Assessment of mitochondrial respiratory capacity in relation to cardiac contractile performance in patients with normal to mildly decreased cardiac systolic function.

Chronic heart failure (CHF) with reduced left ventricular ejection fraction (LVEF) is associated with remodeling of cardiac energy metabolism; however, experimental data from human hearts that are still in early stages of contractile decline are very sparse. In the current study, we probed the association between LV contractility and myocardial capacity for fatty acid and carbohydrate oxidation in patients having normal-to-mildly decreased systolic function. In patients undergoing coronary artery bypass grafting surgery (n=40, EF ≥40%), a sample of left ventricular myocardium was obtained by subepicardial needle biopsy. Mitochondrial respiratory capacity, as well as oxidation of individual fatty acid and carbohydrate substrates (palmitoyl-carnitine and pyruvate, respectively), were assessed by measuring the rate of oxygen consumption. Also, expression of key mitochondrial metabolic factors and tissue accumulation of ceramide were evaluated, and correlation analysis was performed. Maximal mitochondrial respiration, and expression of mitochondrial biogenesis and remodeling factors (PGC-1α and mitofusin-2) were positively correlated with LVEF (r=0.37-0.50; P<0.05). Although there was no relationship between LVEF and respiration driven by individual metabolic substrates, LVEF was positively correlated with expression of key ß-oxidation enzymes. Finally, LVEF was inversely correlated with accumulation of cardiotoxic ceramide (r=0.89, P<0.05). In patients with coronary artery disease exhibiting normal-to-mildly decreased LVEF, cardiac systolic function is associated with mitochondrial respiratory capacity and levels of fatty acid oxidation enzymes, pointing to them as factors involved in early phases of myocardial pathological remodeling.

[Pancreaticoduodenectomy with or without pylorus preservation: a retrospective analysis of 137 patients]. / Duodenopancreatectomia cefalica cu sau fara prezervarea pilorului: analiza retrospectiva a 137 pacienti.

OBJECTIVE: We performed a retrospective study to assess the postoperative results, long-term survival and quality of life after pylorus preserving pancreaticoduodenectomy (PPPD) versus standard Whipple pancreaticoduodenectomy (WPD). METHODS: A retrospective study was performed in a nonselected series of 137 patients who were operated in the Surgical Clinics of "St. Spiridon" University Hospital Iasi, Romania, from January 1st, 1995 till December 31, 2005. Demographics, preoperative and intraoperative data, as well as postoperative morbidity, mortality and follow-up were analyzed. Quality of life, after to at least six months after discharge, was also studied. RESULTS: There were no significant differences noted in demographics data. Jaundice was more frequent in the PPPD group as for WPD patients (p=0.047). For the most patients the digestive reconstruction after resection were performed as in Child technique: the first anastomosis was pancreaticojejunostomy (end-to-end or end-to-side), the second anastomosis was hepaticojejunostomy (end-to-side) and the last anastomosis was gastrojejunostomy end-to-side (duodenojejunostomy in PPPD group). For 31 cases a pancreatico-gastrostomy were performed. We also noted 14 cases with pancreatico-gastrostomy and duodenojejunostomy end-to-end, and a Roux jejunal loop for 3 patients with previous gastrectomy and gastrojejunostomy (Reichel-Polya). The operating time was shorter in the PPPD group as in WPD (p < 10-3), but the mean blood loss was the same. Postoperative morbidity rate was 46.8% in PPPD group vs 39.2% in WPD (p > 0.05), but the reintervention rate was significant higher in PPPD group (30.6% vs 15%; p = 0.027). We also noted no significant differences of Delayed Gastric Emptying, postoperative mortality rate (14.5% in PPPD group vs 10.1% in WPD group) and mean survival time (42.42 months (24.94 - 59.89; 95% CI) in PPPD group vs 46.78 months (28.07 - 61.50; 95% CI) in WPD group; log rank test p = 0.643). Pathological exam diagnosed a malignancy in 109 cases (54 cases with pancreatic cancer); we noted chronic pancreatitis in 22 cases. Quality of life was also the same in the two groups. CONCLUSIONS: PPPD and WPD were associated with comparable results, but, there is a tendency of increase rate of postoperative morbidity and mortality for PPPD patients. We also noted that postoperative quality of life is the same for both procedures.

Taylor's method: a therapeutic alternative for perforated gastroduodenal ulcer.

BACKGROUND/AIMS: In the context of actual trends towards an efficient and less aggressive therapy of peptic ulcer, it seems that Taylor's method, in selected cases of perforated gastroduodenal ulcers (PGDU), comes again into attention. The aim of this study was to present our 16 years' experience with Taylor's treatment as an efficient option for sealed perforated ulcers, and to highlight the indications and advantages of this method. METHODOLOGY: A retrospective study, and prospective since 1990, was carried out on a series of 64 patients out of 592 (10%) diagnosed with PGDU between 1987 and 2003. The patients were carefully evaluated, particularly looking for clinical, laboratory and imaging diagnosis factors, indicating potential candidates for conservative approach: short history, hydropneumoperitoneum in small amount on admission. Two thirds of the patients presented in the Emergency Unit less than 12 hours from the onset of the symptoms. The diagnosis of PGDU was established by corroborating the obvious symptoms and abdominal signs with erect chest X-ray and ultrasonography (US) of the abdomen. The efficiency of Taylor's method, consisting of nasogastric aspiration, fluids resuscitation, parenteral broad spectrum antibiotics and antisecretory drugs, was assessed by meticulous repeated physical examinations, dynamics of WBC (white blood cell) and US. In case of failure, this method remained as a part of preoperative treatment. RESULTS: The method was successful in 57 out of 64 (89%) cases of perforated peptic ulcer disease, selected from the 592 cases admitted with perforated peptic ulcer following the clinical and imaging criteria previously mentioned. The presence of pneumoperitoneum certifies the diagnosis of PGDU, but the amount of peritoneal fluid assessed by US predicts the success of the procedure. Seven patients developed complications (10.9%), mainly intraabdominal abscesses and only four of them needed surgical drainage. The mortality was nil. After discharge all patients were referred to gastroenterologists for monitoring the medical treatment and no recurrence was encountered. CONCLUSIONS: The Taylor's method is a reliable alternative in selected cases of perforated gastroduodenal ulcers, the main advantage being the avoidance of anesthetic and surgical stress with their potential morbidity and mortality.

Trimetazidine does not alter metabolic substrate oxidation in cardiac mitochondria of target patient population.

BACKGROUND AND PURPOSE: Trimetazidine, known as a metabolic modulator, is an anti-anginal drug used for treatment of stable coronary artery disease (CAD). It is proposed to act via modulation of cardiac metabolism, shifting the mitochondrial substrate utilization towards carbohydrates, thus increasing the efficiency of ATP production. This mechanism was recently challenged; however, these studies used indirect approaches and animal models, which made their conclusions questionable. The goal of the current study was to assess the effect of trimetazidine on mitochondrial substrate oxidation directly in left ventricular myocardium from CAD patients. EXPERIMENTAL APPROACH: Mitochondrial fatty acid (palmitoylcarnitine) and carbohydrate (pyruvate) oxidation were measured in permeabilized left ventricular fibres obtained during coronary artery bypass grafting surgery from CAD patients, which either had trimetazidine included in their therapy (TMZ group) or not (Control). KEY RESULTS: There was no difference between the two groups in the oxidation of either palmitoylcarnitine or pyruvate, and in the ratio of carbohydrate to fatty acid oxidation. Activity and expression of pyruvate dehydrogenase, the key regulator of carbohydrate metabolism, were also not different. Lastly, acute in vitro exposure of myocardial tissue to different concentrations of trimetazidine did not affect myocardial oxidation of fatty acid. CONCLUSION AND IMPLICATIONS: Using myocardial tissue from CAD patients, we found that trimetazidine (applied chronically in vivo or acutely in vitro) had no effect on cardiac fatty acid and carbohydrate oxidation, suggesting that the clinical effects of trimetazidine are unlikely to be due to its metabolic effects, but rather to an as yet unidentified intracardiac mechanism.

A TODAY VICTIM OF SECOND WORLD WAR.

Emergency medicine as a medical specialty has to deal with all kind of emergency situations, from medical to post traumatic acute eyents and from new born to the elderly persons, but also with particular situations like explosions. In Romania nowadays these are accidental explosions and rare like frequency, but may be dramatic due to numbers of victims and multisystem injury that may occur. We present a case of a single victim of accidental detonated bomb, a projectile from the Second World War, which unfortunately still may be found in some areas. The management of the case from first call to 112 until the victim is discharge-involves high professional team work. We use these opportunity to make a brief review of the mechanism through the lesions may appear and also to renew the fact that the most impressive lesion may not be the most severe, and we have to examine carefully in order to find the real life threatening injury of the patient.

Cardiac myxoma: diagnostic approach, surgical treatment and follow-up. A twenty years experience.

At the University Department of Cardiovascular Surgery in Zagreb, Croatia, we treated 81 patients with primary intracardiac myxoma, in a period from January 1975 to December 1994. There were 55 female and 26 male pts, in age from 1 month to 80 years, mean 46+/-15 years. Clinical manifestations varied from no symptoms and very poor or no clinical signs to various manifestations of chronic or acute congestive heart failure, syncope and arrhythmias with or without systemic findings such as high erythrocyte sedimentation rate, anaemia, leucocytosis, elevated gamma globulin, thrombocytopenia or low grade fever, as well as cerebrovascular accidents due to tumour embolization. Cardiac symptoms were predominant in 54 pts (66.6%) and cerebrovascular in 20 pts (24.7%). Seven pts (8.6%) were symptomless and discovered accidentally, mostly regarding on an unexplained heart murmur. In almost all the patients preoperative diagnosis of intracardiac myxoma was sufficiently established by echocardiography. The tumour was located in the left atrium in 62 pts (76.5%) and in the right atrium in 19 pts (23.5%). Delay from the onset of symptoms to the diagnosis was 6 months in average (range 10 days to 25 months). The average waiting for the operation was 9 days (range from 1 to 60 days). The echocardiographic diagnosis was confirmed during intraoperative examination followed by histological analysis. All pts underwent excision of myxoma using cardiopulmonary bypass with core and topical hypothermia and cold crystaloid cardioplegia. According to the additional preoperative and intraoperative findings, in 6 pts sinchronous mitral valve reconstruction, in 3 pts artificial mitral valve implantation and in 2 pts atrial wall reconstruction was performed. There was no perioperative mortality. After the operation, we could not evaluate all the patients long enough, mostly because of some paramedical circumstancies, such as war, migrations, etc. Twenty two pts undevent evaluation for at least 5 years after the operation. Among them there was no evidence of the tumour recurrence, 15 pts were asymptomatic and 7 had NYHA II class symptoms. For 17 pts with a left atrial myxoma preoperative and postoperative echocardiographic data were available for comparison, showing a significant reduction of the left atrial diameter (p<0.001) during the postoperative follow-up. Our data, presenting one of the biggest reports concerning cardiac myxomas, showed a broad spectrum of their clinical presentation, importance of echocardiography in diagnosing and postoperative follow-up and efficacy of a proper surgical intervention as a definite, curative therapy since there were no deaths and no significant cardiac dysfunction neither tumour reccurrence as well.

Wound infection after median sternotomy during the war in Croatia.

From 1990 to 1994 at Clinical Hospital Center, Zagreb, 1904 median sternotomies were performed for cardiac operations. Patients shared the same intensive care unit (ICU) with the wounded persons, admitted to the hospital from battlefield. Infection developed in 124 patients, an incidence of 6.51%. Methicillin resistant Staphylococcus aureus (MRSA) was isolated from 90, methicillin resistant Staphylococcus epidermidis (MRSE) from 19, and gram negative bacilli (GNB) from 56 patients, Pseudomonas aeruginosa in 2, and Clostridium pneumoniae in 1 case. Ninety-six patients (5.04%) developed superficial localized infection of subcutaneous tissues and they were treated with frequent dressing changes with antibiotic-soaked gauze in combination with systemic antibiotics. Twenty-eight patients (1.47%) developed mediastinitis and sternal dehiscence. They were treated by operative debridement followed by reclosure of the sternum with continuous antibiotic irrigation. We obtained satisfactory results with our method of closure of sternum which is a modification of Robicsek's technique. Nine of them required further operation. In seven cases we performed muscle flaps and in two omentoplasty. One hundred and twenty patients were discharged in satisfactory condition. The uncontrolled mediastinal sepsis caused death in 4 patients. Higher infection rate after median sternotomy during 1991 and 1992 could be possibly explained with the war circumstances in Croatia, and especially with MRSA strain becoming endemic in surgical ICU.

[Causes of complications in the early postoperative period after heart surgery]. / Uzroci komplikacija u ranom poslijeoperacijskom tijeku u kardiokirurskih bolesnika.

In this study we have evaluated 32 patients who underwent open heart surgery with extracorporeal circulation. The aim of the study was to determine the influence of duration of surgical procedure, amount of bleeding after surgery, duration of assisted ventilation, need for mechanical and pharmacological assistance on the occurrence of complications in the early postoperative period. Sixteen patients who developed signs of systemic infection were evaluated. Other 16 patients had similar clinical characteristics and they were operated on the same day or within the same week as patients in the first group and they served as the controls. There was a statistically significant difference between those two groups in the duration of surgical procedure, amount of blood loss after surgery, amount of transfusions and duration of mechanical ventilation. The group of patients with systemic infection and other complications required in the majority cases left ventricular support and developed multiorgan system failure that resulted in a higher rate of mortality. In conclusion, this study shows that the causes of complications and systemic infection in the early postoperative period could be due to a greater blood loss following surgery, demand for blood transfusions and duration of mechanical ventilation.

[Rare clinical situatons of the diverticuli of the colon]. / Situatii clinice rare ale diverticulilor colonului.

UNLABELLED: It is well known that the diverticuli of the colon gets inflamed in 10-15% of cases, thus becoming clinical symptomatic as a diverticulitis, while in other 15% they will bleed, with the clinical aspect of an inferior digestive bleeding. Our study presents some clinical observations with diverticuli of the colon, that raised diagnostic and therapeutic problems. MATERIAL AND METHOD: Between 2001-2010, 17 patients were admitted in the 3rd Surgery Clinic, University Hospital "St.Spiridon", Iasi, with asymptomatic diverticuli of the colon, that were put in evidence imagistically, intraoperative or on specimens after removal of the colon for other conditions;meanwhile, there were 15 patients admitted with complications of the diverticuli:5 patients had perforated diverticulitis (4-pericolic abscesses and one with peritonitis in the lower abdomen), 4 had rectal bleeding and the other 6 raised particular problems of diagnostic and treatment, being included in the present study. RESULTS: Five out of six underwent operation. One patient refused the surgical treatment. Postoperative evolution was favorable in 4 out of the 5 operated patients. CONCLUSIONS: The complications of colonic diverticuli present on admission under clinical aspects that usually mimic a colonic cancer. In these situations the imagistic examinations do not offer enough details to elucidate the diagnosis. Our six particular observations strengthen the dictum of avoiding the "mirage" of the first lesion. The extent of the surgical procedure in the case of patients with colonic diverticuli admitted under the clinical aspect of a complication is sometimes disproportionate and encumbered of increased mortality and complication rate.

[General principles of clinical and therapeutic management in postoperative external enteral fistulas]. / Principii generale de management clinico-terapeutic in fistulele enterale externe post-operatorii.

Postoperative enterocutaneous fistulas represent a frequent complication in the emergency or cancerous digestive surgery. As to the high level of mortality and morbidity caused by this type of postoperative complication (4%), efforts are made to establish the principles of therapeutic management, on the purpose of decreasing these indicators and thus lowering the prolonged hospitalisation afferent costs.

[Intraoperative injuries of the biliary tract]. / Leziunile intraoperatorii de cai biliare.

Statistically speaking, the intraoperative lesions of common bile duct are rare clinical cases, but they have a high gravity potential. Our study was made on a lot of 11 operated pacients during 1995-2007 in our Clinic and it shows the tactical and technical approach used in solving these complications. The study also shows the high level of difficulty of these cases, as immediate recognition of this type of intraoperative lesions is needed. The successful evolution of these cases depends on how quickly the lesions are found and solved.

[Pancreaticoduodenectomy for pancreatic head cancer, 54 cases]. / Duodenopancreatectomia cefalica in cancerul de cap de pancreas--consideratii asupra 54 cazuri.

UNLABELLED: Pancreatic cancer has an increase rate in western countries. From the first pancreaticoduodenectomy (PD) performed by Kausch in 1909, the value of the resection in the treatment of pancreatic head cancer was disputed. AIM: To assess the PD with or without pylorus preservation as surgical treatment for pancreatic cancer. METHODS: Retrospective review of the clinical records of patients undergoing PD for pancreatic cancer. RESULTS: From January 1995 till December 2005, in the First and Third Surgical Units, "St. Spiridon" University Hospital Iasi, Romania, were performed 137 PD. From these, 54 cases were histologic diagnosed with pancreatic cancer; 23 cases underwent pylorus preserving pancreatico-duodenectomy (PPPD) and 31 patients, classical Whipple procedure (PDW). Mean age was 59.07 +/- 1.42 years old (26-75 years old), and male to female ratio was 29 to 25. Jaundice was presented in 51 cases (94.4%), abdominal pain at 39 patients (72.2%) and Curvoisier-Terrier sign at 37 cases (68.7%). Fever was observe only in 4 cases (7.4%). Other biological and imaging parameters (e.g. main diameter of the biliary duct, tumor and wirsung ) were also discussed, but no significant difference was found between PPPD and PDW. Pancreatico-jejunostomy was performed in 41 cases (28 during the PDW and 13 in PPPD) and 13 pancreatico-gastrostomy (3 during PDW and 10 during PPPD). Mean operating time and mean blood loss in the PDW group were 358.22 +/- 10.53 minutes and 587.74 +/- 60.87 mL. After PPPD, these figures were 326.08 +/- 15.04 minutes and 571.74 +/- 90.50 mL, but no significant difference was noted. Delayed Gastric Emptying (DGE) was presented at 15 patients: 8 in PPPD group and 7 in PDW group (p=0.322). Postoperative morbidity rate (excluding DGE) was 33.33% (8 cases in PDW group and 10 in PPPD group). Pancreatic leak has a rate of 5.55% (3 cases--one in PPPD group vs two in PDW group), biliary leak has a rate of 12.96% (4 in PPPD group vs 3 in PDW group)and duodeno-jejunal anastomotic fistula appeared in one cases (PPPD). Acute postoperative pancreatitis is presented in one case (PPPD group) and postoperative hemorrhage appeared in 4 cases (2 in PPPD and 2 after PDW). Hospital stay was 19.91 +/- 2.28 days in PPPD group vs 18.87 +/- 2.24 days in PDW group (p = 0.751). Postoperative mortality rate was 5.5% (one case after PPD and 3 cases after PDW). Histological exam diagnosed ductal pancreatic adenocarcinoma in 51 cases (94.44%). Mean long-term survival rate was 20.98 months (10.52-31.45 months; 95 CI) and no difference was revealed between PPPD and PDW (log rank test - p = 0.796). CONCLUSION: PD should be performed for any pancreatic tumor even without preoperative histologic confirmation. The results after PPPD (postoperative morbidity and mortality, long-term survival) are similar to that following conventional Whipple procedure, if the principles of viable and tumor free margins are observed.

[Tumors of the ampulla of Vater--local or radical resection?]. / Tumorile benigne ale ampulei lui Vater--rezectie locala sau radicala?

Duodenal ampulla is a complex anatomical and histological site and a tumor may arise from one of three types of epithelium: duodenal mucosa, pancreatic duct and distal common bile duct. Neoplasia from each of these locations may exhibit different growth models and though it is difficult to establish their origin before operation, surgical treatment for all resectable tumors is essentially alike. The outcome of these tumors is vitally influenced by the type of epithelium from which they derive. Benign adenomas appear to be a frequent precursor of carcinoma of the ampulla of Vater, therefore, a local resection can lead to an under treated early cancer which would have benefited from a radical excision, with a much better long term result. We consider acceptable to perform an ampullectomy whenever is possible to safely state the benignity of the tumor or when a major procedure is hazardous.

[Surgical resection in esophageal-gastric junction adenocarcinoma]. / Rezectiile pentru cancerele de jonctiune eso-gastrica.

Between January 1999 and November 2005 there have been a number of 44 cases of cancers of the esophageal-gastric junction. Only 24 of them have been surgically removed. The carcinoma of the esophageal-gastric junction was defined on topographical and histological grounds, complemented by radiological, endoscopical and tomographical aspects. The authors analyzed the location of the tumor, compared the imaging with the intra-surgical findings and chose the surgical strategy. The authors widely used the classification proposed by Siewert and Stein, which should be the reference for such tumors. The distal esophagectomy for type I and II tumors should reach much closer, at a reasonable, oncologically sufficient, distance from the upper limit of the tumor; the transhiatal approach is as good as a trans-thoracic one for an accurate mediastinal lymphadenectomy; an esophago-jejunal anastomosis should not be carried out at any costs, reducing the height of the esophageal resection (a risk of positive resection margins), for the length of the jejunal segment to fit the gap.

[Surgical treatment of esophageal strictures secondary to gastroesophageal reflux disease]. / Tratamentul chirurgical al stenozelor esofagiene secundare bolii de reflux gastro-esofagian.

The end point in gastro-oesophageal reflux disease (GERD) evolution is oesophageal stenosis. The aim of this study is merely to establish the absolute requisite of treating simultaneously the oesophageal stenosis and the causal disorder, GERD. This article analyses the diversity of surgical treatment in relationship with the location and length of the oesophageal stenosis using a group of 35 patients with GERD over a period of 25 years. Treatment of this condition has enriched and diversified in the last decades with more conservative and complex techniques, having the task to preserve, whenever possible, the oesophagus. The ability to decide the optimal moment for the surgical treatment, to elect the most suitable procedure, to treat simultaneously the stenosis and to prevent further reflux guarantee a successful, free of recurrence outcome.