[Transanal endoscopic microsurgery--our initial experience]. / Chirurgia transanala endoscopica--experienta noastra initiala.

UNLABELLED: The aim of this study was to describe a single institution's experience with transanal endoscopic microsurgery (TEMS) in patients with benign and malignant rectal tumors. MATERIAL AND METHOD: This was a prospective descriptive survey. Between January 2006 and January 2010, 14 patients underwent transanal endoscopic microsurgery excision of benign (8) or malignant (6) rectal tumors, located 4 to 15 cm from the dentate line. Median age was 59.7 years and the mean follow up was 29 months. RESULTS: The average tumor size was 3.4 cm, median operating time was 40 min. Median length of hospital stay was 4.35 days. During the follow-up period, benign tumor recurrence was observed in one patient (7.14%), managed by repeated TEMS. Histologic staging of malignant tumors was T1 (2) and T2 (4). In two patients with inadequate resection margins open radical surgery was performed. One had recurrent disease, which was managed by radical surgery. No cancer-related deaths were observed during the follow-up period. There was no operative mortality. No major postoperative complications were recorded. Anal incontinence persisted for 3 weeks in one patient. CONCLUSION: Transanal endoscopic microsurgery excision is a safe and precise technique and should become a procedure of choice for benign rectal tumors and selected early malignant neoplasms.

[Ascending colon perforation by ingested fruit stones]. / Perforatia colonului ascendent prin sâmburi ingerati.

BACKGROUND: Ingested foreign bodies present problems due to the related complications, perforation being the most frequent. MATERIAL AND METHOD: This is a descriptive study of two cases of ascending colon perforation by numerous ingested fruit stones. The main symptoms were abdominal pain with tenderness in the lower right quadrant. RESULTS: In both cases the diagnosis was made at operation, with right hemicolectomy and termino-lateral ileo-colic anastomosis. Post-operative outcome was uneventful with the exception of a wound infection. The possible mechanism of the delayed perforation is discussed. Diagnosis and treatment modality alternatives in foreign body ingestion and the literature data are reviewed. CONCLUSIONS: Delayed perforations by ingested fruit stones can be difficult to diagnose preoperatively but if operated in due time are curable by resection of the affected bowel.

The time for surgery of peritonitis associated with peritoneal dialysis.

Peritonitis is the main complication of peritoneal dialysis (PD) and also an important factor for raising the cost of the method to the level of hemodialysis. Associated with PD, peritonitis is responsible for the increase of morbidity and mortality of the procedure and, at the same time, the main cause of the technique failure. Severe and prolonged peritonitis or repeated episodes of peritonitis lead to ultrafiltration failure. Peritonitis treatment should aim for a rapid remission of inflammation in order to preserve the peritoneal membrane functional integrity. The treatment of PD peritonitis consists mainly of antibiotic therapy, surgical intervention not being usually required. However, it is of outmost importance to differentiate the so-called "catheter related" peritonitis from secondary peritonitis due to visceral lesions, in which the surgical treatment comes first. The confusion between secondary and "catheter related" peritonitis may lead to serious errors in choosing the correct treatment, endangering the patient's life. The differential diagnosis between a refractory or secondary peritonitis in a peritoneal dialyzed patient may be very difficult. In front of a refractory PD peritonitis, surgical exploration must not be delayed. Also we have to keep in mind that the aim of peritonitis treatment is the saving of the peritoneal membrane and not the catheter.

Evaluation of a pharmacy-based surveillance program for heparin-induced thrombocytopenia.

We instituted a pharmacy-based surveillance and intervention program for heparin-induced thrombocytopenia (HIT). Surveillance occurred between August 1996 and July 1999. Platelet counts were monitored by pharmacists in patients receiving heparin 10,000 U/day or more. For patients with declining platelet counts, serology was ordered and clinicians were advised as appropriate. Outcomes of HIT in the surveillance group were compared with historical cases. During surveillance of 8,672 heparin courses, the incidence of HIT was 0.2%; however, the estimated rate in patients exposed to heparin for more than 4 days was 1.2%. Compared with historical HIT cases, the rate of thrombosis was reduced from 50% to 29% (p=0.39) during surveillance. The only patient factor associated with increased risk was the presence of cancer (p=0.03). This pharmacy surveillance method may have a role in improving outcomes of HIT.

Case studies in heparin-induced thrombocytopenia.

Type II heparin-induced thrombocytopenia (HIT) is an immunological disorder characterized by antibodies to heparin-platelet factor 4 complexes and a high risk of thrombotic complications. Here, we present illustrative case histories to educate the reader on evaluation and management of this complex syndrome. Cases include typical and unusual presentations of the syndrome, and commonly encountered problems and pitfalls of therapy. Major points illustrated are, (1) occurrence of HIT with any dose or form of heparin; (2) misperceptions on the diagnostic criteria; (3) correct (thrombin inhibitors) and incorrect (platelet transfusions and warfarin) management; (4) influence of management strategy on clinical outcomes; (5) severity of the syndrome; and (6) potential for both anamnestic response to heparin and disappearance of HIT antibodies over time. Effective therapy of HIT involves both the prompt recognition of the syndrome and its proper management.

Trousseau's syndrome treated with long-term subcutaneous lepirudin (case report and review of the literature).

We report here a case of recurrent venous and arterial thromboembolism, Trousseau's syndrome, in a cancer patient who developed heparin-induced thrombocytopenia. She was treated with lepirudin and after establishing the patient-specific half-life for subcutaneous lepirudin, she was successfully maintained on this therapy for more than eight months. To our knowledge this case represents the longest reported use of subcutaneous lepirudin.