Ruptured Recurrent Interstitial Ectopic Pregnancy Successfully Managed by Laparoscopy.

Ectopic pregnancies are a frequently encountered cause of first-trimester metrorrhagia. They occur when an embryo is implanted and grows outside the normal uterine space. Uncommonly, the embryo can be implanted in the intramural portion of the uterine tube, a condition referred to as interstitial localization. This specific type of ectopic pregnancy may have an unpredictable course, potentially leading to severe uterine rupture and catastrophic bleeding if not promptly diagnosed and managed. We present a rare case of a multiparous 36-year-old female patient who underwent pelvic ultrasonography in the emergency department for intense pelvic pain associated with hypotension and moderate anemia. A history of right salpingectomy for a ruptured tubal ectopic pregnancy 10 years previously was noted. High beta-HCG levels were also detected. A pelvic ultrasound allowed us to suspect a ruptured ectopic interstitial pregnancy at 8 weeks of amenorrhea. An association with hemoperitoneum was suspected, and an emergency laparoscopy was performed. The condition was confirmed intraoperatively, and the patient underwent a right corneal wedge resection with suture of the uterine myometrium. The postoperative course was uneventful, and the patient was discharged on the fourth day postoperatively. Interstitial ectopic pregnancy is a rare yet extremely perilous situation. Timely ultrasound-based diagnosis is crucial as it can enable conservative management with Methotrexate. Delayed diagnosis can lead to uterine rupture with consecutive surgery based on a transection of the pregnancy and cornual uterine resection.

Diagnosis and Treatment Difficulties in a Case of Synchronous Colon Cancer with Ovarian Metastasis and Peritoneal Carcinomatosis.

We present the case of a 46 year old female patient, with a personal history of breast abscess and total thyroidectomy for multiple thyroid cysts, who was investigated in a different healthcare facility for loss of appetite and weight loss. She was referred to our hospital with a suspicion of stage IIIC ovarian cancer, based on the paraclinical investigations which were made: a pelvic MRI (magnetic resonance imaging) and the ROMA score (23,16%). The colonoscopy done at the Clinical Emergency Hospital of Bucharest after admitting the patient revealed a circumferential tumor with an ulcerative and infiltrative aspect, which occupied in totality the lumen of the colon, near the splenic flexure. Biopsies were taken at this level. The histopathology result describes a welldifferentiated colorectal adenocarcinoma. A surgical intervention with complete cytoreduction was performed. Immunohistochemistry and histopathology reports of the tissue provided confirmed the origin of the tumor as being colonic, concluding that the primary tumor was a colonic mucinous adenocarcinoma with multiple peritoneal and bilateral ovarian metastases.

Polytrauma: The European Paradigm.

This review of the literature aims to describe the main advantages and disadvantages of the trauma systems in Europe. Moreover, the purpose of this article is to present the last concepts regarding the management of the polytrauma patients and the newest sets of measures to prevent car crashes in European Union. The articles published regarding the management of the polytrauma patient and trauma systems were identified using PubMed search. Optimal management of major polytrauma requires a national trauma system which should detail every level of organization from the trauma centers to the every member of the trauma team. European trauma systems varies a lot depending on the country and the specialized trauma surgery training programs are more advanced in countries with complex trauma systems. Introducing road safety performance indicators for trauma management decreased the rate of deaths by car crashes in Europe.

Diabetes Mellitus as a Prognostic Factor for Locally Advanced Rectal Cancer.

BACKGROUND/AIM: Currently, the impact of diabetes mellitus (DM) on rectal cancer patients is complex and just partly elucidated. The purpose of this study was to investigate the impact of diabetes mellitus on rectal cancer patients focusing on tumor differentiation grade, neoadjuvant chemoradiotherapy (NACRT) response, disease-free (DFS) and overall (OS) survival. PATIENTS AND METHODS: Our study's population consisted of a group of 53 patients diagnosed with locally advanced rectal cancer, who underwent NACRT, followed by radical oncological surgery. This patient population was further divided into two groups according to diabetes presence. RESULTS: Downstaging rates, local control, DFS, and OS were lower in the DM subgroup compared to the non-DM locally advanced rectal cancer patients. CONCLUSION: The presence of DM at the time of diagnosis of locally advanced rectal cancer patients may be a negative predictive factor for response to neoadjuvant therapy, distant metastases, and local recurrences rates.

Hypocalcemia: A possible risk factor for anastomotic leak in digestive surgery.

Anastomotic leaks (ALs) remain the most severe complication in digestive surgery, as well as the most consumptive in terms of human and financial resources. There is an abundance of international research which has focused on identifying and correcting risk factors, and on individualized surgical management as well. The most frequent risk factors are male sex, obesity, diabetes, advanced malignant disease, ASA score, perioperative blood loss or perioperative transfusion, long operation time, emergency operation and altered nutritional status. The aim of the present study was to measure the preoperative serum calcium level and to find a possible correlation between calcium levels and the risk of AL occurrence. A retrospective analysis of medical records for 122 patients who underwent surgical gut resection with anastomosis for different pathologies was carried out. Preoperative serum calcium level and the occurrence of AL was noted. The results revealed that the average value of total blood calcium was 8.78 mg/dl, without a significant difference in sex groups. Hypocalcemia was identified in 44 patients (36.1%). AL was identified in 8 patients (6.6%), with a statistically insignificant difference between male and female patients. The average value of blood calcium in the AL patient group was 8.07 mg/dl, while in patients without AL the average value was 8.83 mg/dl. Hypocalcemia, defined as a serum calcium level below 8.5 mg/dl, was observed in 7 of the 8 patients presenting with AL (87.5%) and 37 patients who did not present with AL (32.5%), a significant difference with which to consider and include hypocalcemia in the group of risk factors for AL (P=0.001). In conclusion, preoperative low serum calcium level can represent a risk factor for AL in digestive surgery.

The Management of Pancreatic Trauma - A Continuous Challenge.

Background: The aim of this analysis was to assess the factors that influence the severity of pancreatic trauma cases, also underlining the importance of early and accurate diagnosis and proper management of each case. Methods: This study is a retrospective analysis of patients that were presented to the Clinical Emergency Hospital of Bucharest, Romania, in several periods of time: 1985-1990 (50 patients); 1990-1999 (102 patients); 2000-2005 (56 patients); 2012-2019 (48 patients). Results: The mean age was around 40 years old, with predominance of male incidence in all the groups and traffic accidents (blunt trauma) as the main cause of injury. Most patients (almost 50% in each group) were operated on within the first 24 hours from hospital presentation. The general mortality rate varied: 42% (1985-1990), 23.5% (1990-1999), 12.7% (2000-2005) and 33% (2012-2015). Pancreatic mortality rate was 6% (1985-1990 and 1990-1999), 3.5% (2000-2005) and 8% (2012-2019). Conclusions: During the last 35 years, the preoperative diagnosis in patients with trauma of the pancreas remained a challenge and the treatment of the pancreatic trauma suffered a very interesting evolution- from the very frequent laparotomy to the nonoperative management and the damage control. These procedures produced a significant decreasing of the negative or nontherapeutic laparotomies. For the effectiveness of treatment, methods must be correlated with the lesion score.

Changing the Prognosis of Metastatic Cervix Uteri Adenosquamous Carcinoma through a Multimodal Approach: A Case Report.

Adenocarcinoma and adenosquamous carcinoma (AS) are 2 rare histological types of cervix uteri cancer constituting almost 20% of all cervix cancers, leading to a lack in patient management guidelines. We report the case of a 32-year-old woman with an oligometastatic cervix AS for which a multimodal treatment approach was used. Despite the patient's bad prognosis, a complete response was achieved, which further resulted in excellent local control and prolonged survival. This case report serves the purpose of encouraging multidisciplinary team work and out-of-the-box thinking that should result in an individualized treatment for rare cancer subtypes.

Surgical Management of Diabetic Neuropathy Foot Complications.

Background: Diabetic foot complications result from the association between peripheral vascular disease, neuropathy and a precarious healing process. Peripheral neuropathy observed in diabetics affects all components of the nervous system, contributing to the occurrence of leg ulcers, musculoskeletal changes, resulting in severe deformities. The clinical manifestation of these complications ranges from simple lesions to complex entities threatening the loss of pelvic limb or even life (1,2). Methods: In our surgery department, a significant number of patients with diabetic foot lesions are hospitalized and treated annually, 40% having clinical manifestations of diabetic neuropathy associated. In 2017, a total of 448 patients were hospitalized for complications of diabetes. We performed a retrospective analysis of 150 consecutive patients who underwent surgery for neuropathic diabetic foot lesions. Results: The analyzed patients had a favorable postoperative progression, benefiting from distal perfusion. Ray resection was the preferred surgical intervention. Major amputation was performed in 10% of cases with extensive gangrene and sepsis, amputation of the calf being preferred in all situations. Conclusions: The management of these patients is delicate, often multidisciplinary approach being necessary. A well-managed therapeutic attitude can make the difference between preserving or losing the pelvic limb.

Synchronous Locally Advanced Rectal Cancer with Clinical Complete Remission and Important Downstaging after Neoadjuvant Radiochemotherapy - Personalised Therapeutic Approach.

Introduction: The current practice for patients with good response, important downstaging or complete remission after preoperative chemoradiation, is to perform surgery on the basis of initial pretherapeutical staging. In literature, varying approaches, like transanal endoscopic microsurgery and even "wait and see", are described for patients with good response after chemoradiation. However, considering the present level of available evidence, the wide-spread adoption of a "watch and wait" policy in those achieving a complete clinical remission cannot be justified. CASE REPORT: It is presented the case of a 63 years old patient, investigated and diagnosed with synchronous rectal cancer, inferior rectal cancer invading the perianal region and medium rectal cancer, located between 8 and 14 cm from the anal verge, pretheraputically staged cT4N2M0. The oncological board decides neoadjuvant radiochemotherapy. Restaging shows complete remission of inferior rectal tumor and ulcerative infiltrative remnant lesion in the medium rectum. The patient firmly declines colostomy, assuming recurrence risks. A TME low rectal resection with colorectal mechanical anastomosis is performed, postoperative evolution being favorable. Conclusions: Although, the radical surgery to be done would have been an abdomino-perineal resection, the patient's option to decline the colostomy imposed a radical intervention just for the proximal tumor. The inferior rectal tumor, with complete remission after neoadjuvant therapy was submitted to "wait and see" approach.

A Rare Case of Upper Digestive Hemorrhage due to Bleeding Duodenal Tumor.

We present the case of a 48-year-old patient with no medical history, who presents himself to the emergency room with melena, asthenia and dizziness. The blood tests revealed a severe anemia (Hb = 4,8 g/dL). He is admitted in the Gastroenterology ward, where a first superior digestive endoscopy is performed which shows a duodenal bleeding tumor (second duodenum) of 7 cm in length. After the administration of red blood cell mass, plasma and haemostatic agents the level of the hemoglobin increases. The abdominal CT scan reveals a 3/5 tumor localized in the second and third duodenum. The superior digestive endoscopy is repeated and haemostasis of the bleeding tumor is accomplished. The surgical exploration of the peritoneal cavity discovered a partial stenosing, ulcerated duodenal tumor (third and fourth duodenum) and duodenectomy (third and fourth duodenum), segmental enterectomy (first loop of the jejunum), end to end duodeno-jejunal anastomosis, transgastric closure of the pylorus, gastro-enteric anastomosis on Omega loop with Braun fistula were performed, after the result of the extemporaneous histopathological exam suggested a GIST tumor. The postoperative evolution was favorable. The histopathological exam diagnosed the duodenal tumor as a gastrointestinal stromal tumor (GIST) with tumor free resection margins. The particularity of this case is the rare etiology of the upper gastrointestinal hemorrhage and its severity.