Our initial experience with ventriculo-epiplooic shunt in treatment of hydrocephalus in two centers.

INTRODUCTION: Hydrocephalus represents impairment in cerebrospinal fluid (CSF) dynamics. If the treatment of hydrocephalus is considered difficult, the repeated revisions of ventriculo-peritoneal (VP) shunts are even more challenging. OBJECTIVE: The aim of this article is to evaluate the efficiency of ventriculo-epiplooic (VEp) shunt as a feasible alternative in hydrocephalic patients. MATERIAL AND METHODS: A technical modification regarding the insertion of peritoneal catheter was imagined: midline laparotomy 8-10cm long was performed in order to open the peritoneal cavity; the great omentum was dissected between its two layers; we placed the distal end of the catheter between the two epiplooic layers; a fenestration of 4cm in diameter into the visceral layer was also performed. A retrospective study of medical records of 15 consecutive patients with hydrocephalus treated with VEp shunt is also presented. RESULTS: Between 2008 and 2014 we performed VEp shunt in 15 patients: 5 with congenital hydrocephalus, 8 with secondary hydrocephalus and 2 with normal pressure hydrocephalus. There were 7 men and 8 women. VEp shunt was performed in 13 patients with multiple distal shunt failures and in 2 patients, with history of abdominal surgery, as de novo extracranial drainage procedure. The outcome was favorable in all cases, with no significant postoperative complications. CONCLUSIONS: VEp shunt is a new, safe and efficient surgical technique for the treatment of hydrocephalus. VEp shunt is indicated in patients with history of recurrent distal shunt failures, and in patients with history of open abdominal surgery and high risk for developing abdominal complications.

Laparoscopic Approach to Primary Splenic Cyst: Case Report and Review of the Literature.

Splenic cysts are rare benign lesions of the spleen, often asymptomatic and incidentally discovered during imaging studies. While many splenic cysts remain asymptomatic and do not require intervention, surgical management becomes essential in cases of symptomatic cysts, large cysts, or when malignancy cannot be ruled out. Laparoscopic surgery has emerged as a minimally invasive and effective approach for treating splenic cysts, offering advantages such as shorter hospital stays, reduced postoperative pain, and faster recovery. In this case report, we describe our experience with laparoscopic surgery for a symptomatic splenic cyst in a young patient.

Endoscopic Vacuum-Assisted Closure (E-VAC) in Septic Shock from Perforated Duodenal Ulcers with Abscess Formations.

This case report underscores the importance of utilizing E-VAC (endoscopic vacuum-assisted closure) in the treatment of a perforated duodenal ulcer complicated by the formation of a subphrenic abscess and septic shock. It showcases how E-VAC can effectively mitigate the risk of further complications, such as leakage, bleeding, or rupture, which are more commonly associated with traditional methods like stents, clips, or sutures. As a result, there is a significant reduction in mortality rates. A perforated duodenal ulcer accompanied by abscess formation represents a critical medical condition that demands prompt surgical intervention. The choice of the method for abscess drainage and perforation closure plays a pivotal role in determining the patient's chances of survival. Notably, in patients with a high ASA (American Association of Anesthesiologists) score of IV-V, the mortality rate following conventional surgical intervention is considerably elevated. The management of perforated duodenal ulcers has evolved from open abdominal surgical procedures, which were associated with high mortality rates and risk of suture repair leakage, to minimally invasive techniques like laparoscopy and ingestible robots. Previously, complications arising from peptic ulcers, such as perforations, leaks, and fistulas, were primarily addressed through surgical and conservative treatments. However, over the past two decades, the medical community has shifted towards employing endoscopic closure techniques, including stents, clips, and E-VAC. E-VAC, in particular, has shown promising outcomes by promoting rapid and consistent healing. This case report presents the clinical scenario of a patient diagnosed with septic shock due to a perforated duodenal ulcer with abscess formation. Following an exploratory laparotomy that confirmed the presence of a subphrenic abscess, three drainage tubes were utilized to evacuate it. Subsequently, E-VAC therapy was initiated, with the kit being replaced three times during the recovery period. The patient exhibited favorable progress, including weight gain, and was ultimately discharged as fully recovered. In the treatment of patients with duodenal perforated ulcers and associated abscess formation, the successful and comprehensive drainage of the abscess, coupled with the closure of the perforation, emerges as a pivotal factor influencing the patient's healing process. The positive outcomes observed in these patients underscore the efficacy of employing a negative pressure E-VAC kit, resulting in thorough drainage, rapid patient recovery, and low mortality rates.

Laparoscopic Hartmann Procedure-A Surgery That Still Saves Lives.

BACKGROUND: A Hartmann operation, which is the intervention by which the lower part of the sigmoid and the upper part of the rectum are resected with the closing of the rectal stump and end colostomy, has as its indications: advanced or complicated rectosigmoid neoplasm, moderate biological condition of the patient, peritoneal sepsis, intestinal occlusion and fragile colonic wall, especially in the context of inflammatory changes. The Hartmann procedure can save lives even at the cost of a stoma reversal failure. METHODS: The cases operated with the Hartmann procedure by an open approach or laparoscopic approach in our clinic, between 1 January 2016 and 31 December 2020, were admitted in this study and their medical records were reviewed, also making a comparison between the two types of approach. Univariate statistical comparisons but also a multivariate analysis was performed. RESULTS: We performed 985 operations for intestinal and colonic occlusion (7.15% of the total operations in the clinic), 531 (54%) were non-tumor occlusions and 454 (46%) were occlusive tumors (88 Hartmann operations). Of these, 7.3% were laparoscopically performed (7 laparoscopic Hartmann operations and 23 diagnostic laparoscopies). A total of 11 cases (18%) also had colonic perforation. We compared laparoscopic Hartmann with open Hartmann and observed the benefits of laparoscopy for postoperative morbidity and mortality. The presence of pulmonary and cardiac morbidities is associated with the occurrence of general postoperative morbidities, while peritonitis is statistically significantly associated with the occurrence of local complications that are absent after the laparoscopic approach. CONCLUSIONS: The Hartmann procedure is still nowadays an operation widely used in emergency situations. Laparoscopy may become standard for the Hartmann procedure and reversal of the Hartmann procedure, but the percentage of laparoscopy remains low due to advanced or complicated colorectal cancer, poor general condition both at the first and second intervention, and the difficulties of reversal of the Hartmann procedure.

Challenges and Solutions in the Management of Hepatocellular Carcinoma Associated with Non-Alcoholic Fatty Liver Disease.

Non-alcoholic fatty liver disease (NAFLD) has gained attention in the last few years due to its increasing prevalence worldwide becoming a global epidemic. The increasing incidence of NAFLD and the concurrent increase in the number of hepatocellular carcinoma (HCC) cases at a global level is a matter of concern. HCC has several risk factors, of which NAFLD and its associated metabolic disturbances-type 2 diabetes mellitus, obesity, and dyslipidemia-are of great interest due to their accelerating rise in incidence worldwide. There is a high amount of data derived from basic and clinical studies that reveal the molecular pathways that drive NAFLD-associated HCC. Based on these findings, new prevention, surveillance, and treatment strategies are emerging. However, current data on treatment modalities in NAFLD-associated HCC are still scarce, though the results from non-NAFLD HCC studies are promising and could provide a basis for a future research agenda to address NAFLD/NASH patients. Clinicians should carefully assess all the clinical and radiological parameters and establish a prognosis based on the Barcelona Clinic Liver Cancer classification and discuss in a multidisciplinary team the treatment strategy. The specific factors associated with NAFLD-associated HCC which can have a negative impact on survival even in patients with early HCC, such as cardiovascular disease, type 2 diabetes, and obesity, should be taken into consideration. This review aims to discuss the latest recommendations regarding the diagnosis and treatment of NAFLD-associated HCC and the remaining challenges.

Protective or Risk Factors for Postoperative Pancreatic Fistulas in Malignant Pathology.

INTRODUCTION: Malignant tumors are associated with a low incidence of postoperative pancreatic fistulas. The presence of peritumoral fibrosis is considered the protective factor for the development of postoperative pancreatic fistulas after pancreatic resections for pancreatic ductal adenocarcinomas. METHODS: We analyzed a series of 109 consecutive patients with pancreatic resections for malignant pathology: pancreatic ductal adenocarcinomas and periampullary adenocarcinomas. The incidence of postoperative pancreatic fistulas has been reported in tumor histological type, in the presence of peritumoral fibrosis, and in the association between adenocarcinomas and areas of acute pancreatitis. The data obtained were processed with the statistical analysis program SPSS, and statistically significant p were considered at a value <0.05. RESULTS: For the entire study group, the incidence of postoperative pancreatic fistulas was 11.01%. The lowest incidence was observed in the group of patients with pancreatic ductal adenocarcinomas (4.06% vs. 25.72% in the group with periampullary adenocarcinoma), with a p = 0.002. The presence of peritumoral fibrous tissue was observed in 49.31% of cases without pancreatic fistulas, and in 54.54% of cases that developed this postoperative complication (p = 0.5). Also, the peritumoral fibrous tissue had a uniform distribution depending on the main diagnosis (56.14% in pancreatic ductal adenocarcinoma group vs. 37.04% in periampullary adenocarcinoma group, with a p = 0.08). In the group of patients who associated areas of acute pancreatitis on the resections, the incidence of postoperative pancreatic fistulas was 7.8 times higher (30% vs. 3.8%, p = 0.026). CONCLUSIONS: Peritumoral fibrous tissue was not a factor involved in the developing of postoperative pancreatic fistulas. The association of adenocarciomas with areas of acute pancreatitis has led to a significant increase in postoperative pancreatic fistulas, which is a significant and independent risk factor.

Osteopontin and osteoprotegerin in atherosclerotic plaque - are they significant markers of plaque vulnerability?

Atherosclerosis (ATS) is still considered as a major, global health problem. For a deeper understanding of its pathogenesis, in the last years the research was translated from tissue visible events to molecular mechanisms. Osteopontin (OPN) and osteoprotegerin (OPG) are two molecules that have been associated with the initiation and progression of ATS lesions. The aim of our study was to assess the OPN and OPG expression in advanced stages of carotid ATS, to analyze the correlation between these markers and the ultrasonographic plaque properties, pointing out the identification of possible patterns that can predict plaque vulnerability and risks of restenosis. The study group comprised 49 consecutive patients (38 males and 11 females) diagnosed with carotid stenotic lesions by using ultrasonography. The carotid endarterectomy specimens were standardly processed for histopathological and immunohistochemical exams. The OPN and OPG expression was semi-quantitatively assessed. Our results sustained the relationship between histological American Heart Association (AHA) type and ultrasonographic classification (echogenic versus echolucent) (p<0.001). The semi-quantitative analysis showed that in most cases (31 plaques) OPG and OPN had opposite expressions, whereas in the remaining cases (18 plaques) the expression was similar. There were no correlations between low versus high expression of intra-plaque OPN and OPG (p=0.335). We found significant correlation for OPN and plaque echogenicity (p=0.011), but not for OPG (p=0.079). OPN expression (low versus high) was correlated with plaque type (stable versus unstable) (p=0.036), plaque ulceration (p=0.009) and inflammation (p<0.001). OPG expression (low versus high) did not reveal statistically significant differences with plaque type (stable versus unstable) and vulnerability plaque parameters, respectively. OPG and OPN co-exist in carotid atherosclerotic plaque demonstrating a modulatory role in inflammatory and calcification processes. OPG is strongly expressed in stable, calcified plaques, while OPN is poorly expressed in calcified plaques and in plaques without hemorrhage, ulceration, inflammation, or necrosis. Starting from the molecular mechanisms, further studies of biomarkers are important to identify new therapeutic resources meant to prevent and treat vascular calcification.

Factors influencing the pathological quality of the surgical specimen in rectal cancer - a retrospective single-centre study.

AIM: The pathologist's role in the multidisciplinary treatment of rectal cancer is to evaluate and stage the tumor according to the latest standards, as well as indicate the quality of the surgical act. This study aims to evaluate circumferential and distal resection margins as well as quality of mesorectal resection and correlate them with different clinical, pathological and therapeutic factors. PATIENTS, MATERIALS AND METHODS: Four hundred ninety-eight patients treated radically for mid and low rectal cancer within one Clinic of Oncological Surgery in Iasi, Romania, were included in this study. RESULTS: The distal resection margin showed significant correlations with the type of surgical intervention, chemotherapy in the neoadjuvant treatment plan and pathological node staging. The circumferential resection margin depended mostly on pathological node staging and the length of the interval between neoadjuvant treatment and surgery. Finally, the aspect of the mesorectum varied according to neoadjuvant treatment and the type of surgical intervention performed. CONCLUSIONS: The study reached its aim in providing important data for the expected outcome of the specimen after curative treatment for rectal cancer.

The Effects of Adipose-Derived Stem Cell-Differentiated Adipocytes on Skin Burn Wound Healing in Rats.

Both adipose-derived stem cells (ADSCs) and fat grafting promote burn wound healing, but whether adipogen-derived cells using various inducers such as 3-isobutyl-1-methylxanthine (IBMX) and insulin affect wound healing is unknown. Herein, ADSC-differentiated adipogenic lineages were used in rat burn wounds to evaluate wound healing potential. ADSCs were cultivated using six different adipogenic differentiation conditions (IBMX ± insulin, IBMX for 5 days, high and low Dulbecco's modified Eagle's medium) and in vitro morphological changes and cell proliferations during adipogenic differentiation were recorded. Intermediate burn wounds were inflicted in 15 Wistar male rats. Afterwards, the rats were divided into five groups for subcutaneous injections under the wounds: control; ADSCs; differentiated adipocytes (-IBMX+INSULIN and +IBMX[D1-5]+INSULIN) and fat prepared by Coleman technique. Macroscopic changes and histology were documented for 3 weeks. Repeated measures analysis of variance was performed to analyze cell growth and wound healing with a statistical level set of P < .05. Induction cocktails significantly reduced proliferation and induced lipid droplet accumulation. Conditioning without insulin induced the least lipid accumulation, while discontinuing IBMX generated larger adipocytes (P < .001). Adipogenic differentiated ADSCs had similar wound healing abilities with ADSC and fat injections, but differentiated adipocytes (+IBMX[D1-5]+INSULIN) and fat grafting accelerated the early healing process relative to ADSC (P < .001). Reduced fibrosis and mild inflammatory infiltration limited to superficial dermis were observed in +IBMX(D1-5)+INSULIN and fat injection groups, while those reactions were mild to moderate in ADSC group. Differentiated adipocytes achieve similar wound healing results compared with ADSC and fat injections, but differentiated adipocytes (+IBMX[D1-5]+INSULIN) and fat grafting accelerate early healing relative to ADSC.

Histopathological diagnosis and its correlations with anatomoclinical features, surgical approach and postoperative prognosis in sacral tumors.

INTRODUCTION: Sacral tumors encompass numerous histopathological types. They represent an uncommon pathology and, when diagnosed, they are often in advanced stage of the disease, becoming a therapeutic challenge. The correct treatment of a sacral tumor should be established by a multidisciplinary team that will assess the exact anatomical, imagistic and histopathological characteristic of the tumors thus choosing an optimal surgical approach while taking into consideration the risk of recurrence. MATERIAL AND METHODS: We conducted a retrospective analysis of both primitive and metastatic sacral tumors in "Bagdasar-Arseni" Emergency Hospital, Bucharest, Romania, for a period of 10 years, studying demographic data, clinical signs, anatomical and histopathological features as well as surgical approach and postoperative prognosis. RESULTS: Sacral tumors were diagnosed with a peak incidence in the age group 60-69 years, being more frequent in women. Primitive sacral tumor was predominant and, in this subgroup, chordoma was the most frequent. Metastatic tumors appeared in older subjects. None of the histopathological types associated a preferred topography of the resection or increased resectability. Posterior surgical approach was chosen in most cases, total resection being a hard goal to accomplish due to the invasion of vascular and nervous structures. Bleeding was the most frequently reported incident, carcinomas recording the highest blood loss amongst primitive tumors. Overall prognosis was clearly favorable for subjects diagnosed with primitive sacral tumors. CONCLUSIONS: Interpreting imaging data in a clinical context, paying attention to histopathological examination and knowing each histological type characteristics is mandatory in choosing the surgical approach thus obtaining the best postoperative outcome possible.

Experimental study regarding the biocompatibility test of the Prolene (polypropylene abdominal mesh) product.

The polypropylene mesh, although is one of the most used prosthetic biomaterials for abdominal wall defects, proved not to be completely inert, generating from precocious foreign body inflammatory reactions (varying by individual reactivity, the amount of used material and its structure), to late complications such as chronic infections, stercoral fistulae or mesh migration. The present paper was aimed at studying the behavior of implants of this material in three different areas of the body of experimental animals, as follows: intramuscular, intraperitoneal and extraperitoneal. The observation time was 21 days and 90 days. We observed foreign body reactions induced locally by the mesh that remains temporary, generating a moderate number of macrophages and foreign body giant cells. The material did not systemically affect the healing and the scaring of the surgical wounds, but in all three implant areas, the polypropylene mesh generated locally a fibrous proliferation reaction of neoformation tissue, which wrapped and secured the implanted product on all surfaces.

Prostate cancer - peculiarities of the process of adaptation to the disease.

AIM: Psycho-social adaptation to the diagnosis of cancer is a dynamic process, different from one patient to another, depending on many factors (location, stage, treatment, personality of each individual, environment - family, professional background, social-economic-cultural status). The aim of this study is to analyze the process of adaptation of patients with prostate cancer. PATIENTS AND METHOD: Thirty six patients diagnosed with prostate cancer, admitted in the Department of Oncology, Palliative Care for Chronic Patients within Chronic Disease Hospital "St. Luke" from Bucharest, Romania, over a period of six months, answered the Illness Cognition Questionnaire (ICQ), in order to assess adaptation to the disease (helplessness, acceptance, perceived benefits). RESULTS: Results of the study showed that feelings of helplessness were expressed at a high level in 22.2% patients, medium level in 55.6% cases and low level 22.2%. The feelings of acceptance were the following: 61.1% of patients had a high level, 33.3% of them a medium level, while only 5.6% had a low level of acceptance. Regarding perceived benefits due to the disease, the following results have been obtained: 22.2% had a high level, 77.8% a medium level and no patient reported low level benefit. CONCLUSION: The results of this study indicate that patients diagnosed with prostate cancer adapt well to the disease, accept it and even obtain benefits from it.