Pancreaticojejunostomy - Risk Anastomosis after Cephalic Pancreaticoduodenectomy.

INTRODUCTION: The authors bring to attention pancreaticojejunalanastomosis (PJA) performed after cephalic pancreaticoduodenectomy(CPD). This type of anastomosis is renowned forits high risk of complications. Among these complications, pancreatic fistula (PF) is distinguishable due to a significant frequency, averaging 10%. It is perhaps the most unsafe type of anastomosis in digestive surgery, due to its pancreatic partnership. Performing a sealed APJ can be considered a great achievement: a digestive lumen is set in contact with a brittleparenchymal structure, centred by a delicate excretory channel, difficult to anastomose in itself. MATERIAL AND METHODS: We studied two distinct groups of patients undergoing CPD. A first group - 58 cases operated on between 1967 and 1983, and the second one - 70 cases operated on between 1984 - 2013. In all cases we performed PJA; by in-continuity loop technique in the first group, and with separate loop in the second group. In the second group we used a variant own technique that does not allow anastomotic loss of pancreatic fluid. Thus, a decline in the incidence of PF from 20% to 8% was obtained, the final percentage corresponding to group two. Of the 8% of patients with PF losses were recorded strictly at pancreatic level, with no bile or food contamination. Stenting was recorded for biliary- and pancreaticojejunal anastomoses in group two. DISCUSSIONS: The percentage of PF after CPD did not show anynotable revival when comparing the 1980s period to the present. Also, mortality due to FP is approaching 40%, adaunting figure. The multitude of technical options for restoring bowel movement after CPD, over 80 procedures, further confirms the lack of safety and trust in relation to PJA.The authors bring forward several surgical gestures addressing PJA, gestures capable of providing an 8% frequency of PF,percentage which we consider to be reasonable. CONCLUSIONS: The authors consider PJA stenting mandatory.Placing an isolated PJA on the short branch of the "Y", separate from the biliary and food flow, prevents the formation of a complex fistula. The proposed technique does not require a"duct - to - mucosa" type or "telescoping" type pancreaticojejunalanastomosis.

Aseptic mesenteric lymph node abscesses. In search of an answer. A new entity?

Mesenteric lymphadenitis constitutes a frequent cause for abdominal pain and may manifest acute abdominal symptoms. Very often, it is difficult to achieve a differential diagnosis as there are many diseases that can generate mesenteric lymphadenopathy. Many times, it is impossible to determine the diagnosis of the disease that has triggered mesenteric lymphadenopathy even after surgical intervention with biopsy. The failure in determining the precise cause of the mesenteric lymphadenoapathy, as well as its unresponsiveness to conservative treatments increases the difficulty in the management of this disease very much. In this paper we have reviewed the diseases that can trigger mesenteric lymphadenitis in detail, with reference to our experience. To the best of our knowledge, this is the most extensive review on this theme in current specific literature. The case reported by us, with a history of mesenteric adenitis, splenic and ganglionic abscesses, vasculitis skin nodules, pseudotumoral ileal stenosis and remission-recurrence pattern over 25 years, has raised extremely difficult problems of differential diagnosis. Its enlistment as a Crohn's disease, vasculitis or aseptic abscess syndrome seems unsatisfactory. The analysis of the data in this case can raise the legitimacy of the question: should we recognize and define a new entity?

Primitive retroperitoneal tumors. Vascular involvement--a major prognostic factor.

Primitive retroperitoneal tumors, although very rare, arouse an increased interest, because of the poor prognosis, unsatisfactory surgical and complementary therapy results. Up to now, the very low number of cases has impeded the acquisition of a unitary view of these tumors, a unanimously accepted algorithm of diagnostic and treatment being absent. Randomized trials regarding the effects of different therapies have not been possible. The main factor that can fundamentally increase the survival of these patients is radical resection, some authors even recommending compartmental surgery. We found no significant statistical difference between the survival rates of the patients with different types of non-radical interventions, that shoud be therefore, as much as possible, avoided. Our study evidences that vascular involvement is the main limiting factor in achieving radicality. The involvement of large retroperitoneal vessels makes often impossible a radical intervention, usually because of the lack of an adequate material and human endowment for ample vascular resections followed by laborious reconstructions. That is why, in our study, vascular involvement was associated with a decreased survival rate for operated patients. Therefore, we underline the necessity both of a solid material base and of establishing multidisciplinary surgical teams for adequate vascular interventions in oncologic general surgery.

[Radiofrequency ablation for liver metastases--mini invasive therapeutic option for patients with unresecable tumors]. / Distructia prin radiofrecventa a metastazelor hepatice--optiune terapeutica miniinvazia optimala la pacientii non-rezecabili chirurgical.

UNLABELLED: Radiofrequency ablations (RFA), a new therapeutic option for liver metastases, proceeded by open surgery or laparoscopic approach, provide an acceptable control of local tumor process, involved lower risks than resection surgery. OBJECTIVES: We analyzed this procedure, for classic indication in hepatic metastatic tumors, based on four years experience, focused on perioperative complications, recurrence rate and long distant evolution. METHOD: Between December 2006 and December 2010, 61 patients with liver metastases underwent RFA; 46 cases had metastatic lesions from colo-rectal cancer, 9 cases from breast cancer, 4 cases from gastric cancer and 2 cases from ovarian cancer. RFA was performed in 55 patients via open surgery and laparoscopic approach in 6 patients. Postoperative course was followed with CT scan at 1 month, and then at 3 month interval, in correlation with tumor markers level. RESULTS: Perioperative complications occurred in 8 cases, consist of prolonged fever, severe hepatic cytolysis, without other complications such, biliary tract injury, hemorrhage, and peritonitis; no mortality caused by RFA procedure. 10 cases had local recurrence, at 6 and 25 month after post RFA procedure. CONCLUSIONS: Initial experience shows that RFA is a safe procedure for treatment of liver metastases, with low rate of morbidity and local recurrence, indicated for patients with unresecable lesions or high risks for surgical resection.

[The reassessment of indications in laparoscopic cholecystectomy]. / Reevaluarea indicatiilor colecistectomiei laparoscopice.

The gallstone, with its potentialy complications, claims a surgical solution in asymptomatic forms too, often traced out with the abdominal echography investigations circumstances. In all the countries, the symptomatic gallstone, is a surgicaly section, but, the asymptomatic gallstone is a surgicaly indication in some countries, too. A number of transplantation surgeons have begun to recommend pretransplant cholecystectomy for asymptomatic patients to have gallstones. The indications can be extended to: young children, pregnant women, patients with very large gallstones diabetics, immuno-depressed (AIDS, radiation and multiple drug treatments). The asymptomatic gallstone seems to obtain in the last years, an extention of the surgicaly approach indications, the paper, suggesting a laparoscopic cholecystectomy assessment indications.

Late choledochal pathology after cholecystectomy for cholelithiasis.

UNLABELLED: After "simple" cholecystectomy for lithiasis, biliary disorders can appear, with the onset more than 3 years postoperative, like cholangitis or transitory jaundice. Meantime, a whole range of congenital abnormalities initially ignored can become manifest: biliary tract congenital dilatations, duodenal para-Vater diverticulum, Oddi stenosis. AIM: to establish the pathological circumstances that determine late choledochal syndrome, including an analysis concerning the therapeutical approach in these cases. Patients with cholecystectomy complains of late biliary disorders (least 3 years symptom-free) between 1997-2005, were retrospectively studied. Exclusion criteria were intraoperative incidents or accidents, recognised incomplete surgical procedure, early difficult postoperative course. Therapeutical approach was endoscopical, surgical or conservative. 46 patients entered the study group; 38 underwent open cholecystectomy. Mean interval between operation and disturbances onset was 10 years. Following etiopathologic causes of late choledochal pathology were recorded: incomplete cholecystectomy, retained or primary common bile duct (CBD) stones, choledochal cyst or stenosis, Oddi stenosis, duodenal para-Vater diverticulum, anomaly biliary tree. Thirty patients undergone successful endoscopic treatment; in 8 cases endoscopy failed, in 2 cases open surgery was the first choice; 5 diagnostic endoscopic cholangiography with conservative treatment were performed; 1 patient refused any procedure. Cholecystectomy indication is regularly based on clinical and ultrasound examination criteria. Even a simple cholecystectomy can be followed after first 3 years by cholangitis, obstructive jaundice, caused by initially ignored biliary tract pathology. To avoid such omissions, routine intraoperative cholangiography and duodenal endoscopy should precede cholecystectomy. On the other side, cholecystectomy itself can cause late complaints: retained CBD stones, gallbladder stump, and iatrogenic stenosis. The duodenal para-Vater diverticulum seems to have a more important role in biliary disturbances, before and after cholecystectomy.

[The role of laparoscopy in the management of the right iliac fossa syndrome]. / Locul laparoscopiei în sindromul dureros de fosa iliaca dreapta.

Many cases of nonspecific right-sided lower abdominal pain syndromes are still difficult to diagnose regarding the accuracy of identifying which organ is suffering, in spite of the continuous development of various investigations. The aim of our study is to establish the limits of noninvasive explorations and to evaluate the benefits of laparoscopy approach of such cases. 45 patients, admitted and treated for right lower quadrant abdominal pain along 5 years in the Surgical Department of University Hospital "Caritas" Bucharest, were followed up. For all those patients, diagnostic uncertainty indicated laparoscopic exploration. Analyzing the cases, we noticed that the diagnosis was correctly established on the basis of non-invasive preoperative explorations in 13,33% of cases. In 11,11% of cases the diagnosis was completed by laparoscopy approach and in most cases (75,55%) was established by this procedure. The laparoscopic approach allowed diminishing the number of unnecessary appendectomies, detecting and resolving concomitant lesions with minimal parietal trauma and, essentially, avoiding "exploratory laparotomy".

[Acute necrotizing enteritis]. / Enterita acuta necrozanta la adult.

The authors present a retrospective clinical study done on a 13-pacients basis diagnosed during surgery with acute necrotizing enteritis. This study follows the complexity of pathogenic factors and the difficulties one confronts with when establishing a diagnosis since the clinical manifestations are non-specifical and shows the contribution of laboratory data to an earliest possible diagnosis. Both medical and surgical treatment are analyzed depending on the results achieved with an attempt to determine a therapeutic approach as beneficial as possible, aiming at making clear either enterectomy or a conservatory surgical decision should be made. Mortality rate under such therapeutical approach was 38%.

[Mini-invasive treatment, through endoscopic papillo-sphincterectomy, of post-surgery biliary fistulae]. / Tratamentul miniinvaziv, prin papilosfincterotomie endoscopica, al fistulelor biliare postoperatorii.

External biliary fistulas associated both with open and laparoscopic biliary surgery, need a quick solution to prevent local and general complications. Open surgical treatment was the only solution until the minimally invasive techniques, such as endoscopy, were developed. The authors present 10 cases of postoperative external biliary fistulas, successfully treated by endoscopic papillosphincterotomy alone, technique which is compatible with other endoscopic procedures of treatment, performed in association with endoscopic papillosphincterotomy or not.

[Unusual hemorrhagic complication after surgery for severe generalized appendicular peritonitis]. / Complicatii hemoragice neobisnuite dupa o peritonita apendiculara grava operata.

The 22 year old male patient, was admitted in hospital for severe generalized peritonitis subsequent to acute perforated appendicitis and toxico-septic shock. On examination and relying on the previous history of the patient onset of the perforation was start assessed to have occurred some days earlier. Severe generalized, putrid peritonitis was found on surgery of the peritoneal cavity. Appendectomy was successfully carried out with a simple ligature of the appendix stump, and the ligature of the mezooappendix was performed without identifying the appendicular artery. Early in the postoperative stage there occurred diffuse bleeding localized in the peritoneal cavity. The source of the bleeding could not by found at the first reoperation. Subsequently the septic syndrome evolved simultaneously with the bleeding in a milder form, however, leading to growth in size of retroperitoneal hematoma. On marking the diagnosis, relying on CT examination, a new, second surgery was performed which afforded evacuation and drainage of the retroperitoneal hematoma. The authors have remarked and have tried to clear up the circumstances which had been conductive to the occurrence of hemorrhage, a thing absolutely unusual in the evolution of diffuse peritonitis by perforated acute appendicitis.

[Therapeutical options in lithiasic biliary fistula]. / Optiuni terapeutice în fistulele biliare litiazice.

Chronic lythiasic cholecystitis is a disease distinguished by the pathologic changes because of the chronic inflammation of the biliary extrahepatic tree. Sometimes these morphological changes are associated with internal biliary fistulas arising spontaneously in patients with advanced calculus cholecystitis. The vast majority of fistulas result from the adherence of the inflamed gallbladder or common bile duct to an adjacent viscus and erosion of the gallstones into the adherent organ. The authors analyze an amount of 43 patients with bilio-biliary and bilio-digestive lythiasic fistulas, caused by the long evolution of chronic lythiasic atrophic cholecystitis, for 126 cases which were operated in the Surgery Department of the Caritas Clinic Hospital along 20 years. In these 126 cases the surgical strategy was determinated by the method of dealing with the pericolecystitis sclerotic blocks, by the identification methods of the biliary elements and by the approach of the main billiary way and digestive loops injuries occurred after suppressing the fistulae. The surgical solutions adapted for each separate case and the advantages of the axial drainage of prostheting the surgical reconstructions of the main biliary way as well as the results obtained along this project, are in fact the aims of this presentation.

[Endoscopic sphincterotomy in the treatment of common bile duct benign lesions (experience with 100 cases)]. / Papilosfincterotomia endoscopica în tratamentul afectiunilor benigne ale caii biliare principale (experienta a 100 de cazuri).

The authors present the experience of the first 100 endoscopic sphincterotomy performed in Caritas Hospital, Surgery Department between 1997 and 2000 for CBD benign lesions treatment. The patients to whom we performed this procedure had a biliary syndrome associated mostly to obstructive jaundice of unknown etiology previously diagnosed echographically or by ERCP. The etiology was in 72% of the cases represented by migrated, residual or primary common bile duct stones. The aim of the procedure was the removal of the stones. We performed endoscopic sphincterotomy either before or after laparoscopic or open surgery. The morbidity was 8% and the related mortality was 0%. Endoscopic sphincterotomy is an efficient procedure for the treatment of the benign obstruction of the common bile duct and not only. Our results were similar to those published by other authors.

[Controlled stomach fistula for acute operated ulcer. Case report]. / Fistula gastrica dirijata pentru ulcer acut postoperator perforat. Prezentare de caz.

The authors analyze the case of a 65 old woman which was hospitalized for sigmoidian stenosant and haemorrhagical neoplasm, confined to the colic wall, without peritoneal or hepatic metastases, and without peritoneal or parietal invasion. Surgical management included sigmoidectomy and termino-terminal anastomosis for reconstructing intestinal transit followed by peritoneal drainage. In early postoperative stage the aspect of generalized peritonitis occurs and there is suspicion of anastomotic fistulae. On surgery, acute and perforated gastric ulcer is found, located in close vicinity to the cardia, on the anterior side of the stomach. Suture of the perforation is undertaken with drainage of the peritoneal cavity, but successfully because fistulization of the sutured perforation followed. Under the given circumstances controlled drainage of the gastric fistulae was carried out, using a Folley probe extended through the fistulae orifice and through the anterior abdominal wall, lateral to the median incision. The blowing of the intragastric balloon and the setting into tension of the gastric wall to the front abdominal wall allowed the sealing of the fistulae route but it took about three months. This technical contrivance has afforded good postoperative evolution and recovery of the patient, who after five years from surgery is in a good condition and has no subjective complaints.

[Recessive hiccup of rare cause (compressive pleuro-pericardial lymphocele). Case report]. / Singultus rebel de cauza rara (Limfocel pleuro-pericardic compresiv cu evolutie lenta) prezentare de caz.

The authors discuss the case of a 40 year-old woman, which was performed surgery for a stenosant duodenal ulcer by bilateral troncular vagotomy and hemigastrectomy, using the Pean-Billroyh 1 anastomosis. Immediately after surgery untractable hicongh gradually set in which lasted over a 14 year, till the moment when a compressive pleuropericardic lymphocele, of the right phrenic nerve was revealed, a very long time growing cyst. After the surgical removal of the lymphocele was performed, which had compressed the right phrenic nerve, singultation totally disappeared, the patient has been monitorized through periodical medical checkings for more than 4 years. The period of 14 years when the patient constantly complained of steady untractable singultation has comprised 30 admission or more, to various surgical, gastroenterology and psychiatry wards. The patient was finally considered an incurable psychotic and was medically pensioned. The authors discuss a number of possible sequels of the initial gastric surgery which could have triggered untractable singultation, without being able to control them or totally ruling out the psychotic causes. There is natural suspicion cast of either existence or beginning of this cyst simultaneous with surgery since clinical tests and explorations were able to reveal it only after 14 years.

[An endoscopic treatment method for postoperative stenoses]. / Metoda endoscopica de tratament a unei stenoze postoperatorii.

The endoscopic procedures include a great variety of procedures for the treatment of the upper and lower gastrointestinal bleeding of the benign and malign jaundice, of the primary or secondary gastrointestinal strictures. The authors present the case of a patient with a postcaustic oesophageal stricture for whom the surgical treatment was an esogastroanastomosis. Quite early in the postoperative course the anastomosis got, very tight due to a anastomotic fistula, and we succeed to dilate it with endoscopic procedures.

[Intraoperative exploratory endoscopy in surgery of the digestive tract]. / Explorarea endoscopica intraoperatorie în chirurgia tubului digestiv.

The intraoperative endoscopy as a way of the range of the surgical exploration of the abdomen is a valuable procedure combining surgical and endoscopical maneuvers. It proved useful in following conditions: A. delicate surgical approach of the anatomical segment; B. equivocal findings of the conventional endoscopy; C. as a way of achieving therapeutical goals. In 56% of the cases a transperitoneal approach was used and in the rest of the cases a conventional technique. Sterilization was performed using glutaldehide 2%, 20 minutes before the intervention. The methods was used in 50 cases, concerning reinterventions, as well as primary diseases of unclear origin. Some were high-risk patients. Therapeutically benefit was proven in all cases.

[A rare cause of postoperative digestive hemorrhage]. / Hemoragie digestiva postoperatorie de cauza rara.

Despite all the diagnosis's technical progress achieved in the past years, there are possible haemorrhagic complications after abdominal surgery, creating problems of diagnosis and treatment. The author presents a rare case of postoperative gastrointestinal bleeding due to an ulcer of the jejunal mucosa, located quite close to a hepaticojejunostomy. The mucosal ulcer, with consequent severe, massive bleeding was caused by the migration of a thread from the hepaticojejunostomy, proved by histopathological examination.