Clostridium difficile Infections in an Emergency Surgical Unit from North-East Romania.

Background and Objectives: Colitis with Clostridium difficile is an important health problem that occurs with an intensity that varies between mild and severe. Surgical interventions are required only in fulminant forms. There is little evidence regarding the best surgical intervention in these cases. Materials and Methods: Patients with C. difficile infection were identified from the two surgery clinics from the 'Saint Spiridon' Emergency Hospital Iași, Romania. Data regarding the presentation, indication for surgery, antibiotic therapy, type of toxins, and post-operative outcomes were collected over a 3-year period. Results: From a total of 12,432 patients admitted for emergency or elective surgery, 140 (1.12%) were diagnosed with C. difficile infection. The mortality rate was 14% (20 cases). Non-survivors had higher rates of lower-limb amputations, bowel resections, hepatectomy, and splenectomy. Additional surgery was necessary in 2.8% of cases because of the complications of C. difficile colitis. In three cases, terminal colostomy was performed and as well as one case with subtotal colectomy with ileostomy. All patients who required the second surgery died within the 30-day mortality period. Conclusions: In our prospective study, the incidence was increased both in cases of patients with interventions on the colon and in those requiring limb amputations. Surgical interventions are rarely required in patients with C. difficile colitis.

The Management of Wound Healing in Infections after Hip Arthoplasty Using Stimulan and Negative Pressure Wound Therapy.

BACKGROUND: medical teams continue to face challenges with infections following hip replacement surgery, whether they occur shortly after the procedure or months or years later. Certain medical conditions like diabetes, rheumatoid arthritis, and obesity are risk factors that make patients more susceptible to infections. Traditional intervention methods such as DAIR, one-step, or two-step procedures are being enhanced and refined to ensure quicker and more effective treatment. Some cases present particularly difficult challenges, featuring persistent fistulas and unpredictable responses to treatment. METHODS: in our article, we share two unique cases, detailing their histories, progressions, and treatment decisions. We explore the use of antibiotic-impregnated calcium biocomposite as a local adjuvant therapy and the application of negative pressure therapy to expedite healing. The system of NWPT has seen widespread uptake and is now implemented routinely for open wounds, such as open fractures, fasciotomies, ulcers, and infected wounds. RESULTS: our findings demonstrate that surgical debridement and calcium sulfate bead insertion successfully treat bone and joint infections without causing any side effects or complications. As a particularity, in the first case, we encountered the exteriorization of Stimulan pearls after surgery, without other complications related to the biocomposite. CONCLUSIONS: we have found that NPWT is a beneficial tool in managing complex wounds in both acute and chronic stages, after the infection is cured, reducing the need for frequent dressing changes, shortening hospital stays, and enhancing patient comfort.

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.

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.

Severe Acute Pancreatitis Treated with Negative Pressure Wound Therapy System: Influence of Laboratory Markers.

(1) Background: An open abdomen is a serious medical condition that requires prompt and effective treatment to prevent complications and improve patient outcomes. Negative pressure therapy (NPT) has emerged as a viable therapeutic option for temporary closure of the abdomen, offering several benefits over traditional methods. (2) Methods: We included 15 patients with pancreatitis who were hospitalized in the I-II Surgery Clinic of the Emergency County Hospital "St. Spiridon" from Iasi, Romania, between 2011-2018 and received NPT. (3) Results: Preoperatively, the mean IAP level was 28.62 mmHg, decreasing significantly postoperatively to 21.31 mmHg. The mean level of the highest IAP value recorded in pancreatitis patients treated with VAC did not differ significantly by lethality (30.31 vs. 28.50; p = 0.810). In vacuum-treated pancreatitis patients with a IAP level > 12, the probability of survival dropped below 50% during the first 7 days of stay in the ICU, so that after 20 days the probability of survival was approximately 20%. IAP enters the determinism of surgery with a sensitivity of 92.3% and a specificity of 99%, the cut-off value of IAP being 15 mmHg. (4) Conclusions: The timing of surgical decompression in abdominal compartment syndrome is very important. Consequently, it is vital to identify a parameter, easy to measure, within the reach of any clinician, so that the indication for surgical intervention can be made judiciously and without delay.

Gallstone Ileus. What therapeutic options are there?

Gallstone ileus is a rare disorder in emergency surgical practice with diagnosis usually difficult and only achieved at surgery. The current approaches are: enterolithotomy, cholecystectomy and fistula repair (one-stage surgery), enterolithotomy with cholecystectomy performed later (two-stage surgery) and only enterolithotomy (most reported surgical procedure). METHODS: The clinical, operative and follow-up data on 14 consecutive patients treated in our clinic for gallstone ileus was retrospectively reviewed. RESULTS: Gallstone ileus was recorded in 0.06% of all operations for biliary lithiasis and 1% of all enteric occlusions. There were 11 women and one men, with a mean age of 77.3 (range 67-100) years. There was a mean delay of 3.16 days for onset of symptoms to admission. Urgent laparotomy confirmed gallstone obstruction and a cholecysto-duodenal fistula (13 cases) or cholecysto-colonic fistula (1 case). We performed one stage surgery in 4 cases, enterolithotomy alone in 8 cases (one case operated initially in another surgical service), Hartman procedure, cholecystectomy and fistula repair in one case and a spontaneous evacuation of the gallstone with cholecystectomy and fistula repair later in another case. We recorded 2 deaths in patients with multiple comorbidities in which only enterolithotomy was performed and with 1 and 2 reinterventions, respectively. Postoperative stay was 9.4 days for cases with simple enterolithotomy and 18.6 days for cases with radical treatment. We did not record any recurrence. CONCLUSIONS: Although rarely encountered in surgical practice, gallstones ileus should be noted in the differential diagnosis of intestinal obstruction in patients with a past history of biliary disease, occlusive syndrome, pneumobilia and possibly ectopic gallstone. The one-stage procedure should be the offered to stabilized patients, but in cases with associated comorbidities, only enterolithotomy represent a best option. KEY WORDS: Gallstone ileus, Cholecystoduodenal fistula, Intestinal Obstruction.

Abdominopelvic Actinomycosis-The Diagnostic and Therapeutic Challenge of the Most Misdiagnosed Disease.

Abdominopelvic actinomycosis is a rare chronic or subacute bacterial infection caused by Actinomyces israelii, a Gram-positive anaerobic bacterium that normally colonizes the digestive and genital tracts, clinically presented as an inflammatory mass or abscess formation. METHODS: We reviewed the medical records of the patients from our clinic with abdominopelvic actinomycosis who underwent surgery between 2002 and 2022. In this period, 28 cases (9 men and 19 women) were treated. The mean age was 43.36 years and they were hospitalized for abdominopelvic tumors or inflammatory tumors in 15 cases and inflammatory disease in 13 cases. RESULTS: Causes of actinomycosis in the studied group were an intra-uterine contraceptive device in 17 cases, foreign bodies in 2 cases, diabetes in 4 cases, stenting of the bile duct in 1 case, and immunodepression. For 6 patients, we performed surgery by open approach and for 21 patients by a laparoscopic approach. For nine patients, abdominopelvic actinomycosis had been mimicking a colon malignancy (cecum and ascending colon, four cases; transverse colon, two cases; and on the greater omentum, three cases) and for six patients, a pelvic tumor (advanced ovarian cancer). After surgery the patients underwent specific treatment with antibiotics, with good results. In two cases we discovered and treated hepatic actinomycosis, one case by a laparoscopic approach and one case by a percutaneous approach. In our lot we noticed three recurrences that required reintervention in patients who had had short-term antibiotics due to non-compliance with treatment out of four such cases. CONCLUSIONS: For abdominopelvic malignancies, actinomycosis should be included in the differential diagnosis, as well as for inflammatory bowel diseases and bowel obstructions. We have a wide range of patients considering the rarity of this condition. Long-term antibiotics are necessary to prevent recurrence.

Laparoscopic approach for nonparasitic splenic cysts and splenic abcesses.

Splenic cysts are classified as primary (parasitic and nonparasitic) or secondary cysts. The aim of this study was to evaluate the efficacy of laparoscopic approach in surgical treatment of splenic cysts and abscesses. METHODS: Between 2002 and 2017, 17 patients underwent laparoscopic approach for splenic cysts and abscesses: 9 laparoscopic splenectomies (4 hydatid cysts, 3 primitive nonparasitic cysts, one posttraumatic cysts and one abscess) and conservative laparoscopic treatment 8 patients (2 hydatid cysts, 2 primitive nonparasitic cysts, 2 secondary cysts and 2 abscesses). The lateral approach with a four-trocar technique was used. Patient demographics, diagnosis, and outcomes were reviewed. RESULTS: In laparoscopic splenectomy, spleen volume was 300 ml and blood loss 30 - 65 ml. There are 3 conversions and 2 postoperative complications (Clavien II). No late complications were observed during the follow-up. CONCLUSIONS: The laparoscopic approach to splenic cysts offers many advantages and may be the treatment of choice for this pathology. Spleen-preserving techniques should be attempted in every case of splenic cyst types 1,2,3, especially non-parasitic cysts, in young patients. KEY WORDS: Abcesses, Splenic cysts, Laparoscopic approach, Laparoscopic splenectomy, Laparoscopic cyst excision.

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.