors present their experience in addressing the gastrointestinal stromal tumors (GIST). MATERIALS AND METHODS: 15 GISTs operated in the last five years (2008-2013) were analyzed. RESULTS: The preoperative diagnosis was difficult: established by clinical examination and CT in two cases; imagistic accidental discovery in four cases and revealed by evolving complications in nine cases (gastrointestinal bleeding in four cases and bowel obstruction in five cases). CT may be useful in the preliminary estimation of the tumor extent. Tumor location was: stomach four, duodenum one, small bowel seven, and colon three. Pathological examination set the main criteria for assessing the risk of recurrence and indication for adjuvant therapy: the tumor size, the histological type (spindle cell nine, epithelioid four, and mixed two) and the mitosis rate, while the immunohistochemistry examination established the correct diagnosis (positivity for CD117 and CD34) and criteria of aggressiveness (positivity for Ki67). All cases were operated, the surgical procedure being chosen according to the tumor location and stage. Adjuvant therapy with Imatinib 400 mg/day was performed in the 12 cases with high risk of recurrence. The therapeutic outcome was: a postoperative morbidity rate of 13.3%, four patients cured, one local recurrence under Imatinib therapy, a mortality rate of 6.6% and 10 patients in different phases of adjuvant therapy. CONCLUSIONS: GIST has been imposed over the last decade as the main type of non-epithelial tumor of the digestive tract. The preoperative imagistic investigations can be very useful for setting the surgical strategy. The improvement of the mitotic index and/or Ki67 labeling index (LI) determination could render more accurate the scales for prognostic assessment. The two steps algorithm - surgery + adjuvant therapy - still remains the only option to make this dangerous condition a curable one.

Retroperitoneoscopic lumbar sympathectomy: prospective study upon a series of 50 consecutive patients.

BACKGROUND: Lumbar sympathectomy (LS) is still indicated for peripheral arterial occlusive diseases (PAOD) with critical ischemia beyond any vascular reconstruction. The retroperitoneoscopic approach was proven feasible and effective but its results were never evaluated in larger series. METHODS: Between January 2007 and January 2009, 50 patients were included in a prospective study (age range = 49-71 years; sex ratio: M/F = 9:1). Their comorbidities included arterial hypertension, n = 12 (24%); atrial fibrillation, n = 4 (8%); cerebral stroke sequels, n = 4 (8%); diabetes mellitus, n = 6 (12%); chronic coronary ischemic disease, n = 20 (40%); and obstructive bronchitis, n = 4 (8%). Fifty-one retroperitoneoscopic lumbar sympathectomies were performed (31 on the left side and 20 on the right side; 1 patient was operated on both sides). RESULTS: Intervention was successful in 50 cases (98.04%), with one conversion in the first three cases. Results were excellent in all patients, with warming of the extremity and regression of pain. The pathology report confirmed excision of the ganglia in all cases. Complications included 3 cases (6%) of accidental peritoneal tear and pneumoperitoneum which were resolved by insertion of a Veress needle in the hypochondrium; 2 (4%) retroperitoneal hematoma, and 6 (12%) superficial wound infections. Operative time was 65-105 min in the first ten cases and <40 min for the last 41. There was no neuralgia, sexual dysfunction, or postoperative mortality. Associated interventions included necrectomy in 10 cases. The limb preservation rate was 77.09% at 1 year and 58.69% at 2 years. CONCLUSION: For a larger number of cases, retroperitoneal LS has been proven effective and safe in PAOD beyond reconstruction.

Acute bowel obstruction - the main complication of colorectal cancer. Therapeutical options.

AIM: to choose the proper therapeutical approach in obstructing colorectal cancer. MATERIAL AND METHOD: 77 (29.2%) obstructing colorectal cancers, 88.15% aged between 61 and 80 years, selected from 260 patients admitted in the last 10 years were analyzed. We noticed associated cardiovascular (42 cases=55.2%) and/or respiratory (18 cases=23.6%) disease in 89,55% of cases. The distribution of the obstructing lesions throughout the colon and rectum was: 39 cases on the left colon, 18 cases on the right colon, and 20 cases on the rectum, with the following pTNM staging: stage II 10%, stage III 67% and stage IV 23%. The infiltrative character of the primary tumor (61 cases) and the extension to the adjacent structures (24 cases) were the main causes of the acute bowel obstruction. The diagnosis was established on the clinical aspects and plain X-ray findings. The delay between the onset of the acute obstruction and the admission was 3 days on average, and we noticed severe biological disorders pertaining to the acute bowel obstruction in more than 75% of cases. 76 patients (99.6%) were operated on. We performed primary resection in 8 cases and staged-procedures (cecostomy or ileotransversostomy followed by resection and anastomosis after 3 weeks on average) in 33 cases. In 35 cases we performed one of the so called "exigency procedures" (colostomy, internal diversion or Hartman colectomy). RESULTS: 55 (72.36%) patients had a fair evolution. We registered 21 deaths, with a general mortality rate of 27.6%, and a mortality rate of 25% for primary resection, 9.09% for staged surgery and 47.05% for the so called exigency procedures. CONCLUSIONS: Acute bowel obstruction is the most common complication of the colorectal cancer, charged by multiple major risk factors. An adequate colon decompression and the treatment of the biological disorders are the main therapeutical objectives. Surgery of the obstructing colorectal cancer is always a palliative one. Staged surgery is the safest therapeutical option for colorectal cancers with acute bowel obstruction.

The esophagogastric junction cancer: diagnosis and surgical treatment challenges.

AIM: To present our experience in esophagogastric cancer. MATERIAL AND METHOD: Fifty nine subjects with esophagogastric junction cancer (52 men and 7 women, aged between 41 and 74 years), selected from 79 esophageal cancer patients admitted in the last 20 years (1982-2002) were analysed. The diagnosis was established on the clinical picture (esophageal syndrome 54 cases, weight loss 51 cases, anemia 49 cases), on the imaging tests (chest X-ray, barium swallow and CT scan) and endoscopy. The delay of the diagnosis was more than 1 year in 71.5% of cases. 47 (79.7%) cases were operated on; we performed 18 resections (14 total esophagogastrectomies with end-to side esophagojejunostomy and 4 partial esophagogastrectomies with intrathoracic esophagogastrostomy), 24 gastrostomies and 5 exploratory laparotomies. The surgical approach was left thoracotomy with frenotomy in all 18 resectable cases. All resected cases were adenocarcinomas, belonging to the II B and III pTNM stages. RESULTS: refer only to the resected cases. We registered: fair evolution in 13 cases (72.2%), postoperative morbidity rate of 27.8% (5 cases) and postoperative mortality rate of 5.5% (1 case). We also registered the following long term survival: 7 cases less than 6 months, 6 cases between 6 months and 1 year, 3 cases between 1 and 3 years and 2 cases over 5 years. CONCLUSIONS: 1. preoperative assessment of the local invasion and lymphatic spread is very difficult; 2. surgical exploration is the only certain method for the assessment of resectability; 3. left thoracotomy with VII or VIII rib resection and frenotomy is the best surgical approach; 4. total esophagogastrectomy with end-to side esophago-jejunostomy is the main surgical procedure in the esophagogastric junction cancers.

Cystic tumors of the pancreas. Considerations upon 34 operated cases.

AIM: To point out the morphologic, clinic and therapeutic aspects of pancreatic cystic tumors. MATERIAL AND METHOD: 34 pancreatic cystic tumors (21 males and 13 females, aged between 21 and 68 years), admitted in the last 15 years were analyzed. They were true cysts in 3 cases (9.9%) and pseudocysts in 31 cases (91.1%), located on the head of the pancreas in 8 cases, on the body in 19, on the tail in 6 and on the body and tail in 1 case. We noticed in the past medical history of the patients with pseudocysts a recent acute pancreatitis attack (26 cases), chronic pancreatitis (4 cases) or a recent abdominal trauma (1 case). The delay between the acute pancreatitis attack and the onset of the pseudocyst varied between 18 days and 2 months. The diagnosis was established by clinical picture (Shefer-Silvis triad), laboratory findings and imaging tests (barium meals, ultrasound test and/or CT test). Thirty cases (27 pseudocysts and 3 true cystic tumors) were operated on: the main surgical procedures were cystogastrostomy (12 cases), cystojejunostomy (6 cases) or cystoduodenostomy (3 cases); we also performed distal pancreatectomy (3 cases), laparostomy or external drainage in 5 cases. RESULTS: We registered 1 death (mortality rate of 3.3%), 2 pancreatic fistulae, 1 pancreatic abscess and 2 recurrences. CONCLUSIONS: 1. The pseudocyst, as an evolutionary complication of acute or chronic pancreatitis, is the most frequent cystic tumor of the pancreas, true pancreatic cysts being extremely rare. 2. The diagnosis is established by clinical pictures, laboratory findings and imaging tests. 3. The treatment is surgical, cystogastrostomy or cystojejunostomy being the main surgical procedures.