Surgical Emergencies in Patients with Hemophilia A-What to Expect.

Surgical emergencies in patients with hemophilia A represent a major risk of mortality without proper multidisciplinary management and require prompt and effective treatment to prevent complications and improve patient outcomes. We present a short number of cases that were hospitalized in the I-II Surgery Clinic of the Emergency County Hospital "St. Spiridon" from Iasi, Romania, with hemophilia A requiring surgical emergencies. The timing of surgical intervention is very important, so the indication for surgical intervention must be made judiciously and without delay. Consequently, it is vital to ensure access to hemostatic support so surgery can be performed on these patients, ultimately saving their lives.

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.

Hemoperitoneum as a Life-Threatening Complication of an Acute Cholecystitis in a Patient with Hemophilia A with Inhibitors: A Case Report.

We present the case of a 52-year-old male with severe hemophilia A with inhibitors, who was diagnosticated with acute lithiasic cholecystitis that required surgical intervention due to lack of favorable response to conservatory treatment. During surgery, hemostatic support was performed with activated recombinant factor VII (rFVIIa, NovoSeven®). The surgery was performed first laparoscopically with adhesiolysis, followed by subcostal laparotomy and cholecystectomy because of the findings of a pericholecystic plastron with abscess and massive inflammatory anatomical modifications. The patient presented postoperative complications, requiring a second surgical intervention, due to the installation of a hemoperitoneum. Hemostatic treatment with rFVIIa was given for a further 3 weeks postoperatively, and the patient was discharged in safe condition. A surgical intervention increases the risk of bleeding in hemophilic patients, which may have vital complications in the absence of adequate hemostatic support and the support of a multidisciplinary team with experience in hemophilic surgery.

Laparoscopic Repair for Perforated Peptic Ulcer: A Retrospective Study.

BACKGROUNDS: The incidence of patients presenting with perforated peptic ulcers (PPU) has decreased during the last decades. At the same time, a laparoscopic approach to this condition has been adopted by increased number of surgeons. The aim of this study was to evaluate the early postoperative results of the laparoscopic treatment of perforated peptic ulcer performed in eight Romanian surgical centers with extensive experience in laparoscopic surgery. METHODS: Between 2009 and 2013, 297 patients with perforated peptic ulcer were operated in the eight centers participating in this retrospective study. The patients' charts were reviewed for demographics, surgical procedure, complications and short-term outcomes. RESULTS: Boey score of 0 was found in 122 patients (41.1%), Boey 1 in 169 (56.9%), Boey 3 in 6 (2.0%). For 145 (48.8%) patients, primary suture repair was performed, in 146 (49.2%) primary suture repair with omentopexy. There were 6 (2.0%) conversions to open surgery. The operative time was between 25 and 120 min, with a mean of 68 min. Two (0.7%) deaths were noted. Mean hospital stay was 5.5 days, ranges 3-25 days. Postoperative complications included: 7 (2.4%) superficial surgical site infections, 5 (1.6%) cardiovascular, 3 (1.0%) pulmonary, 2 (0.7%) duodenal leakages, 3 (1.0%) deep space infections and 1 (0.3%) upper digestive hemorrhage. CONCLUSIONS: This study shows that the laparoscopic approach for PPU is feasible; the procedure is safe, with no increased risk of duodenal fistulae or residual intraperitoneal abscesses. We now consider the laparoscopic approach for PPU as the "gold standard" in patients with Boey score 0 or 1.

Morphological changes of the peritoneal membrane in patients with long-term dialysis.

Morphological alterations of peritoneum in chronically dialyzed patients involve fibrosis and angiogenesis as pathogenic mechanisms. The aim of this retrospective study was to evaluate morphological changes of peritoneum in chronic peritoneal dialysis (PD) at 4, 8, 12, and 14 years. Peritoneal changes were investigated in 110 patients with end stage renal failure, which were included in a PD program. Intraoperative biopsies were grouped in four study Groups (A: 1-48 months, B: 49-96 months, C: 97-144 months, and D: 145-168 months), and were processed histologically and stereologically. Mesothelial denudation was found in percentage volumes of 5.49% - Group A, 16.10% - Group B, 16.68% - Group C and 19.88% - Group D. Reduplication of the basement membrane was observed in patients with over five years of PD. Interstitial stromal fibrosis recorded percentage volumes of 25.49% (Group A), 26.10% (Group B), 35.85% (Group C) and 56.63% for the patient with 14 years of PD. Subendothelial hyalinizing vasculopathy was recorded in percentage volumes of 2.22%, 6.63%, 9.16% up to 9.20%. Vascular permeability reduction was recorded as decreasing percentage volumes from 22.59% to 12.81%, 7.77% and 7.37%. Perivascular inflammation was marked in the serosa of the patients in Group A (4.55%). Calcifications recorded percentage volumes of 1.63% at eight years, 3.74% at 12 years and 4.03% at 14 years of PD. Peritoneal morphological changes appear at 3-4 years of PD and progressively aggravate with long-term PD.

Hind right approach pancreaticoduodenectomy: from skill to indications.

Background. Pancreaticoduodenectomy is the potentially curative treatment for malignant and several benign conditions of the pancreatic head and periampullary region. While performing pancreaticoduodenectomy, early neck division may be impossible or inadequate in case of hepatic artery anatomic variants, suspected involvement of the superior mesenteric vessels, intraductal papillary mucinous neoplasm, and pancreatic head bleeding pseudoaneurysm. Our work aims to highlight a particular hind right approach pancreaticoduodenectomy in selected indications and assess the preliminary results. Methods. We describe our early hind right approach to the retropancreatic vasculature during pancreaticoduodenectomy by mesopancreas dissection before any pancreatic or digestive transection. Results. We used this approach in 52 patients. Thirty-two had hepatic artery anatomic variant and 2 had bleeding pancreatic head pseudoaneurysm. The hepatic artery variant was preserved in all cases out of 2 in which arterial reconstruction was performed. In nine patients with intraductal papillary mucinous neoplasms the pancreaticoduodenectomy was extended to the body in 6 and totalized in 3 patients. Seven patients with adenocarcinoma involving the portomesenteric axis required venous resection and reconstruction. Conclusions. Early hind right approach is advocated in selected cases of pancreaticoduodenectomy to improve locoregional vascular control and determine, safely and early, whether there is mesopancreas involvement.

Minimally invasive treatment of hepatic hydatid cysts.

BACKGROUND: Hydatid cyst is a parasitosis caused by Taenia Echinococcus. In the last 10 years, new methods of treatment of the hydatid cyst have been proposed (percutaneous or laparoscopic). METHOD: This retrospective study includes 24 patients with hepatic hydatid cyst (HHC) who were treated by a minimally invasive approach, 18 women and 6 men (average age 49.3 years), representing 10% of all patients with HHC. RESULTS: The average operative time was shortened to about 70 minutes. The conversion rate was 25%. In all cases managed laparoscopically, the prophylactic flooding of the peritoneal cavity was realized with peroxide solution 10 per thousand or with hypertonic saline 30%. The inactivation of the cyst was performed with hypertonic saline in most of the cases. Most cysts were univesicular (62.5%), but there were also multivesicular cysts (37.5%). In two cases patients presented hepatic and pulmonary hydatid disease which were also approached in a minimally invasive manner. The average postoperative period of the cases treated laparoscopically was 6 days and for the converted cases it was 13.3 days. CONCLUSION: The open surgical approach of HHC is highly expensive due to the postoperative period, therefore a laparoscopic approach may be advocated. The minimally invasive method shortens the postoperative hospitalization period, reduces the number of complications as well as the overall costs and facilitates a rapid social reintegration. All these arguments recommend the laparoscopic approach as a standard procedure for hepatic hydatid disease.

Hydatid disease cured by minimally invasive therapy.

Hydatid disease is relatively frequently encountered in general surgery services (4-5% of the total operated cases). The association of the hepatic and pulmonary localizations is quite common, but the involvement of more organs is rare. The asymptomatic rupture of the hydatid cyst in the peritoneal cavity is exceptional. We present the case of a 69-year old female patient who was hospitalized in the 1st Surgical Clinic for irritative dry cough, loss of weight (4 kg in the last 3 months), fatigue, itching and dyspnea. She had been hospitalized in a department of internal medicine for respiratory symptoms when, during X-ray investigation, an opacity was observed, which was suggestive for a pulmonary hydatid cyst. The abdominal ultrasound revealed a multiple hydatid localization (liver, spleen, lower right abdominal quadrant and hypogastrium) and the patient was sent to our clinic. The patient was treated with albendazole 10 mg/kg/day for 10 days before surgery. Surgery was performed by a minimally invasive approach, first by thoracoscopy and, in the same operative session, the other hydatid localizations were approached by laparoscopy. The parasiticide treatment was continued about 3 months after surgery, when the patient was hospitalized again in order to cure the splenic hydatid cyst. Postoperative evolution was complicated by a biliary fistula which resolved spontaneously in 10 days after the intervention. The postoperative hospital stay was 14 days. This case was unusual because of the paucity of symptoms in spite of the multiple abdominal cysts and because it was cured by a modern, minimally invasive approach.

Ogilvie's syndrome--acute colonic pseudo-obstruction. Case report and review of the literature.

We present a rare entity of colonic pseudo-obstruction, characterised by severe colonic dilatation in absence of any organic obstacle. Clinical symptoms, diagnostic approach, and therapeutic measures are analysed and discussed. Many factors have been associated with this syndrome which include electrolyte imbalance, systemic infection, drugs, and occasionally, neurologic disease. Reported here is a case of acute colonic pseudo-obstruction which developed in a patient with restrictive respiratory dysfunction. Colonic decompression by means of colonoscopy, the most effective therapeutic approach for pseudo - obstruction failed, and surgical cecostomy was required. The acute colonic pseudo-obstruction, Ogilvie's Syndrome, most often appears as a complication of other clinical conditions. It is characterized by massive colonic dilatation in the absence of a mechanical cause and may lead to cecal perforation in absence of treatment. When colonic obstruction is suspected, one should always consider the possibility of the occurrence of Ogilvie's syndrome

Mucinous digestive tumors. Case reports and review of the literature.

We present three rare entities of mucinous tumors: appendiceal mucinous adenomas, enteroid mucinous cyst and pseudomyxoma peritonei, the latter as a developmental course or separate idiopathic etiology of mucinous tumors. We attempted to clarify the term of pseudomyxoma peritonei, a poorly understood condition, characterized by a diffuse intraperitoneal collection of gelatinous fluid with mucinous tumoral implants on the peritoneal surfaces. With this rare condition it is often difficult to establish the histological and developmental malignant or benign characteristics. We analyzed 4 patients admitted during the period of February 2000 - February 2002 in the First Surgical Clinic of St. Spiridon Hospital and in addition we referred to the current approach in the recent literature. In three of the four patients the diagnosis was possible preoperatively by imaging techniques and consequently they were operated by laparoscopic procedure for the complete removal of tumor cells at macroscopic level. We preferred to administrate chemotherapy accordingly to the malignant/ benign aspect, choosing the long term follow up of the patients to ward off the eventual relapse. We considered the future state of these cases to be uneventful, with a real chance of long term survival. In conclusion, the symptoms are not always specific, allowing errors in diagnosis. Imaging techniques offer real elements of diagnosis. Laparoscopic techniques could offer an oncologic approach with no less benefit compared to open surgery. This methodology also allows different surgery for a different pathology at the same time. The origin of these tumors is more frequently digestive and less ovarian.